Event ID: 2345487
Event Started: 4/4/2014 8:15:51 AM ET
Please stand by for realtime captions.

[Captioner on stand by]

We will get everybody 30 seconds to get settled. Welcome everybody. I know we have a number of new members today and we will go around the table and the phone into introductions in a little bit. My name is Bruce Siegel and I have the privilege of sharing the Council and I am thrilled to be here. I will mention that we have some panelists and participants and visitors. For those of you who are new, I want to warn you you are being webcast today so be on your best behavior.

In terms of housekeeping, members here on the council who need transportation after the meeting, we ask you sign up at the registration desk behind me by the end of lunch. I will also note all the members are going to be meeting in the wellness room at the beginning of lunch to break for a group photograph. I think some of the staff here will lead us in that direction at that time. After that photograph, we ask the six new members in attendance also stayed behind in the wellness room and have an individual photo taken. It goes up on the wall here at the agency. Members will be escorted to a room during lunch time in a secure location unbeknownst to anybody else were you may purchase lunch privately and either privately at that time. That will not be webcast. A couple other things is we will have public comment as always as part of the agenda. That public comment will be at 11:15 or 1:45, actually both times. People planning to make public comment can also sign up at the registration desk behind me.

We will ask councilmembers to introduce themselves and we ask when you do that to use your microphone so people on the web can hear you as well.

Rick Kronick, I am the Director of AHRQ. Welcome to all of you.

David Meyers, primary care prevention and [Indiscernible].

Jeff Brady.

[Indiscernible]

Henry Yang and I'm the president of [Indiscernible].

Mary -- chief medical services officer.

Paul Sherman.

Sheree Davidson.

Hairy

Hairy -- Harry [Indiscernible]. Jane Crowley, executive vice president for Catholic health partners.

Greg Baker, director of pharmacy.

Mike Johnson.

Carol --

Jed Weissberg.

Anne Hendrik.

[Indiscernible].

Patty Skolnick.

[Indiscernible]

Bruce Siegel, CEO [Indiscernible]. We also have folks phoning in. I will ask them to introduce themselves. David Ballard?

David Ballard, [Indiscernible]. I am a Lexington, Kentucky native and have Louisville meeting Florida for the championship.

Andrea? Leon?

Leon Haley, executive associate Dean for -- and chief medical officer of the Emory medical care foundation.

Jean Rexford? Are there any other members on the line I have missed? Okay. Our first order of business now that we have done introductions, you should have the draft minutes and 10 minutes of our meeting from November 15 in your folders. I am going to ask for any changes or edits people may think are required.If I am hearing none, I will ask for a motion to approve those minutes.

Moved.

-- we will move into the next item which is the directors update.

Thank you, Bruce and thank you for your time and energy and commitment to the agency. I am very much looking forward to your input and hopefully we use your time well today and look forward to feedback on the meeting.

First, I want to thank Jamie Zimmerman for putting this meeting together and also congratulate Jamie on the t iming. I don't know how long ago the meeting was scheduled, probably a couple of years or something but it is fitting that it is three days after the end of open enrollment. We have collectively spent a tremendous amount of energy over the last four years and more worrying about and working on expanding access to care and expanding coverage. I am sure we will continue to spend a lot of time and energy on that over the coming years. We're just getting started, but certainly 7.1 million people enrolled in the marketplace and some number of millions more new Medicaid enrollees is a very good start. We will be hearing later today from Cindy Mann and Joe Thompson from Arkansas and Tom Selden and have some time on the Medicaid part of the expansion which will clearly continue to be contentious and we will be working on for quite a number of years. Marketplace work is just getting started and the 7.1 million we have seen so far, expectations are perhaps will double more or that next year. The coverage work is far from done but I think we are beyond an opening threshold there and we will collectively have more time and energy to work on all the other issues that are needed to try to make sure health care works in the United States and the issues of quality and safety and affordability that are at the heart of what the agency does. A very exciting time I think and an appropriate time to be having this meeting.

I'm going to spend 20 minutes to half-an-hour of initial updates. Please ask questions on the way through. At the end of this I will definitely have a question for all of you which would make it to even before that and then have David Meyers present a very exciting new initiative of the agency and Jeff Brady similarly present on work we are doing to try to produce evidence to make healthcare safer.

First, I do want to welcome the new NAC members. David and Sherry and Mary, welcome. Paul and Patty and Jed. We have the new director of the national Center for health statistics. Charlie Rothwell.Welcome to all of you and again thank you for your willingness to provide advice and I look forward to your advice and feedback.

I want to spend a few minutes on mission and priorities. We covered some of this at the last meeting when it was extremely new but we have bits of updates and Jeff and David will spend more time on updates but we want to remind you the mission of our agency. Our mission is to produce evidence. We are research agency but to produce evidence to do what? Make healthcare better, safer, higher quality, more accessible and equitable. Producing evidence doesn't do anything by itself, so to work with partners throughout the federal government and outside to try to make sure the evidence is understood and used.

We have for priorities following the mission statement, producing evidence to improve quality, safety, accessibility in each of these areas attention to equity, an important part of what we are doing throughout.

David Meyers is going to spend much of his presentation on this first priority. We issued a funding opportunity announcement about three weeks ago asking for grantees to provide support to small and medium-sized physician practices with the goal of improving the ability of these practices to incorporate patient centered outcomes research and evidence into their practice with a particular focus on improving performance on cardiovascular risk factors. The million hearts campaign, aspirin, blood pressure control and smoking cessation services. We issued to FOA's to evaluate at a separate one as an over arching evaluation. I am very excited about this initiative. I think it highlights the role of the agency in trying to produce evidence about how to change practice which motive you around the table have been aware of for many years and is really hard to do and we don't know very well how to do. We are working on trying to produce evidence about how to make this work. The FOA for the of 28 grantees is up to $40 million a year for three years. This is funded out of the -- trust fund. For the agency a large initiative and it is both engaged in trying to produce evidence about how to do this as well as a boots on the ground approach at a sort of medium scale of disseminating patient centered outcomes research, but it does recognize we are helping to reach about 6000 physician practices that are primary care practices taking care of around 9 million people. It is a reasonable sized initiative in and of itself although there are still 200,000 primary care physicians in 300,000 primary care providers, a pretty small part of the universe so the goal is to develop evidence about how to engage in this kind of transformation and work with other partners in and outside the federal government to make sure if we can figure out how to make this work that it gets taken up and implemented much more broadly.

The second priority to make healthcare safer again has some very exciting work going on. Jeff Brady is going to spend a little bit of time explaining this, and I'm not going to say more about this now.

The third priority, producing evidence to make healthcare more accessible will focus on understanding the effects of the coverage expansion on newly insured people, all providers, particularly safety net providers who have been taking care of these newly insured people on the structure of the labor market. The goal is to provide evidence for my boss and members of Congress who will be making decisions over the coming years about how to make the coverage expansion work better and there is a lot of information they are going to need to make those decisions and with partners we will be involved in producing that evidence, much of it through investigator initiated studies.

The fourth area, producing evidence to make healthcare more affordable. We have been doing some investigation of how we might be able to contribute to the movement to try to increase price transparency. Talking with Sherry Davidson and colleagues and many others and still trying to figure out what might be possible in that area. I know I don't have the answer there and would be interested in any advice you might have. More broadly we issued a special emphasis notice in December saying we were interested in understanding the comparative performance of healthcare delivery systems the United States. First trying to understand what our delivery systems. Care is being delivered by systems that we don't really have a good understanding of what they are and the taxonomy of those systems much less being able to understand their performance on quality and resource use and even more importantly the characteristics of systems that lead to higher performance and the kinds of interventions and initiatives that would move toward higher performance. This is also a fruitful and exciting area for the agency to be developing evidence. We are also interested in this area in understanding the value and developing better evidence about what parts of healthcare are worth it and what parts are not. That is an area the agency has spent some energy in and potentially a hot button area, but an area of interest. Any questions about mission and priorities. -- Patrick Conway, welcome, nice to see you. Any questions before I go on to some discussion of where we ended up in the 14 budget and the proposal for the 15 budget?

In your priority number three where you talk about the evidence of health insurance coverage expansions and the effects on labor markets, would you expect some of that work would look at effects on or demand for healthcare professionals of various types?

Not so much in the labor market piece that on the effects on providers which is part of priority three that we would like to understand the effects of the expansion on providers and thinking primarily around safety net providers but that certainly includes people working in the healthcare field. When I say the effects on labor markets, I'm thinking more of the concern about what the effects of the expansion would be a part-time workers and decisions on whether to offer employer sponsored insurance and trying to understand those issues.

The only reason the highlighted that, I think the issues of health professionals training and supply will become more acute in the next few years and I think there is a lack of clarity over what the future scenarios might look like.

That is a very good point. Our colleagues, are doing a lot of work in the affordability priority, certainly the work we said we are interested in around delivery systems as a big piece of trying to understand how workforce is used in various delivery systems and particularly the use of mid-level practitioners and supply and demand issues there. Thank you.

The valuation of the ACA, you obviously know ASPE a lot [Background Noise]. I think it is an excellent priority that you've evaluated here. Can you distinguish the kinds of research you want to have done that will help us understand A CA? This is the biggest experiment anyone has done in healthcare so we want to learn from it. Can you say a little more on how that would be distinguished from the other sister agencies and offices?

Sure, thank you for the question. ASPE, which I have a fondness in my heart for, it tends to have a shorter term time horizon and all of its external work is through contracts.Here we would look for investor to initiated work, and I'm excited about the energy in the field about trying to figure this out as well as doing some work internally with Tom Selden and the folks here who have been working for many years on issues like this using primarily the medical expenditure panel surveys. There is a lot of expertise that has been developed internally as well as the ability to have somewhat longer term and investigator initiated work in this field.

This morning we were talking about how disparities in the quality report would be a great platform for least revealing what we can learn.

Great point.

Henry?

The AAA is better care, better health and lower cost. In the priorities I can see two of those. I wonder if you could talk about the better health piece and whether that was a strategic choice not to address that were not seeing it in their.

On the priority to improve quality and safety and improve delivery systems, and access, these are all oriented toward better health. The purpose for any of this is to get to better health. We don't explicitly have a focus on let's say public health issues so if you're asking why we are not focusing on trying to reduce obesity, the answer is our colleagues at the CDC are heavily engaged in that, and we are certainly doing work that tries to develop evidence about how to do that better but that is not an explicit focus.

I think you would hear some of that at the committee report this afternoon. As you recall in this room less than a month ago, the search group had a session on medication adherence and we had the acting surgeon general releasing a report on medication adherence. I want to make sure AHRQ continue several focus on that with patients and their health.

That is the main focus of all this work. Office of the work is how we get to better health. The whole purpose of this is to get to better health. I would say the only reason of this is to improve health.

If I could add to that, AHRQ is actually funding a project at the national quality forum around population health and build community action guides around that. We have actually created one of the better dialogues between healthcare and public health around actionable steps that can be used to improve health so there are things happening out of AHRQ that could be helpful and are helpful. Henry?

I would like to harken back to priority number two with regard to healthcare safety. I think there may be additional opportunities to generate initiatives that would be useful for many different kinds of vulnerable populations which AHRQ can impact. When we think about environment of care we think about people and place. Some of the factors we have identified have to do with different processes and communications that have shown much improvement in morbidity and mortality. There are pieces to tie in with regard to translating the effects of clinically and culturally competent care and how that impacts medically vulnerable populations including those who do not speak English, gay, lesbian, transgender patients. An example of competent care referring to persons by their prudent name or there chosen name or their pronoun of choice is important and that creates an affirming a permit. Individuals who do not have a chance to interact without -- that leaves them with inadequate healthcare and the inadequate health care and the opportunity to improve their health status overall.

Thank you. Jeff, I think when you get to your presentation it will address some of those issues.

Let me move on to the 14 budget enacted in 15 budget information. This graph shows the history of appropriated dollars to the agency over the last 10 years. You can see the appropriated dollars in 2014 were $364 million and I will show on the next slide more detail about that. What is not on this graph are dollars that come to the agency through the PCORE trust fund which in 2014 is $92.8 million or in that neighborhood. Also not on this graph are dollars that came to the stimulus bill through ARRA and were quite substantial, about $300 million directly to the agency and another $100 million or so that went to the office of the secretary but ended up being managed from the agency.

A gory detail on the 2014 budget, the appropriated dollars which I seem in sort of the middle slide -- $364 million in 14, very similar to the level in 13. Close to $30 million more than what was requested in the president's budget in 2014 so our friends in Congress appropriated about $30 million more than what is requested . I will show in the next couple of slides have asked that money to be spent. As I said, close to $93 million on the bottom line transferred from the PCORE trust fund.

The various portfolios within the agency are mostly close to the 13 level patient safety in the middle. You can see it increased by $5 million from 13, the large crosscutting portfolio is flat from the 13 level. The health information technology line item increased by $4 million from the 2013 level. The task force has got a small increase from 13, but pretty close to level. This was the valuation funds in the patient centered health research, it has no funding in 14 and that has been expected for a long time. That is the part of the portfolio that has moved over to PCORE. Any questions about the 14 budget before I move on?

New initiatives in the 14 budget, $5 million for patient safety learning labs. We issued a funding opportunity announcement that closed on February 7 and we intend to fund multidisciplinary teams to develop and test interventions and provide training opportunities for new investigators. Jeff will talk a little bit more about this. We also received $4 million for health IT and patient safety to do research on how to make health IT safer. How to use health IT to make health care safer and we issued special emphasis notices with applications due by the end of March.

The president's budget 15 very much follows reviews patterns but has some new initiatives.The request is for $334 million. Appropriated funds is about $30 million less than was enacted in 14, but similar to the level that was requested in the president's budget in 14. The estimates from the transfer from the PCORE trust fund increased about $93 million in $142,105,000,000 or so in 15 but in the president's request, we would be still about $24 million lower in 15 and 14 enacted. As you know the president's request is the beginning of a process and we will see were Congress ends up. There is certainly the possibility of a continuing resolution and the possibility of an actual bill. In the request there are two new initiatives. One extending the work we have done in patient safety beyond the hospital to other settings. In 14 we will be doing some work in nursing homes, but the proposal in 15 is to have $15 million focusing on developing evidence and doing some early bits of implementation in improving safety in nursing homes and also doing some work in ambulatory care which is sort of a frontier on the safety side. One of the big issues there is around diagnostic errors which is an area which we don't even really know how to measure much less know what to do about. We have done a little bit of work in that area, but there is much more to do. The other initiative in the 15 budget proposal is to have $15 million in investigator initiated work in health economics area and in this area we would be interested in work both on evaluating the coverage expansions but also understanding the effects of new technology on healthcare utilization and spending. It is a very exciting area as well.

The health services research and disseminated portfolio which is the largest portfolio in the budget supports initiated work and much of the measurement work and data collection activities including healthcare cost and utilization Project and the HIV research network. And important parts of much of our health services research. The request is for around $18 million less than was enacted in 2014, although we have largely protected B request around investigator initiated research in which we're requesting $40 million for initiated research including $20 million in new grants of which $15 million would be in health economics initiatives. There is always lots of interest in investigator initiated work. This slide shows the history relatively flat funding over the last five years. The request in 14 was for $26 million so the request in 15 while still below the 14 enacted level is 14 million more than what we requested in the 14 budget.A pretty substantial increase they are. Again, we will see where this ends up after congressional action.

Any questions on the budget information?

In EMS settings, there's a lot of question on how quality is measured which is not a lot. There was an IOM report on that a few years ago. Every time there is an ambulatory out of hospital look, it seems like EMS isn't so much included in that. It seems like it is an area getting missed and it seems like not an insignificant area. I wonder if EMS is going to be involved in that?

This is Jeff Brady. Maybe not a complete reaction to that but a couple of points. One place in the patient safety -- healthcare simulation work and looking at the role of simulation, not just on training but how the system functions and how teamwork is an important role but also focused on individual skills and competencies at various levels of training and again different roles within the system. That is at least one place we have represented that setting within patient safety research.

[Indiscernible]

We have had a number of meetings with the assistant Secretary for preparedness and response and folks at NIH working on emergency medicine. We have little bits through the work we do in collecting emergency department data as part of the healthcare cost and utilization Project where we have data from 27 or so states. 32 states, thank you. Those data are fairly limited in their ability to really get at safety, but we're trying to remind them in figure out what we can do with that. Any other budget questions?

I was going to point out that I see a connection between the work on IT safety and ambulatory. A lot of the conversation about IT safety is what problems EMR's have caused. In our experience the reverse is much larger. The number of safety problems immediately used EMR's can address.There are risks of course, but I think the main barrier is -- physician practice offices has been the data was manual and it was difficult to extract and is not true anymore because of the meaningful use stimulus money. We have an incredible penetration of automated practice data and many systems have chosen data in the practice setting as one of the qualifying projects to achieve there meaningful use status.I think the days that you will find is very rich.

That is an excellent point. Any other budget questions?

I would do relatively brief agency updates. For those of you who are not new members, this has been in the past a much longer part of the presentation. I have chosen to shorten, but I would be happy to answer questions about other things I haven't included but I want to get more of what we want from you today. First update on staff transitions. We announced yesterday that Bob Kaplan who is been the Director of social and behavior research at NIH for the last few years is going to join the agency as the chief science officer. That transition will happen in early May and I'm very excited about having Bob and his talents here. Bob has a PhD in psychology but as work in health services research for the last 30 years and doing a lot of work in measuring quality of well-being and quality of life but also tremendously broad portfolio of work with a lot of clinical research in HSR focus and a very pleased Bob will be joining us as chief science officer which is a new position for the agency out of the office of the director. Gene -- who have director -- for probably a decade or so left in February to join the quarry where we are fortunate where we get to continue to work with her and -- is the acting director and doing a wonderful job. Jeff Brady who has been at AHRQ for eight years and ran parts of CQuIPS has become the director for quality improvement and safety and Bill -- who was the director of CQuIPS and did a great job of making that part of the agency a vital part of what we have done that kind of headlines around reductions in central line infections and the work you would hear about from Jeff was initiated and grown. Bill is now running the patient safety organizations team which has been a passion and a love of Bill's for many years.

A few updates on what we have been doing since we met the last few months ago. -- co-authors and published a study in the New England Journal in late January analyzing the rates of 21 adverse events in hospitals between 2005 and 2006 and 2010 and 2011 showing a substantial decline in adverse events among patients being treated for heart attack and heart failure. 81,000 fewer adverse events of those patients although no significant decrease in surgery patients and patients being treated for pneumonia. When Jeff represents what we are working on, you will see substantial energy and effort around surgical site infections and went [Indiscernible].

Pam and Claudia who work in the center for delivery organization and markets with Irene Fraser had an article in JAMA analyzing the rate of surgical site infections following outpatient surgery.There has been a lot of work on surgical site infections in the inpatient setting, but hardly anything for ambulatory surgery. The good news here is the rate of SSI's following ambulatory surgery is quite low.3.1 out of every 1000 surgeries, but there are so many ambulatory surgeries that as an absolute matter, there are a lot of surgical site infections following ambulatory surgeries. This article will bring attention to that and begins to ask questions about what can be done and how to improve that over time.

Steve and Julie and Tom who work in the center for financing access and cost trends -- published an article in health affairs quite recently showing newly eligible adults for Medicaid are little healthier than adults who are correct Medicaid enrollees.They are a lot healthier than disabled Medicaid adults. Even when you are looking at non- disabled Medicaid e nrollees, the new eligibles are somewhat healthier and there are still 24 states that have yet not expanded Medicaid and we expect this evidence is likely to be helpful in those states arguing in favor of the expansion. There was always concerned about how much this is going to cost, and even with the 100% financing of the expansion, there were still some concerns about the 10% they will eventually be responsible for and this finding provides useful evidence about the cost of that expansion is likely to be.

As I mentioned earlier, we issued funding opportunity announcements between three and four weeks ago. David is going to spend more time, that it is certainly an exciting and important part of what we have been working on. We have been working on collaborations with agencies throughout HHS. I was down in Atlanta a few weeks ago and had a very fruitful day with a lot of discussion around the work around safety and hospital acquired infections but also work we are doing in the measurement area and some in the CDC public health area.

Aviary brief update on employee viewpoint surveys. All employees in HHS are surveyed every year and asked a number of questions about what it's like to work where you w ork. The overall rating from AHRQ was 71. This is between a zero to 100 scale. This was done in the spring of 2013.

[Indiscernible]

In the interest of transparency you'll probably see this slide one way or another. Employees did rate working here quite positive.There were so maximum items that have come out of the survey we will be working on. When is there was concern, and I think this is an issue throughout the federal government and in some organizations outside the federal government that many people are working very hard and completely devoted and dedicated to the agency. We have limited ability to reward those people. There are some people perceived by their colleagues and by supervisors as not performing so well. We have not done such a great job on dealing with the poor performance.We will be putting into supervisor performance plans that the part of the evaluation is how you were doing with poor performance.There was a request for more transparency about how the limited bonuses we are able to provide and what the rules are there and we have provided information on that.We have a committee called M agic . They are going to conduct a best practices seminar which will have good attendance from supervisors here about creative ways to recognize performance. Those are the action steps coming out. Any questions about any of these update materials?

I was going to make a comment and compliment you for your transparency in talking about the items you are addressing in terms of the internal culture. Thank you.

A year from now the proof will be in the pudding. Let me turn to where I would really like your input.One of the fundamental questions for the agency is where should we be on the continuum of producing evidence and trying to make sure the evidence is actually used and implemented?

In making change, a lot of what we are involved in is trying to figure out how to encourage changes in how healthcare is delivered and the practice of healthcare. It is an incredibly hard thing to make happen.There are a variety of pieces needed to make that happen. Beginning with the design of what kinds of innovations and inventions might work? Piloting ideas and trying to develop some evidence about what does work and more importantly, under what situations does work? Figuring out how to implement beyond the pilot but not yet really broadscale and it is in the early implementation part where much of the evidence the circumstances in which innovations may work get developed. All of this bound up with the questions of incentives and why would organizations move toward change and improve how healthcare is delivered? Eventually, once we can figure out changes that might work and the situations in which they might lead to improvements in healthcare, had you get that implemented more broadly? Given the size of the agency -- and parts of this diagram for the top in developing evidence about what works and the circumstances in which innovations work, we are not resourced or sized to be very effective on the bottom. Patrick Conway and partners in the insurance industry and health plans are the folks who need to be engaged I think in large-scale implementation. On the other hand, Patrick and I talked a couple times a week if not more, as much as we are working with partners, partners often have a difficult time committing to what they're going to be able to do in the future. One of the challenges for the agency and folks thinking about how much funding we can get, folks ask what you have done and what to have accomplished? We can say we have produced really good evidence about what does work and they say you haven't actually changed practice.You will hear more of this as David describes the accelerating PCORE FOA and a balancing act we are trying to figure out about where we should be on producing evidence as opposed to saying in the end we have been able to change practice, I am struggling with how to approach this and I will say this again, my instinct is we should be focusing on the producing evidence in the early implementation stages, but then I am concerned about how to respond to what you have actually done? To some extent I can say what I have done is I have given to Patrick and two health systems and insurers the evidence about how to do this and help them figure out about how to implement. If they have done it, can we as an agency get credit for it? Jay?

Just a quick comment on this last topic. It resonates to a large degree with some of the work I have been doing for the last two years. As part of that we commissioned an analysis of 17 change campaigns, if you will, mostly in healthcare but in some other areas of the economy to try to look at the constituent elements of going from one point to the next and to summarize it very quickly. The creation of the knowledge base of itself well not easy is not the hardest part. I think everybody understands that. The creation of incentives is even not that difficult. What is most difficult and often the obstacle to change is the capacity to change. I think as we look at change at the level of physician p ractices, it is easy to envision the larger institutional practices having that capacity. It is harder to envision how that takes place in some of his mother practices that represent still the majority of physician practices and tackling that capacity issue is critical.

An excellent point, and this will be a great segue to David Meyers and is exactly the focus of the new work we are trying to get started. Jed?

A question about your graphics. In the light blue evaluation, does this imply take five has a role in those evaluations?

Very much. I think that is the main value added we provide.

That is the feedback loop on accountability and credit in terms of how large-scale implementations go. I would feel the least bit reticent to claim that.

I'm not reticent to claim that. In some circles, it's hard to get credit for.

I have one other question around large-scale implementation going back to the million hearts campaign. One of the things recently is how you do implementations and evaluations of multiyear large-scale campaigns when the evidence seems to shift under your feet. Are you looking that at all?

A little bit. David, do you want to jump in?

When we talk about change I think capacity is an important piece, but I think what we see, and we rent patient centered medical homes for large employer groups so we higher doctors from the outside and they come in. We implement EMR's, but I think her biggest challenge is like the first step of addiction, you have to admit you have a p roblem. A lot of physicians with everything on paper historically don't really see what their true quality measures are. The first step is to get physicians offices as a baseline if I am doing good or bad and what tools we can give them to self identify how they are doing first. I think once they have the baseline of two I have good quality in my practice or not, then they're going to figure out if they have the capacity to change. We spent a lot of time talking to them about evidence -based medicine that they think that applies to everybody else a lot. I'm doing a great job myself but we need to get to that first.

A great set up for David who will be coming soon.

Amy, Michael and then Anne.

This is a question about how far you want to go in the development and implementation. The diagram is helpful in thinking about some examples to possibly consider. We have always been the group that takes the evidence and implements it but one thing we have been trying to do is get involved in the design of clinical trials from the get go so whatever becomes effective, and were talking more complex interventions, there are things that are implementable to begin with and that is one thing. The other thing is we have taken lessons learned from the CDC research to practice framework and it was about taking underlying theories of technology transfer and anthropology to basically replicate effective programs. If you go around and see the impact of that program, there is not a service organization that has said we have got a package to implement -- so they invested time and effort to create an economy of scale to have a package and a technology transfer program for every evidence -based prevention initiative they had.

You would hear from Jeff Brady that a lot of our work is in that direction as well and the question is kind of how far do we go?Do we spend a lot of energy trying to get folks to use it, etc..

Michael?

This is interesting. Greg mentioned the patient centered medical home, encourage the agencies thinking about implementation to think about it not just with the patient centered medical home but what I referred to is the patient centered medical neighborhood.The definition is primary care and specialty physicians. I'd like to expand on that definition which is all of those providers that are putting their hands on patients so I applaud the efforts to move hospitals into the nursing home arena but a lot of the care and the majority of the care that is delivered by nurses and physical therapists and dietitians. As much as we can be as broad in looking at the patient centered medical neighborhood, I think the better the patient will be served in the end.

I think is another area that may not be included in this graphic which is really around rapid spread and adoption of evidence that is already known in the experience comes from the partnership for patients. We have demonstrated rapidly how quickly 4000 hospitals can work together and spread evidence and adopt and move the curve. He seems to me between early implementation and large-scale spread, there is another area that is rich for learning which is around what causes that rapid adoption and spread to all Curt? Before the partnership, I don't really perceive there is an agency directing funding toward that area. Most of the answers of what we are dealing with with higher spittle acquired conditions, the evidence is there but the hospitals have not yet adopted it.

An excellent point and I think highlights the tension we face. If you develop the evidence in some of that evidence was developed by work we funded, but if it hasn't been out there, I can turn to Patrick and say here it is, is that good enough or should we be putting energy into doing something more?

A couple comments. We are also involved in the partnership and I would perhaps be arise the success of the partnership may be due to the different nature of the relationship between the hospitals and other entities in the partnership.People feeling they have some control over their destiny. It is assisted. But I think the organizational relationship may be important and interesting to look at some point. I hope as you do this you think about the world as it is -- and I say that because the point about physicians still being smaller practices is true. I don't know how long that will go on for. I think the ACA has released some forces of consolidation and we will perhaps encounter lots of speed bumps and false detours and antitrust issues but I expect the trend will be in one direction and very quickly in one direction. You may even think about a future where these improvement networks and platforms are much more aligned entities.

As opposed to most of the other comments which have been a wonderful set of for David, yours is going to be a challenge for David.

I think the wisdom of what Anne says is the early implementation research should be on what are the variables that will predict success of large-scale implementation. Why did it take -- 20 years to get it done everywhere?Maybe that is the source of the resolution and detention.

Thank you. Let me introduce David Meyers who is the director of the Center for primary care -- CP 3 is how we know it here. David?

Thank you so much. I had this idea that I'm so excited by this idea I was going to take you of the mountaintop and this was going to be and -- and you're going to stand up and cheer. Then my boss told you in one minute everything he gave me 20 minutes to do. Instead of going to the top of the mountain I would take you closer to the weeds. Were going to do a deeper dive on one area of the AHRQ agenda and priority one. This is the set of funding announcements we are calling accelerating PCORE. I hope we will have some time for the discussion. In some ways, this train is moving. I'm not asking for your feedback on should we do this, I wanted to think about now that it is going, what are the speed bumps going to be and how can we make this better and reduce the risk. I gave you much more information that I have time to go over so for those of you who have areas of interest, you can even go deeper. We can get you the electronic copy because many of these are embedded links. I didn't have my coffee today so I wouldn't talk to quickly but I will still go quick. A bit of background for those of you who are new, the affordable care act created the patient and outcome centered trust fund and directed a portion of that money every year to AHRQ with specific purposes around disseminating and translating PCORE findings. Here's specifically are the areas. Disseminate and translate. Get it out there and used. Build the next generation of researchers who can do this kind of research. Work with communities, real Americans as well as r esearchers, which is not to imply researchers are not Americans, but to get their feedback on what needs to be done and how to do a better and a specific call out to AHRQ because we do work on how health IT can improve quality and safety and a specific push to use PCORE evidence and how linking health IT can better deliver that. Here are our strategies for doing this. In the next few slides I wanted to show you in each of these areas a taste of some of the initial that when we got this money going into overdrive in figure out how to use it and put out a number of quick FOA's and contracts to move this down the road. Sympathizing transiting in developing evidence to build within the effective health care program and synthesizing knowledge into evidence into the Eisenberg center, creating products for patients and healthcare professionals for healthcare decision-makers and policymakers about what the evidence means. All of this got a nice boost. We started working in the engagement area with exciting and innovative work on something called deliberate approaches and working with people in communities to move them on a journey so they can be partners in research as well as a focus on how evidence is going to be used to reduce disparities.

Spreading it to healthcare professionals and getting the information into the hands of people who use it. Some novel work on dissemination using partnerships with healthcare specialty organizations to help them think about how to work with their members as well as communities and how they can build infrastructure for using evidence in a sustainable way. Finally in our training area, a number of initiatives across the spectrum of. New and senior investigator awards. Many of these are ongoing opportunities for advancing the field by developing the research in PCORE. Then we get to 2014 in the next installment and we decide everything is moving in to take a breath and what really needs to be done. All the work I am about to show started at your last meeting and has been done in the last four months. And so the secretaries question, what are we doing to get evidence implemented and used in practice, to narrow the timeframe of that 17-year gap? Reflect AHRQ new priorities and quality safety access and affordability. Make sure this work aligned with the larger efforts of the department so this work would be multiplied in its effectiveness because of work going on around the department, and most importantly have real outcomes that matter to Americans.

With that charge brought together a large team. This many smart minds I think made a really innovative set of FOA's. We also made sure not to do this and isolation. We reached out to colleagues across the department to ask what they were doing and what they needed and that gaps in making sure our work would not be duplicative. Some of those folks are in the room and we are grateful for all of their help.Two FOA's and three goals. Here are the links. I called the implementing one, the doers. I will give a little more detail on what we are asking them to do. We have a lot of evaluation but this is growing out of our work in comparative effectiveness. We want to understand how this works for whom and which different aspects work so we are commissioning through the grant mechanism and external evaluation of this project. Here are the three goals. The first is to to directly help primary care practices improve heart health along -- by using evidence about what we know. We know already a lot about heart health. We don't have to wait more -- we know Americans are not getting those services at. Not doing that is a one-time isolation campaign. Using this opportunity to go deeper with practices into their processes and their structure and culture about how they use evidence and do quality improvement. With the long-term goal of building capacity for quality improvement and the incorporation of new evidence going forward. The PCORE evidence here will probably change little on the other areas we need them to work in. The third area was trying to deepen our understanding about what works in delivering evidence into practice and getting it used. The grantees themselves are charged with a very robust internal evaluation and then the -- will provide an overarching external evaluation. The grants are on the street right now. They are proposals for three-year demonstration implementation projects. We will award eight of them. They are designed to be collaboratives. This is bringing together multiple stakeholders and communities to do this work and evaluated. Focusing on direct support to primary care practices -- that is aspirin for those at high risk, blood pressure control, cholesterol management and smoking cessation counseling and services.

The theory behind this is the quality improvement techniques, and there is an evidence base behind this, about how you help independent small offices c hange. Through a series of techniques such as practice assessment, you have to understand the practice about how they are doing. Expert consultation. Local peer learning. Continuous data and feedback and the glue we believe that brings us together is what we call practice facilitation which is a form of organizational coaching. Life change agents and practices working with them on an ongoing basis that many small and medium practices don't have the capacity to have alone. If done in partnership we believe it can make a d ifference.

We're building this initiative on work AHRQ has already done. Howard happens and what techniques work. We had a series of grants over the last three years in four innovative states, about how to build state-level collaboratives to do this kind of work. This work will accelerate or build on their work. We have done a lot of work on how Paul improvement happens and often doesn't happen in primary care. We have done a lot of the groundwork about practice facilitation so there are tools based on what innovators of already done so anybody who wants to get engaged can do this kind of work. We have set up in training curriculums for practice facilitation. If we had all this evidence, why are we doing this as a grant? The reason is we don't know the details if and how this kind of work works for sustainable capacity but -- how can we better disseminate and implement PCORE findings? That is what this set of FOA's were charged with answering. As you heard they will each work with a minimum of 250 primary care practices. There was a real commitment to work inequity that it just not be the cutting edge cutting-edge practices that are already innovators in doing this kind of work. Applications are going to be based on their ability to reach out to garden-variety practices, different practices of PHR adoption and recognizing some were not there yet and need to get their. Most importantly communities that serve underserved communities including those in inner city areas. When the critiques of this kind of work I heard some concerns about is to really understand this you have to have a control. If you're just doing the dissemination and spread work, you don't care about that anymore because we are doing this with an evaluation component. They could do a randomized controlled trial. We realize that is often not practical when you're trying to make trusted partnerships with people. We talked about some innovative methods of having control groups in addition to the potential of [Indiscernible].

This is a major investment, about 10% of AHRQ's budget. We want to show not only are we generating the evidence that we are making a difference in l ives. This initiative should touch over 9 million people. If you base this on what is currently being done and that we could improve care up to 80% of to not -- over 1 million Americans would have their heart health improved.

Measurement has been the challenge in this one and that is why resources of -- implementing grantees will be collecting and reporting measures about all 250 practices every three months throughout the intervention period and beyond. In the areas of a BCS -- when to do it in six measures and have those reported. Based on other work we highlighted them to potential measures of capacity for change that all -- and a minimum of six months later. That is the minimum data set.There internal evaluation, probably have the funds will go into that. Here are the five areas they will work in. -- what is happening with -- and how that changes things -- as well as a realistic work of the theory that going to come to us about what really happened and to detailed assessment of their implementation of their efforts. $120million over three years, $5 million per grantee. That is about 15 to $20,000 per healthcare professional. That is a large number that may not be large enough. Based upon earlier work we estimated a cost between $8000 and $12,000 in a practice to do a longitudinal quality improvement work given the additional money -- the grantees will be doing all of that extra evaluation.

The second half of this work is that external evaluation and a comprehensive and independent one. Again, a long list of things but looking across all eight grantees providing AHRQ and the larger public about information about how they are doing as the initiative rolls out, but a lot more work in comparing.We built in collaboration between the groups and we are funding that and we know that takes money. We are funding meetings to bring groups together to work on coordination and problem solving and we made sure the evaluation was a your longer. When the project stopped that is when we hoped to get the last data and to give them time to wrap it up. It is about a $14 million evaluation. The question is when were going to know anything about that. We design this projects so the earliest results will focus on change and the delivery of services should start coming out after the project begins. It is a little ambitious but I think we can do it. Interest about practice capacity will come out around two years and the final evaluation and the summit of work definitely within four years. Here is the timeline that went out about a month ago. Lots of good questions. We will be having a technical assistance: Nationally on A pril 24. This is a lot of thinking when you actually read the FOAs. It's about bringing collaboratives together so we gave them -- applications will come in July and we will go through the review of grants which will be to grants being awarded in early 2015. There is a whole other team making sure we do that and we are grateful to them as well.

What if we learn something? Where is AHRQ going with it? Part of the answer is right across from me in Patrick. We're recognizing sort of the Stage 3 box. This is no longer piloting. This is a early spread. The goal is the information could be packaged well enough our partners at CMS -- and even those in the private sector could take this information and use it for their own purposes when they want to know how we help primary care practices improve quality and incorporate new evidence? That is part of our plan for where this goes next for the national spread.

These are some potential questions for you. What do you want us to hear about when we think about the grantees and who they should be? What her ideas about things they may need that through work over the next few years that AHRQ should be developing? What are some of the risks and how can we mitigate against them and what are things we can do to ensure the success? If you want to talk about any of the other quiet of the priorities, feel free to use this time as well. Now you're at the top of the mountain and are cheering. You are now deemed ambassadors for AHRQ on this initiative.Please help us spread the word so people know to look for this information and use it.

David, thank you. I will start off with the first comment or question. A great visionary. Some risk obviously. There are models for this.Greater health better Cleveland brought together [I ndiscernible]. When you think about grantees, I would advise thinking about the organizational capacity history of his grantees. I don't have a clear sense of who you expect to be the applicant. This is a fair amount of resources and a relatively complex project with many practices. You literally going to be hiring people on the ground. We may have limited bandwidth in terms of how to engage with these resources. I would caution some counsel about getting grantees or organizers who have some history in management in relationship with this practices. Having worked in the quality program [Background Noise].Some careful thinking about going to people who are just starting up. This is some serious delivery that has to happen.

Sherry?

I know large employers are being asked by their health plans to put money in care coordination fees and pay for performance for primary care and each of the health plans have a different program but let's say they're going into small and medium practices and putting boots on the ground and helping them with identifying the report and helping them figure out how to do health IT. They are incorporating a lot of these things in a very timely way because they have to report back to their employers whether total cost of care has gone up or down. I am curious if we are incorporating some of those initiative into this.

Indeed FOA we ask the applicants to talk about what else is happening and show the Wells and how they're going to coordinate. One of our theories or what we would like to see happen is by focusing on the practice and not which payer. If we can get payers at the table behind them so they work together and have one relationship of the practice at a community level, it might increase the chance for all of these working well. At this point for asking them to talk to us about that and those who commit without any understanding of their initiatives from CMS and individual health plans from quality collectives in the community would do well here.

Amy, Jed and Harry.

Maybe I missed it but one of the things we're working on our large-scale quality improvement studies meaning PR not considered research, they are considered quality improvement because the evidence has been demonstrated and there's also the curl around the extra cost and burden around individual patients in terms of consent where might not be appropriate. If he And he thought about whether or not these projects or programs would be considered QI? I understand major healthcare systems are also going that route as well especially when they're looking at delivery system questions.

The grantees get to tell us and they have to do -- and they may be able to come in with an application that shows they are not. Because this has a large evaluation at least and research component to what is working and what is not, some of this we think is research and will meet that but it is the practice that will be consented, not the patients within the practice. That is our hope, but it is a great point. It is an ongoing national discussion about QI and r esearch. If you have other ideas, please share them.

I would be happy to share our experience in VA and written policies that have helped to the field to understand delineation between the two. Data?

A quick question or comment, to the current FOA's supplement or replace research capacity you mentioned from last year?

Supplement. Some of those were at one time, sort of both. The training grants are all ongoing.Some of the earlier -- anyway. Some of the earlier ones were one-time funding things running from two to four years.

Did AHRQ fund the evaluation of regional centers for meaningful use?

No, we did provide a lot of the technical assistance work but the evaluation was not done here.

You mentioned the coordination with other agencies [Indiscernible]. I saw an initial earlier evaluation of the effectiveness of those regional centers but I haven't seen anything subsequently and that was one of the largest practice changes we had seen.

Agreed. Dr.White stepped out, I could ask for the final evaluation but ONC is one of the partners.

I have to comment about the human subject things. It's one of the most confusing things within this building and as the -- is hopefully being revised, I hope you will weigh in and get involved with that conversation because it needs to improve if you're going to get this work done. My question is more technical. Focusing on things like the million hearts project. It occurs to me if you are doing something everyone else is working on two, everybody has a metric on this and you might learn less about what your implementation is which is what you're trying to do. You thought of doing something that is a little more specific or more isolated from all the other efforts all over the p lace. Almost everybody is involved with cardiac projects of this sort.

That's why we built in the control, to see if there is an additive effect. I hope you will continue to work and say in one of the areas -- one of the Mrs. Is children. Future initiatives and supporting quality improvement, -- and how we could move that as well.

You might want to pick something that is not so targeted. Maybe I look at that -- and see whether or not you were hitting it.

I were going to have confounded data.

The counterbalancing forces on that is how you motivate practices to change. The fact that this is aligned with P Q R S gives an incentive to the practice to accept this help other than the desire to give the best care they can.

Asthma and mammograms, -- I don't disagree with what you're doing same Mac.

Two things, user microphones, then I'm going to go to Mary and Jay and then I will cut it off at that point.

David, coming from a QIO, the scope of work we currently have and also continuing into the future as you probably know is very similar to what you just put out. Small and medium-sized practices with no support available to them, that is our charge. Also to focus on million hearts and disparities and so forth. I wonder along with everybody else, there is a lot of confounding and we know the Medicare advantage plans is also focusing on blood pressure control and lipid control.One of the considerations for selecting the grantees, we say for example in a state we have to target a certain number of providers edit this grantee were to target a separate set, that would stretch the dollars harder in terms of technical a ssistance. That would be a consideration in selection of the grantees.

Thank you very much for that. That is a good suggestion and we would definitely use it. The most weedy thing, the QI i n's are being called out in the new scope of work and the timing is challenging of who they are and who they will be is a little different. We ask people to be aware of that and work with it and propose partnerships. I think it grantee that will come in and here is the QIN and their plan will be a stronger application and any help you would like to do in helping us get the community to be aware and be partners, we would love to take you up on that.

Again to the question of selecting grantees, it strikes me as I look at your slides that there are at least two goals. One is let's see if we can't improve the health of the population being studied or part of this study, lowering blood pressure and cholesterol and stopping smoking, getting people to take baby aspirin.Another goal appears to be to try to understand what it takes, what is the knowledge you are going to create out of this that will lead to more rapid and broader diffusion of this? A lot of it has to do with what it really takes to implement the change on the ground. It seems to me if that is the case in selecting grantees, if the first goal was the only gold you would select those organizations with a proven capacity to do this because then you get the best results and the best population health improvement. If you're trying to study in addition what it really takes to go from one point to the next you would have to include some grantees with less of a track record. I would just say to your c omment, it seems to me selecting only those with a proven tracker is only going to give you one kind of result but not necessarily the other. You have to consider taking a risk in selection of some grantees that they may fall on their face that you would learn something from that failure which would then be applicable to later improvement.

Again, thank you all, and spread the word.

Thank you, David. Next is Jeff Brady who directs the Center for quality improvement patient safety is an internist by training and will provide information and look for your input on what we are doing around producing evidence and trying to improve the safety of care that is delivered.

Thank you and good morning. Time is short and I think I can be brief because our boss sort of covered the bulk. I am from a part of the country that speaks a little slower. I could've used your extra cup of coffee. I think I can move quickly and highlight some points. We are at a stage to preview this quickly, the staging patient safety and research where we have a fair amount of items along the delivery system timeline that Rick laid out. I think we very much feel the tension of where to invest resources further upstream generating patient safety research. What are the risks and hazards that really drive safety problems and how to address those, or implementation. I think this group is fairly familiar with some of the successes we have had at various points along that continuum including near the latter stage, and we will talk more about our cusp, but I will highlight that in a way I think resonates with the point about this tension aware we focus our research dollars.

The agenda here very much mirrors not only the discussion today but the agencies mission of producing research and getting that used at the local site and particular I think I will highlight the fact the local site is always at the forefront of our decisions and research and where we try to focus things but we are saying with help from federal partners held more national attention and through initiatives such as the partnership for patients sort of puts a booster rockets if you will on some of the work we have been doing. I think that has been a fairly helpful collaboration. Again our mission, these are the five components Rick mentioned within this overall priority about making healthcare safer. I won't go through all of these in detail. I have got a brief slide on e ach. Here we are highlighting specific areas of focus. There is a lot of underlying not only these areas of focus but patient safety research in general and we continue to support those areas. Things like simulation which is featuring prominently within one of these specific components of priority 2 and not only represented within the work to reduce harm associated with obstetrical care but again it is a very prominent feature. It is a prominent part of underlying all the patient safety? A bit of a drill down on the budget and safety. We have three major components of the patient safety portfolio. More than half of our focus healthcare associated p revention. We are working with the CDC and others including CMS. There is a departmental leadership with an actual action plan that is an important tool for the coordination. The historical part of the patient safety portfolio, the general patient safety risks and harms that continue to be present and essentially decreased relative to prior years but that is a little bit of a budget artifact because as Rick is described with this to initiative, these are 2015 budget request dollars. That is to move our focus more into other settings of care beyond the hospital, a particular focus on primary care nursing home but not exclusive to those. I think those are targets within that initiative. I will say a lot about the patient safety, -- the national resource I think continues to grow in its importance. I won't get into all the d etails, then I think we have our annual meeting here at the end of this month and we are always pleased to hear about the success that PSL's are getting across the country. This is no federal support directly to patient safety organizations. AHRQ supports the regulation of this program. This group knows very well about some of our more impactful projects within the patient safety portfolio. I want to see say a little more in a second about both of these. With this slide I want to point out with the first adverse event we address with the program again building on the work of Peter and extending that to as much of the country we could reach with the funds we had available, we have I think made a difference that is measurable and I think this is the example would look back to. I want to come back to that in the second. Team steps is a core component of patient safety and quality in general. We see persistent demand for this work and I think some of that is due in part to support from CMS and including it in scopes of work. I think that is a large explanation for the demand. I think the sheer fundamental value of this kind of work and the value this training is delivered in a way that is efficient and focused very pragmatic. We are pleased the investment continues to pay off, not only for the agency but also for the country.

I want to make the point that we think about the full spectrum from local level and what are we asking in trying to support with local providers and what they do every day. This is probably not readable from your seat but this is a daily goals worksheet that is one component in the toolkit with many different tools for use and organizations. The second item on this list is the patient's greatest safety list. This is a prominent focus and were trying to not only shift attention to this area but with subsequent questions to specifically address these problems. They are team -based way to set the foundation within an organization for enabling clinical groups to make that happen. Again we're Again we are keeping in mind these ultimately rollup two national results would talk about and we don't get to those results unless we keep an open mind. The point I want to make, this is a summary of our work in general that has two main components that essentially mirror the agency mission in generating evidence, that is the first bullet, basic patient safety research. The direction of our appropriations cover specifically directed us to continue to advance programs. I want to talk for a second about the way we're doing that. I think we are appropriately adapting this foundation for patient safety improvement in a way that is sensitive to not only the specific problems we are trying to address, but this is a major approach to addressing the capacity issue. These are unique problems but all the solutions are not u nique. What were doing with this approach to adapting CUSP is to change only the part that is necessary once the organization has invested and hopefully had success in using CUSP, and they only have to focus on adapting the parts that need to change and we don't have another initiative for every problem that faces the organization. It is a central part and one way in which we're hoping to address capacity with the efficiency and quality improvement. Think of this as everything that is the hospitals other than healthcare associated infections and we have some toolkits, what is in the progress of being revised in light of new evidence and that is the embolism t oolkit. The others we are looking at ways to help accelerate the use of these tools and apply the evidence as we have talked about throughout the course of the morning. Perinatal care, this is packaging many different components that have been shown to be helpful in addressing harm associated with obstetrical c are. I'm going to move quickly through these slides. We're getting a lot of attention with patient safety and medical liability program. This is a program in progress for some time. One of those examples is a communication and resolution program which I think is one of the most exciting pieces coming out of this work. Similar to our approach to not only generating the evidence as we do over the years with our program, now we are at the stage of let's package it in a way that it is actionable and can be used by different sites. The other point I failed to make but I think this group recognizes is one of our challenges is people generally understand they don't want patient safety problems occurring, either in their organization and not part of their own care. I think that is the simple fact and that has been a propellant inputting patient safety on the leading edge of quality. There is no argument about the badness of patient safety health problems. What we're seeing is more appreciation for what it takes to address those problems. It is not always a simple fix. That point is reflected in an actual weight and the research being produced by the folks we work with and grantees and contractors and that is actually a good representation of our national progress and progress in the field. This is a toolkit we are hopeful to get out as soon as possible.

[Captioners Transitioning] [Please hang up the phone so the new Captioner may dial in. Thank you.]

Tools that we produce a really one step towards implementation. Mailing out -- really out toolkits is not the answer. We are much beyond that. Whether we are supporting the project directly or working with partners to make sure they are integrated in CMS programs for example and others. I'm going to skip over this quickly. Sometimes what gets lost in how we're doing patient safety are all the different components underlying the science and safety and we continued to enforce advancement in all these different areas. This was to remind me inches we didn't talk about the partnership for patients we are clearly on a map for that. Again, I think foot we hope we're doing effectively is can shipping to all these national goals that have been articulated. I know we are overtime but the initial work in patient safety I think was focused on addressing the problem as an epidemic. Let's learn what we can, establish data systems, a lot of the focus on reporting that continues to be a challenge and I think one of the things that has come out of this initiative is a focus on measurement that I think really highlights highlight these ongoing challenges with standardization and Mike of standardization in many cases w here -- also highly rollup national data in a way that helps us know how we're doing. That has been no easy feat but I think we're making progress. I have more about that in another slide. With that, I just want to -- these are the very similar questions that I think there again reflect our discussion so far this morning. Balancing resources between various stages of delivery system improvement and one of the things we certainly do our best to keep track of emerging trends or activities that we need to be sensitive to and link with that is certainly something we'd like to hear from this group and in addition to stages along the research continuum generating evidence we have these other tensions just a tween the topics within patient safety and cross cut such as health care settings. Avenue to remind myself to address Henry's question about culture he competent, and culturally sensitive care and I've talked to this group before about the patient and family patient guide that's reflection that as we field -- peel the layers of the onion's of patient safety we realize these are not really silo problems that need sideload solutions. And patient and family engagement is one clear example that there are ways to effectively involve the patient and family not only patient safety but in quality and what providers we found really need in some cases are what are the actions apps and how can you move be, path to action even quicker so that toolkit is very much like other toolkits where it has specific kinds of tools that are ready for use in the hospital. Things like how do you Jered staff, a medical clinical staff to do shift change reports. What are the issues you anticipate encountering not only with patients but staff itself. Those are very practical pragmatic issues and how to solve them. Hopefully that gives you in a quick overview of looked at one of the other mountains in the mountain range and I definitely appreciate your feedback.

Could you go back to the question slide and I will go to purchase.

I was just wondering, being new to the party I'm not patient engagement family engagement, you share decision-making part of that and having informed consent is a process instead of just a piece of paper that you sign.

Absolutely thank you for the question. I think while it's not addressed as one of the main strategies that are highlighted in that tool, I think those things run throughout the entire toolkit so the short answer is yes. One of the biggest I think or a big value of that project is that within a single project of developing a toolkit we invested a Fairmont of effort early on reviewing the evidence so evidence revealed confident synthesis of the environmental scan Wally think it's not nice -- not something that all audiences would like to see if it clear example of how we looked at where the right spot were first patient and family engagement the consent is it runs throughout an underlying theme.

It sounds like Patty if you have not seen that toolkit or the toolkit or seen it recently we will send a link to it and be happy for your comments on it.

We're a little behind. Keep your questions as focused as possible.

A quick point is around healthcare setting in sponsored research in different segments of the care continuum and I'm thinking along with the group if we would shift our thinking to continuum of care search that moves with the patient or person versus segments of the continuum there so many as we all know overlapping points of drivers of what causes readmissions that will cause a person to come in and out of the hospital from their home and we really need research that's looking at it from a continuum of care focus. Second quick point is around human factors. You talk about it but I think the amount of research and that area is falling short of what we need. We need that to get a hold of vendors in the manufacturing of products that are contributing to air so I would like to see more of that.

Thank you for both of those comments. I will take the sequel Blasts. I think this patient safety learning laboratories that I did not go down and I think the human factors topic will be well represented within that upcoming -- those up coming grants. Those applications are and review now. The first question, absolutely. I think while this is an oversimplification, healthcare settings thought about in silos, absolutely not the case and I think we are fortunate to have tools that already reflect that and tools focused on readmissions and in particular the discharge process we have the tool recently released that specifically focuses on transitions from the neonatal trends -- Jerry care unit to home. What are the kind of special needs that patients and families have around that particular care scenario. So transitions feature prominently among the patient safety research that we supported and they think we will continue to support.

Thank you very much. Just a couple of quick points. I think this really points to the need for meaningful conversation and communication between provider and the patient and what is going on, what can I expect, what should I not expect, what should I be alert to and anything that falls outside of those categories should be raising flags. Which leads us to pick up on the informed consent is a method for education as well as the legal document the sick of the hospital but also discharge instructions. Are those clearly written. Do people understand what it means? Are there medication timings which can be very confusing and lead to all sorts of complications. There's a whole range of items in there that could be addressed and make it simple.

I'm going to go to Michael and then to Jane and then to Harry and then we will and at that point.

I first went to agree with Anne's comment. We have to figure out a way through transitions or to continue with the patient will walk through. I don't know what the appropriate level of balances but what I would suggest is it is overweight on design or discovery, excuse me and I say that hesitantly because there is so much that we don't know but one of the things that we do now is that much of the evidence about what works in practice doesn't happen in practice so I want to make a push for the implementation side and the practice facilitation stuff he talked about, David, is fantastic. I don't want to underscore the difficulty and challenge from going from hypothesis to getting it published but I would suggest that -- that that is easy compared to behavioral changes. I'm seeing a bit of that and it's one of the things I appreciate about the agency so thank you.

The second question, what are the emerging trends, I would suggest you look at when we make a fairly abrupt change in payment methodology, what are the safety implications. We've moved 20% of admissions to outpatient status with the midnight rule. I know you haven't heard anything about this. [ Laughter ]

We are skipping all kinds of processes in discharge planning that have been established for over a decade to improve care or prevent safety events really in the first 24 to 48 hours and yet it's done Mike that. The second example would be with Medicare advantage approaching 40% of all Medicare beneficiaries the normal cadence of care planning is disrupted you are on a 24 hour clock now suddenly to be approve a skill day and families or put in and mom's coming home tomorrow environment where's those protections and required share decision-making that are mandated just don't apply in the Medicare advantage world. Those are two examples that the emerging trend is that we change payment methodology very rapidly. It has unknown effects on safety and we're going to be in catch-up mode. Really great comments. First about I create with what Mike said about implementation and the experiment we are running by changing payments, if we don't study that carefully we are idiots. We never get to do this kind of experiment since it was done 30 years ago my point was about you're making lots of toolkit and I love that idea but I want to hear more about and I think the main question you should be asking is how do we get this into changing healthcare? What's the translation in practice? A couple of years ago some of you remember a fabulous presentation Illinois about that error handling not just malpractice litigation for taking the money inhumanity and putting it back into the process and doing it in a better way. There were a lot of people seem to be picking it up as organizations and can you give me or us a report now about that translation. You mentioned some of the toolkit of how far did it spread? What's it impact because it is such an important contribution you make to so many dimensions of medicine.

I think I moved over little bit at the two best examples if I'm understanding your example, the two best examples we have on the patient safety research arena are really teams steps. As I said --

-- I'm actually asking about a specific project the one that was handling the malpractice in Illinois.

[ indiscernible - Multiple Speakers ]

Could you just talk about that one because that would be a great case study.

I am from New York but I will go quickly. This is really an interesting example and we've been putting energy in your previous that of grants into trying to get this implemented in more settings. There was an article in health affairs recently about attempts in New York that actually have not gone so well. It's been difficult to figure out in a bunch of institutions that don't have strong champions and how to make this work. We have a project that we've expanded actually since I've come here in which we are going to be working it tried to implement this first -- first in 14 places. You know the University of Illinois, a great champion, often possible when you've got someone strongly behind who is visionary to get it done and then the top bastions are how do you do this more broadly and we're working now exactly on that.

[ Indiscernible - low audio ]

I can't resist to jump into gams and say I think this is the perfect example of a of a misunderstanding in some areas about the complexity of sort of implementing a solution like this. It's very healing, we saw this with cost and we're seeing this now where the intervention or the solution is reduced to the checklist and in this case it's reduced to an apology. We know from tech -- Tim McDonald has spoken to this group to couple the full flavor and challenges of that project. Just one I will mention as an example. Before the apology can or should happen the organization really needs to have the capacity to understand what happened. Is this an appropriate situation for an apology or not? Diseases that sounds of course that's not always easy and so that again what I was trying to quickly capture is an appreciation for the complexity. I don't think we are at the complete states that we need to be at to really drive all the change that's necessary but I see more and more appreciation for lots of other elements like a sort of not charging a patient that's been harmed for ongoing care, that's no trivial operational thing to tackle within an organization. Tim has talked about a special card that they get so there's a lot that surrounds what people focus on as the intervention and the apology. There's a lot of ground that.

Well said. We are we to break at this point. I'm going to ask everybody to be back at five minutes of the hour. We have presenters. Would that be okay? We will reconvene at five of. Thank you.

[ Event on break. Will return atF0 [ Event on break. Will return at 10:55 a.m. EST. ]

I'm delighted to introduce Patrick Conway. Patrick is the deputy administrator for an efficient and quality and the chief medical officer for CMS. If both the director of the center for clinical standards and quality and the director of the Center for Medicare Medicaid innovation so to small jobs. When I first got to asking Patrick briefly work for me and quickly as appeared.

It was already planned.

And to spend a delight in the job. Working really closely with Patrick and thank you very much for taking time and we look forward to hearing about innovations and hopefully some transformations.

Thank you, Rick. It's great to be here. I promised my departure before, it's great to work with you again and it just a few things before jumping. It's always great to be it AHRQ and I was a White house fellow at one point and had an office on the third floor. It's near and dear to my heart and I was in AHRQ funded research when I went back to Cincinnati so you can now claim me as you want as one of your funded researchers and then now being back in federal government I think the collaboration between CMS which I will talk on a few times in the presentation is critical and they do think AHRQ it's essential including the evidence-based and system transformation so I will try to weave that in throughout.

A few other things. I have now been back in federal adjournment about three years. If you had asked me if I'd ever been in federal government a while ago we -- before med school I would've said no way. It's my second tour of duty. The chief medical officer at CMS for three years. It's like in dog years and it's been 21. Three years and I earned -- learned it's longer than the average tenure and if I make it five years I will be the longest serving officer ever and that's my goal to last five years. On the cc SQ side which I won't talk a lot about today but I think there's a lot of great coverage with AHRQ AHRQ and evidence-based underlying AHRQ conditions of participation AHRQ welding safety standards are Q-letter I work in CCSQ focused on quality improvement and just an array of connections and quality measurement work were we work very closely benefit from AHRQ on the science quality measurement and I will focus more today come a better quality measurement but mainly, innovation center. I'm quick to talk about some of our goals in early results and quality measurement and I will leave I heard the sidebar making sure there's plenty of discussion. I do remember that from sitting in the next meeting subtitling to give time for discussion. This next slide, this group knows this. Our current state is often producer centered on sustainable fragment care and we really want to work with the public and private sector to get a future state that is more people centered, outcomes driven and sustainable coordinated did care. On the bottom right of this slide this is certainly not all the levers but we certainly a policy levers within just payment levers such as value based purchasing, episode based payments, medical homes, data transparency, I thought it was quite be asked about the physician data release observation, whatever you want to talk about today. But really an array of levers that we are trying to utilize to help catalyze transformation. I was actually Michigan yesterday talking to a group of physicians and hospitals in Michigan that are doing transformation work. In the public and private sectors there are two groups I call out directly. First is patient think consumers and how we engage patients and consumers and the transformation effort into his clinicians. Halloween kids condition -- clinicians and front-line clinicians providing care and the transformation effort and I will come back to that.

This is a paper we work -- Gemma said we could only have two authors. Carolyn's and author and in an example of mentorship Carolyn offered to take her self off this mentorship and leave -- and leave Denise and I on. Many of you may have seen this. Outcomes research and who benefits from what care and the how of healthcare delivery and how to we reliably do it in the right setting at the right time. I know a number of you to this work and health systems and are used to do this work in children's h ospital. I scale and spread effective interventions. I think Rick said this earlier but it really do think that's the key question right now. We've had enough examples of success of the real question is now how do you scale that -- scale that success across the nation. Carol up -- Carolyn and I wrote a follow-up. Most of my family members are small box and I hear a lot from them about how programs are broken. My sisters a solo practitioner in Cincinnati and they said what would this look like to truly help those small practices and whatever setting transform anything quality measurements that matters is critical. I think line payment incentives to matter. Have the benefit of being in a health system that moved from fee-for-service to accountable care. In a real way I will give you one example. Sorry, I practice as a pediatric medicine. I don't have enough primary care examples from my own Michael practice so I apologize. I distinctly remember I facilitated our presentations to our CO we had our neonatal chief and of the hospital medicine chief and ran our -- many of our quality program say you know Patrick when we worked on preterm births and we started at about three or four years ago, we did really welcome we decreased preterm birth by 50%. Gets what. We get all neonatal I missed -- admissions and are Nick you is not full and all our financials are r ed. And I'm scared the CEOs going to be upset. The CO said terrific, great work in our went to migrate our contracts to reward this behavior. We need systems in place and whatever your population that are held up better care intervention is is truly rewarding financially as well. Competitive factors and evidence available I still think this is a struggle. P court I think will help fill this gap. I take care of kids with multiple chronic conditions in the hospital and I will tell you the evidence-based there's clicking I routinely have conversations with parents that are disappointing and health information technology is a critical and quality improvement collaboratives and training clinicians in multidisciplinary teams I think I can say this, I'm not asking anyone to lobby Congress but I will tell you one was a white house fellow you could make an argument that AHRQ needs to be a billion-dollar plus agency because the amount of investment you need and transformation, is this okay to say? I'm not lobbying I'm not saying -- as the federal employee I can't actively ask and the reason I say that is just look at this sheet and this one slide which is many of the things that AHRQ does and as a nation we could easily invest over $1 billion in multiple areas and still not actually be where we need to be. It really cause out the importance of AHRQ in the work that AHRQ does. Just an early example and hopefully that was okay. I didn't ask anybody to lobby.

Can I ask them to lobby?

You can.

Lobby.

[ Laughter ]

That was good.

Early example results as well quick to talk a bit about now and I'm quick to call out where I think HR Qs played a role. This is lowest cost growth and lower than GDP the last couple of years, our own CMS actuary which is a conservative group says that part of this is fundamental transformation in the delivery system and obviously part of it is a debate -- debate about what portion of the economy but our actuary that said that part of this is shifts. This is Medicare readmission rate and I have this control chart on my office wall and it keeps going down in this really is -- AHRQ has been critical in this work in partnership for patient and other work in 2012 we made a large commitment in the key point here is we invested in quality improvement to our quality improvement organizations, through community-based care transition program so many others and we did payment incentives on readmissions as well which I see him now colleagues and delivery systems enable them to convince their CMO to have larger investment and care coordination. We are now heading towards 17%. That's over 150,000 beneficiaries. We do a rolling 12 month average home and help the observe going back to the hospital. Actually published a JAMA paper. We published a JAMA paper a few weeks ago at a population level admissions plus observations and positive return to hospital are down heading towards seven% per 1000 Medicare beneficiaries so that's just overall admissions and observations. Within dirty days of discharge is down 11% nationally. So major reductions across the nation. Some communities by the way you didn't publish this data, some communities are really significantly better than others, not surprisingly. Some communities and states we could study why that is but some communities are driving much better results than others. This slide -- I have to think about this. We are now down to 45%. This is a little outdated and I apologize. Center line infections down 45% from baseline. To bring in a clinical example, I remember as a resident and neonatal that align infection in the attending at the time thing these things just happen they're not preventable which was the thinking. We now East on work funded by AHRQ now they are preventable, proof digital larger scale in estate and now skilled it nationally and are driving down a national rate that matters to patients and families. We need more of these types of examples. This is a very powerful example of being evidence to the bedside in accredited providers across the nation. I should ask if I can show this slide. I've been starting to show the slide. The key here is estimated and we are working with Rick I'm getting a final number that we would put out. If you look at the AHRQ national scorecard which is really a gold standard data is source, this is the second time I've such -- I've shown this slide, eliminator data show nine% reduction in healthcare acquired conditions across all measures. This, the preliminary estimate is up to 15,000 lives sees them a hundreds of thousands of injuries and we're quick to finalize those estimates and have a formal release. This point being major improvements in patient safety. The one below our partnership for patients are public. Ventilator associated pneumonia down 55% early elective deliveries down 50%. A major risk factor for the term births, major improvements in patient safety and this work really is collaboratives with AHRQ and others. This is the partnership for patient hospital engagement networks. With that over 3500 hospitals now through December 2013 that are engaged in reporting five or more areas of harm. We now have it was 64% in S eptember, over two thirds of hospitals are improving significantly and five or more areas of harm and we define significantly as a 30 res% reduction and really Germanic results in terms of improvement I'm back in February or March we challenged the team and this is based on improvement work I did in Cincinnati that that identify best in class and tell everybody what it is and challenge them to reach it. This was three% of hospitals thought was best in class. Picture measure. 33% of hospitals achieving what we thought was best in class and five or more you areas of harm. I've been involved with a number of improvement networks and I think certainly this will could include -- improve and there's variability and we should study that but I think overall really moving a national Nido -- needle and the credit goes to Don and others driving and accelerating likely in the right direction.

I showed this slide for two reasons. One the main point of this slide if you look at 2009 at 16% of beneficiaries and in 201,455% am -- we tried significant financial incentives to our ratings that we saw so -- we've also done interesting costs that we should work more on archive. We did a randomized sample letter to bent -- to beneficiaries that said you happen to be in a three-star or less plan and in your market here the four and five star plans and here's how much they c ost. The switch rate was unbelievably higher than the regular switch rate of Medicare advantage of fish areas with -- it's a gentle behavioral knowledge and said here's your plan and other plans and the quality ratings and the cost and they would be higher quality and lower cost in your market. We did get some feedback on that knowledge from some health plans as well but we really viewed it as we're just empowering patients with information value based purchasing. We have good discussions on value based purchasing and you can tell me if you agree with the principles. I think we have to define that and goal not the process for achieving it. I think there's evidence and examples of the ammonia measure for example where we got ahead of the end of it -- the evidence and defining a measure. So defined that and goal not the process and all providers incentives must be aligned. For readmissions and admissions, postacute hospital etc. so it's not just hospital issued to state the obvious. The right measures must be developed and a rapid cycle. Of give you the cholesterol measure right now. Changing guidelines and can't speak for what that agency would put in rulemaking but real issues around as evidenced change how do you change that Mr. Quick enough. If you can't do suspended for year? How do you address that issue. I will say since I have started CMS and this is publicly known, we've generally suspended measures. We had to make a choice previously and keep that measure that's not evidence-based versus suspended until we have the better evidence measure and we have in the past. Actively support quality improvement and clinical community and patient actively engaged. I'm going to shift and I'm from Texas. Talk fast. Sorry. Accountable care organizations. This is the CMO my model and the other major models out currently. I'm putting them in buckets on the slide and I will talk to a few the buckets. Accountable care organizations calmly we now have 350 programs serving over 5 million beneficiaries so MedPAC and it's awards are discussing fee-for-service market and the health plan market and I think that's actually an interesting construct and the way one could think about it. And our pioneer program generated care savings and overall cost growth rate was 0.3% and on the quality side outperformed public benchmarks and 15 out of 15. Really good early promising r esults. We've got some plate and some the pioneers migrated to SSP. It was designed that way. The point was to have a pathway where providers could move among ACO tracks because you actually -- it's not a good idea to tell provider here's your track for the next five years and you have no ability to switch. That the hard conversation to have. It was designed so providers could migrate and the actuary estimated 11 and only nine did. The program we view as very successful trip I don't have numbers to share yet but we watched data quarterly now which is a very different model than running a CMS demo for five years in doing an evaluation the kids published three years clear -- later about what started [ Indiscernible ]. The quarterly data is looking good. We are monitoring data quarterly and we also do formal evaluation then I think we are actually working with AHRQ closely about rapid evaluation methods and how you think about evaluations differently. Underpayments. These are for acute them post acute care. Essentially various iterations on the slide. We now have 41,000 hospitals and Keeper visors participating in various iterations. Major interest in bringing down cost and improving quality. 1 million hearts goal is to prevent 1 million hearts and strokes, major initiative and we have one that was around $1 billion and we have to that were under review for state innovation models I think it's quite interesting so here we have states that they want to redesign care me state to get better healthcare lower cost and here's the policy levers I would pull. We had around one and we funded 19 designed states and six testing states just to give you a brief flavor, I can't list them all, or none is testing coordinated did care organizations and the governors written about Arkansas is testing primary care medical homes and bundled payments and Joe? Joe's here? Joe is doing traffic work. We hope in the next month or so we're going to announce where we fund more states to move in the testing mode or even states, Virginia did a public private partnership and had a plan how they wanted to transform the state of Virginia. This is very promising work on the state level and as you know you can test things and state and communities that you can't test on the federal level. We've got our Medicaid focus demos and our dual eligible focused demos as well. I will finish with plenty of time for discussion. I started on the innovation center in June. I'm 10 months or so and now and I actually when I first started we did a number of things, we've got our strategic plan out and out the finalized staffing plan but the strategic thing we did over the summer which I will talk a bit about as a I worked with Kinsey consulting 20 years ago. My brother is still there. I went back to colleague and I said I just inherited this organization that has 10 billion over 10 years and like private it -- I've equity. What would they do. I got a lot of advice. The high level advice was analyze data, analyze your portfolio and make a diverse array of investment that you think will have the likelihood for the most impact and use decision analysis. And that led to some possible model concepts that we talked about publicly that we have under development in your request for information on some of these and it could be more after this and but the general copy out. These are concepts and they go through development process which may or may not pan out. We have outpatient models and development. Everything from oncology to procedural or surgical based specialty models so bundles on the outpatient setting for example to complex specialty care. I've got a lot of input from the physician committee on these models which is been helpful. I've heard a lot that we should consider ending guess -- an investment like partnership for patients but an outpatient setting. Do some of this work through the QIO program -- QIO program. But not unlimited funding and so this could potentially be working with ambulatory clinicians and physicians to move them through stages to managing quality and population and ultimately being successful and approved quality and lower cost. I share a lot talking to physician clinician groups, I am at 20% practice. 10 docs, five, nurse practitioners. I want to transform but I've got to be honest with you. I've got a hospital that wants to buy me up and down the street it's coming with the check and you guys keep coming at me with all these different requirements of things to do and I want to do about -- do well by my patients and I want to stay in private practice and I don't know how to get there. How do you support practices in transformation. What does that look like. Initially the evidence here, AHRQ has laid a strong foundation about what works and what doesn't but we will need to continued to learn what works and what doesn't. Health player innovation is a huge part of our market. You could have a model that essentially allows the health plan to innovate in various ways with value-based insurance design or networks are other ways. I've heard recently that maybe we have rules that are restricting ability but health plan innovation. One it's not I'm here is we already launched it didn't did not get picked up in the press which disappoints me is last week or the week before we announced a model for the first time ever were Medicare will pay for hospice and palliative care service is the same time is curative care services. It took a while to get this model through the process. I think it's a major step forward. It just the conversation that you have with the patient or family that now you're not making a choice between curative and palliative care, you can actually have them at the same time. There's pretty strong evidence that it's likely to save dollars plus have better quality so the model I'm very excited about. Consumer incentives. We do more in terms of consumer engagement -- engagements but we've got a few innovation awards but not really a portfolio. He feels version 2.0 what we've heard from people is we would like to essentially we have shared savings models and health plans with that pioneers that starts the respective alignment but how can I then organization move to more of a for example. Type model where you're telling me more prospectively what I patient populations -- population is and what the payments are likely to be and I managed patient population. We also hear a lot on Medicaid and how can we bring it to the ACO concept. The last one I will mention here which is related and I will touch on at the end as we've heard communities around, ball health community construct that essentially we invested in states and we've got provider based ACO's and what we have done is have it targeted funding stream that could go to communities on the cities, counties, smaller geographic areas that want to work with their providers of public health system and they are sort of purveyors of health in that community and get better health and better care at lower cost. The people think similar to state innovation we can make a valid test relatively low catalytic investment that will drive change we're looking at that as well. Post acute care space we're looking at value based purchasing and other models. So future while the measure improvement accountability. We need to write together more. I've got all these papers with Caroline. We will start. With Caroline and [ Indiscernible ] we wrote a paper in 2013 June and the future of quality measurement accountability and shifting gears. We're talking about quality measures and need to transition away from settings with Nero snapshots and reorient measures around patient centered outcomes that span across settings. It doesn't mean there's not a role for processor structured measures, there is. Québec about the will work folio. I didn't so this time but we is the national quality strategy where we worked with AHRQ to translate into a CMS quality strategy that's no public and I'm our website to six measure areas that align with that of the strategy and all of our programs we look at those areas and we save what measures in these areas are topped out that we need to remove. We've done a lot of that. We have gaps? Where do we need to fill in more measures and we think about for value based purchasing programs what is the right need for the various areas so I think similarly sort of interesting internal thinking driving alignment of measures and also thinking about how could measures most powerfully drive improvement. We think a lot about capturing measures at three main levels. At a population community level and it of that group and individual clinician and patient. For example blood pressure control come out what is the blood pressure control for this community and having this same measure, another good example because the evidence be be changing or a group of clinicians and patients they care for and down to that individual patient and condition and why we measure improvement? I can't tell you there L most common comment that is thank you for writing that that we measure for improvement because that's the point but it seems obvious to me but it's not obvious to everyone and these are my last two slides. This was a paper in the New England Journal and the hardest 1200 words ever written in my life. The opportunities and challenges with the for lifelong health care system. Payers, I will give you data points. Everett 65-year-old that enters Medicare will be insured by Medicare for more than 15 years. Medicaid can be insured for very long periods of time. We should arguably care about health trajectories overtime and that we know they are modifiable and also the pediatrician, the early years of life with that how would you think about this differently of the health system so we talked about horizontally integrated health integrated social services that promote health. There's a lot in that sentence. What could argue if we executed on that sentence our health outcomes would be much better in this country. Consumer incentives including v alue-based insurance design and testing things like warrantees and bundles which I alluded to in innovation Center we are testing those types of activities and make sure we're measuring health outcomes and improvement over time. Community health investments I talked about this and that community, ball health systems. We wrote about this a year ago and how would you invest in c ommunities. It's hard financial model. Thinking about what is sustainable is arguably one of the hardest pieces of this but we are time to think about how one might structure that to be useful and sustainable and what can we do together? I only to cap my time, I think we have to focus on Ettore health, better care and lower cost of health system improvement. Not surprisingly I was a research person so I'm probably a little biased but I think it's critical and I think we still broadly underinvested in these areas we need to have the right evidence available and we need to know how to implement it reliably. There's a huge amount of learning give it still needs to take place. I know our kids made investments and review those investment as in that -- is beneficial. 2007 I wrote a strategy for the arcs focus on quality measures of the future. It's probably up there in some drawer.

I'm happy to get it out. Transparency of data on quality and cost so we think transparency is important in terms of driving quality cost and price. Aligning public and private sector issues. We do a lot of work trying to align with I've talked plans, with employers of purchasers and I didn't say this but this literally is markets where we went in with payers and paid care management fees try to transform care with quality measures etc. I do think we need to keep testing these and scale successes rapidly. This is one of our troop court challenges including the way we think about evaluation. There's one method of evaluation that still thinks about it like a randomized trial or drug try out. 195% confident interval and I one randomized designed. There's an alternative view that says this is complex interventions and health system transformation arena and it should not be thought of as an evaluation standpoint at the drug a Coke versus the drug C trial. This is still an area that actually gets debate -- debated. I think the science around that in the rationale couple and training future clinicians and scientists and multi-display dairy research, I don't even know what percentage goes where. I think the metrics [ Indiscernible ]. Relentless pursuit of approving health outcomes. I want to thank AHRQ and Rick for the work that you do and think -- thank you to the national advisory committee and look forward to the discussion.

I think there's going to be a lot of questions. I will make one comment and go to a meeting and then Harry. You touched upon population health and I think both you and AHRQ are making significant investments we have measures an endorsement and development and a group working on creating a family of measures is part of the map and another work -- group working on community it limitation. One suggestion I would make is I think there's a lot of discussion and people are excited and trying to figure out when will this get real and how will this get real in-depth one -- at what point does this enter policy world in some way in a way to change behavior. When I've been asked that question my response is been I don't know but in the world of ACO's maybe this is a real 1st and issue think about refresh I hope you can consider taking population health in those programs to the next step.

Can I say back and I think that's right. A field version two-point on I will put in their the concept of, ball health communities that you want to measures and I will also put out there and I said this publicly and other forms, one could imagine a framework wherefore work core value based purchasing programs, I talked about three levels of measurement, you could've community level measurement that's a piece of value based purchasing and there's pros and cons and we would get this the kind of attribution it and not really changing my community and the pro, you could just start with feedback and eventually five%. I think the pro- would be a strong message that you're part of the community it's not as controllable as the patient goes through your drawers -- doors but you may have some role in driving community yourself.

I was down in Atlanta a few weeks ago and everybody knows the money we spend in healthcare, two% or maybe three that some public health has been declining over the years and many people the room have been working for long time to figure out how to change that on the thought that if we are focused and improving health status in some different balance their might be helpful in this kind of conversation I think is the best hope I've seen in 30 years that I've been doing that we might actually make progress but still long way to get there.

Amy?

I really enjoyed your presentation and I have to say we're glad to have Carolyn at the VA should so she can help us write more papers as well. It's always good to have productive members on your team. I wanted to talk about and get your thoughts about a problem bring my research cannot and I've done research on implementation of collaborative care models and Michigan and our system in Colorado and we have a separate problem in Michigan in terms of really the number one problem and a lot of these ACO's is what to do with people with because they are the highest cost individuals with mental disorders, not just a serious mental illness and don't get labeled and therefore don't get the benefits. I really like the idea of the concept of bundled payments that currently in the state of Michigan we still have a separate budget for mental health and everyone is fighting over insurance and I'm wondering if you have any thoughts about how these value based insurance designs and how we can think about bundled payments that can maybe be sending a signal to the states from the top of how we have to be dealing with this population in him or integrated way to begin with so that no one at the end is fighting over these populations in terms of money to help them.

Anomie, it's a great question. I will give some thoughts but I don't know if there's easy answers. I think one on the state innovation model we are encouraging states to try to break down those budgetary silos and the way they think about their health budget. I think some successfully and some more challenging. And the Medicaid space we've made what we called Medicaid accelerated investments. We're planning whether to do more of those but how do you get support to Medicaid for grams that want to transform into care integration and think about their data and analytics but aren't sure how to get there. AHRQ supports the medical doctors learning network check been a part of, the mental and integration of mental disorders I think is critical issue that even our ACO programs and sales are ones that are even just now sort of tackling which you could argue should've happened earlier. I think we will learn from them collaboratively tackling together. We have people here the probably no more about this than I do. And probably you, Amy but those are a few my thoughts. I think it's one that we're going to continue to work on throughout the models, if you will.

Harry and then Jane?

First about the billion is a should, that was the term I put together about 15 years ago. The rest of the story as I was telling Congress I don't think and I don't necessarily think that AHRQ should be larger than the NAH and I don't know why it should be strong smaller either. You are demonstrating that and CMS and it's really exciting to hear you're up to. I want to ask a question about A CO's but I have to complement to on that change in hospice care that it's fundamentally important. Is a conflict about the reimbursement package and about the way you have people that are supposed to die within six months and suddenly they need a transfusion. I don't have to say more. It was fundamental and it also bring something that Mary and I were talking about last night. The VNA in the always this system that you have and you're talking about you would suspend quality measures on an evidence-based or maybe worse. I would just suspended all. That awaits us is a detriment to care because people are filling this out and stuff talking to their patients. That's just my clinicians point of view all going to ACO's. Oasis, we just talk after. We try to illuminate some data elements. Try to delineate them from quality measures but we should talk after.

It became an interesting circular battle.

I'm happy to join that conversation expect Kevin Shulman wrote an interesting argument a few years ago and JAMA where he talked about ACO's in some ways positive in rural areas or underserved areas this vertical integration that would run rampant in pretty soon it would have a detrimental impact on the triple aim. Are you and position in the position to be able to evaluate that because it's an important issue.

I know there's concerns and comments on this as well. We are evaluating -- let me answer that a few ways. One, I will break the question apart. Which ACO's are successful there was a real concern will be all sort of urban large etc. or will it all be physician-based hospital-based? It ended up eating a pretty broad mix of what I will called structural types. Some physician-based and some hospital some urban several some small some large. We tried to dig into the stop that actually think it's more organizational culture that sort of structural type so what the team things in their hypothesis and experience with population health management, data analytics, cultural improvement etc. to get your point of integration in the rural areas are trying to evaluate unintended consequences and things like are people consolidating just to read prices for example and therefore becomes more costly so monitoring that international level and drill down to states and regional levels and then you get to an interesting step of questions as to what if you do if you find it? We won't solve that right now. Actually it's not as easily resolvable as you might think? I guess we worry about positions and are monitoring for them. I think it's an area we will have to continually adjust and think about.

Okay.

Patrick, again on ACO version two, it seems to be the popular topic right now. He talked about trying to more fit in the direction of more risk assumption and I agree and I think that's a good direction. As you move in that direction the issue of attribution becomes more important and mechanisms within the existing so security act to try to get the beneficiaries to receive as much care as possible from the delivery system and I just wondered along those lines are you thinking about either issues of benefits or beneficiary incentives number one or this concept that's been batted about a little bit called the soft lock in which would be the member taking the Pledge of Allegiance to the delivery system for period of year without any legal responsibility but changing the psychology of the relationship.

We don't call it a soft lock in but let me describe the concept. We are talking about what I call attestation meaning of beneficiary says this is my primary care provider and ACO and therefore we say okay you are aligned in the provider knows that the beneficiary is in and in for period of time which is not part of pioneer now but we are looking at that, which would get where you want to go with the beneficiary and the provider now this person has attested and said I am in this ACO and we would on our and has said they get put out of your ACO be part of your turn. We keep them in because they've attested. What we have heard of the pros of that approach is that I know the beneficiary is in my CO and I will actively manage the more. We've also looked at things like lower cost and perspective alignment etc. and with our benchmarking methodologies were looking at making the more simple and understandable work we also have looked at things and potentially have allowable lower cost sharing so we can't have the opposite higher cost sharing but one reading of the statute would now lower cost staring -- sharing same within accountable share -- up accountable care organization in a way that is beneficial to the beneficiary within the high-value network.

I think I will go to Jane next and then Henry.

Okay. Just saying with that one point. I know that the technical aspects of solving the truck -- problem of attribution gets technical squared very quickly but it makes no sense. Medicare advantage almost 40% of the population today is allowed to do it. And ACO's are not. It's a strategic problem that agency should solve and then go to the detail. Tyvon solvent from the detail up I would suggest is the rabbit hole. The second thing I wanted to comment on is similar in that many of this because today have struggled with how to really help practice midsize and small practices and one of the reasons in your example that the choices seem to be for your sister and others become employed by health system or I don't know what I'm the only way we are allowed to help them is by employing them and again and artificially created rule that comes out of legitimate fraud concerns there would be other ways to solve that that are nearly -- I'm not nearly so onerous. At 100 PCP or 300% shall us I would rather not employ them. These are MGM eight numbers 301 employee a surgeon and I don't of your numbers are similar but these have been widely reported. It's not like health systems refer to claimant as a form of alignment it's just we are limited by lot to many other fairly rational ways that we could help doctors and the department of justice test for A CO's pretty narrow and clinical integration is pretty narrow.

Let me take the first one first. I think you very much could start from a high-level policy principles of beneficiary choice matters, if the beneficiary chooses to be in ACO we will keep that beneficiary in the ACO for period of time in it's mutually beneficial. I value policy principle without saying what we will put in rulemaking. We have said publicly we are updating the rules now. I think it's probably a longer off-line conversation on some of the DOJ OIT prayer matters and within the innovation models we are able to wave AHRQ bundles another ACO program that is using innovation. Obviously in the core medication -- Medicare programs the questionnaire which are statutory and how are they interpreted and if you don't have the waiver with the wording that we as an agency may not be able to wave but I think we don't have the waiver authority we have an interesting [ Indiscernible ]. I think it's a valid point on some of these and how to we think about the parameters on some of these rules and how to we make sure they are beneficial to patient. Henry?

I would actually like to peel back to the future quality measurements for improvement accountability and look at let for and capture measurement of three main levels, individual clinicians group facility and population community and for me the focus is often sometimes on the last. I wanted to point out a really great opportunity to align the work of CMS with AHRQ and also with PICOR populations especially realizing being attention to the press release even yesterday from HHS announcing an update on Medicare information on individuals in same-sex marriages and whatnot. We are going to see many more enrollees were members of the LG BT communities anticipate and Medicare and health quality and outcomes will be important to measure and a great way to look at this target population.

I think it's a great point. We are also by the way looking at all of the clinical standards and surveyor guidance and what altar we need to adjust to make sure that we address all the associated issues.

I see no more questions from the group. I would just make one comment. I know on this slide, Patrick UXO it -- accidentally omitted the bullet the demographic adjustment for of these measures I know you feel passionate about that. With that said, a little bit inside baseball here are there any other questions from the committee?

Patrick we're covering a lot of territory with you but I don't know if you can comment on the interest in population-based reimbursement or care for Medicare beneficiaries in the interest of the northern New England group or the health care collaborative group and that topic in general to see some movement along those lines?

I do. Occluding we are building our IT systems so we can administer which is by the way not an easy lift.

Can you describe this a little bit more?

Don't understand the question.

Let you try and David you can tell me that answers the question. And the -- I'll use a couple examples. In the comparable care organization they have the option to move to population-based payments were literally they may get 50% and you've got an a likely aligned population we give them a monthly check for 50% which is basically up population-based payment. Without these models to date there some sort of reconciliation at the end based on the fee-for-service claims and you could imagine a model someday that there's not a reconciliation and it looks more like a health plan patient payment or population-based payment. Then you get the provider ministered of claim or CMS. I don't know how far you want to go on this but we're thinking about those issues and on it primary care space some of her other medical homes are making population-based payment to primary care target -- providers and trying to move them away from fee-for-service to a model where they are improving quality and lower costs and again population-based team and set of fee-for-service. Some of our specialty models even some of the and colleges have said we think you should go p opulation-based payment and a shared savings model and we will figure out within the drugs and all the classes of spending how to save significant amounts of dollars and get that are quality. Your fee-for-service is driving care that's worst -- we're said higher cost.

David, does that start to answer your question?

Yes. That is what I wanted you to comment on. This is of interest a lot of organizations including mine.

Rate. Thanks, David. Other questions either from our members on the phone or in the room?

Thank you very much, Patrick. Appreciate it.

Patrick, thank you very much. Clearly you simulated a lot of interesting -- stimulated an interesting discussion. We have Michael Harrison on the agenda to talk about what AHRQ is doing around delivery system innovation. Given the time and that this is a topic that I don't want to short we will probably bring this back at the next meeting. Just one comment, much of what Patrick talked about, not quite all but most of the innovation centered work is around changing payment models. There are some pieces that are closer to trying to directly change how care is delivered but for the most part the lever is around cleaning. Our work is much more around delivered how care is actually delivered and trying to develop evidence and tools to change that and this worker I think -- both parts are needed. Getting the incentives right is important but not sufficient if no one knows what to do. So we're working on the what to do to dovetail with our getting incentives.

Thank you.

At this point, hearing no more questions from the group we're going to do is head into our public comment period. At this point I will ask if anyone wants to make a comment? Seeing none we're going to head into her lunch break now. There's a little change to the drill. I think because we have a number folks that are not here today we are not went to do the group photograph of our counsel but we will do that individual photograph for those of you that are new. We will help to the wellness room area touches the next hallway over back towards the lobby and make a right and Jamie here will help u s -- help escort is over there. Some of you have individual photos taken there and lunch will be available for purchase in that a rea. For those of you that are new many of us eat here in this room at the table. We will reconvene at 1230 shirt -- 1230 shirt for the afternoon session. Thank you.

Thank you, Michael. -- 12:30 p.m. sharp for the afternoon session. Thank you. Thank you, Michael. [ Captioners transitioning, please stand

[AHRQ Meeting on lunch break until 12:30 Eastern]

Okay, we're going to start with our afternoon session on health insurance expansion update and I'm going to turn it over to Dr. Chronic.

Thank you, Dr. Siegal. Quite a shift from this morning when we were focusing on delivery system reform and practice transformation although we will cover some of that this afternoon. Cindy Mann is in traffic and en route that but will be here soon. We are going to switch orders to accommodate traffic. I am pleased to introduce Dr. Joe Thompson who was the surgeon general for the state of Arkansas and the director for the Arkansas Center for health improvement. Dr.Thompson's work is centered at the intersection of clinical care, public health and health policy and one of the nations leaders in bringing the insights from public health and clinical care into health policy and doing this in the state of Arkansas. We are just really pleased you could join us today. Sorry not to have you here in person, but thank you for joining us on the phone and the floor is yours.

Thank you, Rick. It is a pleasure to be asked and I look forward to share with you what is going on and available to answer questions today or later. Jamie, I think you have control of my slides. If we could just go to the next one. I thought I would start off I sharing that you have at least 50 or 51 geopolitical units and within each one probably sub fragments. The Arkansas landscape is faced with significant challenges. We have the second lowest median household income in the nation. The last available data we had one force of our 19 to 64 euros that lacked health coverage is some counties and as high as 4 0%. 50% of our adult population has a chronic disease and we were tied with Alabama for the lowest Medicaid eligibility income limit in that if you were an adult that was not disabled, you only had Medicaid eligibility if you were apparent that made less than 17% of the federal poverty level. In addition we have got many areas medically underserved. We represent the face of a failed U.S. health care system on multiple fronts going into the process.

About four years ago, in the fairly unique role I have as surgeon general, there are only two other states that have a Surgeon General, mine is a legislatively codified strategic advisor to the governor. I worked for former Governor Hecate and about four years ago the governor said with got to do something and we are in the middle of a financial recession and our healthcare system is falling apart.apart. We put a four-part strategic improvement effort in place predating the affordable care act and we started with a workforce strategic plan. We moved our providers in an aggressive way under the recovery and reinvestment act to adopt electronic health records and health information technology. We started a payment improvement effort I would share a little bit at the end and obviously with the affordable care act had an opportunity for insurance coverage with the Supreme Court decision that became a challenge because as the first time since Reconstruction we have a majority Republican house and Senate, not only that we had the highest bar to pass appropriation bills. Have to have 75% of our house and Senate both to spend either a federal dollar or estate dollar every year. We had the opportunity under the affordable care act but fairly significant need that obviously some political challenges.

This is a little busy. It is the patchwork quilt I've I used locally and some of the national presentations. Income and age. If you're over 65 and folks of Medicare, the gray boxes Medicare and catch up to age 18. We believe out of our 3 million citizens we have about 600,000 that were uninsured between 18 and 64. About a quarter million below the 139% income line in 250 to 300,000 above that had the potential to gain tax credits under the affordable care act. Obviously we had a huge opportunity. We tried to mobilize the research community and give us the firepower to make it work. We asked for an assessment of the implementation of the affordable care act. For our 3 million citizens we could end up with 400,000 400,000 newly insured. A net benefit to the state broadly at a little over half a million dollars a year. Also the jobs impact and the lives saved impact. That would be more of a challenge in the political sphere. We did account for the outflow of taxable revenue and stress the importance of outreach. We went into the political process, and before we got into our solution, there was a wrinkle in the accountable care act that we tracked back to the Senate Finance Committee in that the tax credits under the affordable care act are offered down to 100% of the poverty level and not below. Conversely with the Supreme Court's decision, a state must expand Medicaid all the way up to 139% and in doing so he wrote the tax credits for individuals between 100 and 139%. The political discourse ended up on the more conservative side if we expand Medicaid, we are taking away the opportunity for individuals to buy private insurance coverage. On the more liberal side, if we don't expand Medicaid, our use of federal funds will be essentially an upside down policy where we are helping people and higher at higher income levels to get insurance while denying lower income individuals. That wrinkle led to a fairly creative innovative approach we called the healthcare independence program. You would here within this tracking SKU will resonate with, but this was the healthcare independence program. We came up with an innovative approach to Medicaid expansion we took to the secretary and with Cindy and her team to work through the issues. Essentially, Medicaid states through Medicaid have historically used either direct fee-for-service payments through discounted fee-for-service mechanism or they appeared out their book of business to Medicaid plans through Medicaid managed care contract. They always had be available to option -- that if the benefit structure with equal or better to Medicaid and if the cost to the state would be equal or lower than it would otherwise cost, states goodbye private premiums through employer-sponsored plans. The challenge is why would a state Medicaid directory evaluate 1000 different plans to see if those caveats are met? Most states had never explored the use of premium assistance. It is not Medicaid managed care, but we went to the secretary and said, can we use premium assistance to buy onto the individual marketplace?Where we ended up was expanding Medicaid eligibility other than those limited to the parents and place the majority of the newly insured people in private carriers on the health insurance marketplace.

We are using private insurance plans to purchase coverage through the m arketplace. We restricted to the qualified high-value store level policies, the 94% actuarial plans offered on the marketplace. It establishes the essential health benefit plan and importantly incorporates private provider payment rates so we are no longer paying discounted Medicaid rates, the same provider rate for an individual at 50% of the poverty level as somebody at 400% of the poverty level. We wanted to keep the dual eligible and children on Medicaid excluded. We have retained those into the traditional Medicaid program that we anticipate transitioning some Medicaid beneficiaries in. Currently we cover pregnant women up to 200% for their pregnancies. We anticipate in the future years these women will be covered with a full benefit plan and not come back on for pregnancy only coverage. One of the things, those exceptionally needy, the near disabled but not yet qualified, we intentionally defined them as medically frail and wanted to keep them out of the commercial carrier rates because we did not feel like they would be optimally served. Between the time we passed the legislation saying we would keep the medically frail out and the time we went to implementation, CMS defined medically frail, but it was a broader definition and would probably include more people we intended. We intended to extract about 10% of the population to protect the risk pools and better serve the consumers that have those medical frailties. You will see a difference in definition between CMS and our healthcare independence program definition. Our hope -- the medically frail and those that would be more effectively covered under the standard Medicaid program to be retained and added the individuals with exceptional needs as defined. Importantly nationwide, no one had developed a mechanism to identify medically frail individuals prospectively without the ability of knowledge about previous diagnoses, underlying limitations and previous claims data. We turned to partners at the agency for healthcare research and quality. I had to ask for help from Tom and his team there to develop a medically frail questionnaire. What we needed was to prospectively identify and retain the individuals in the traditional Medicaid program. We wanted to miss a minus -- minimize the -- so in collaboration with the center for financing cost trends, we utilized some of their expenditure panel survey and developed I think for the first time a short questionnaire intended to try to identify individuals that had limitations and activities of daily living, limitations in the social setting that would enable them to function within the private insurance market. For example if you were homeless, or individuals that have long-standing severe persistent mental illness for which enrollment into the commercial market at the outset would probably not offer them the best service. We have two paths into our private insurance marketplace which is the green box on the right. The top that path is the HealthCare.gov path where again we think we have about 250,000 people eligible for tax credits supported coverage. We ended up with about 71,000 who have completed an application.The federal marketplace has decided about half of those were Medicaid eligible and about 33,000 were eligible for the tax credits. You can see on HealthCare.gov 5,250,000 person denominator, we have successfully enrolled a little over 33,002 claim their tax credits and go into the marketplace. On the lower tier, we established Arkansas -based entry point and at the 250,000, we believe eligible for Medicaid, we have successful applications for about 195,000 through that portal. When you add the eligible for -- we end up confirming 150,000. We put the healthcare needs questionnaire in place so we have retained about 15,000 in the traditional Medicaid program and contributed a little over 100,000 to the marketplace.At the end of three months, this is our report in terms of where we are -- we think of 500,000, about 140,000 that have enrolled in private coverage and another 15,000 in the traditional Medicaid program so about 155,000 in. 80% of that because of the private option is represented by the -- we undertook to Medicaid expansion. The healthcare independence program has several goals in addition to restricting the growth of state government. It had the goals of improving the risk profile of the insurance marketplace, increasing the competitive of the marketplace and transitioning the marketplace into a more concerted cost-containment effort. This is a graphic of all of the state marketplaces nationwide and on the X axis is the proportion at that age or lower. The first way is it 34 years and what proportion are at that age or lower in the marketplace. Based upon the private option enrollment which on average is about 10 years younger, we are buying down at least the risk represented by age in our insurance marketplace. We had about a 10-year lower age-adjusted average because of the private option. Next to the District of C olumbia, we in that being the second lowest state in terms of our age risk profile of the private individual marketplace.

We were largely a state dominated by a single large carrier and a smaller secondary carrier. In each of our second market places, we end up with at least two carriers and some of the marketplaces four competing carriers. The counties depicted represent the proportion of uninsured with the darkest blue having over 35% of their 19-64 -year-olds that are uninsured. That is the status report if you will of how we did it a little differently. What the impact is on both the enrollment and potential goals of the program.

Because we have linked our healthcare independence program with our payment improvement effort, not only was that a politically necessary event for us to get support for Medicaid expansion, it is an important event for the nation to consider. We did cost-containment first before we moved to increase access to expanded coverage. Predating the affordable care act we brought our peers together. It was led by the state to avoid antitrust issues. We convened the two largest pairs of our state and established a multiplayer effort to improve care within the state and contain costs. The goals and objectives were aligned to incentives and a change of practice patterns, invest in infrastructure and support and overcome the barriers of transition, and give motivation efforts to patients to play a larger role.

We don't see it as a demonstration or pilot project. We are moving to the goal of 80% of all payors in a new payment model. We originally started with proposing a bundled payment.We are fairly non- integrated state when it comes to our healthcare system. I think we look a lot like other states that have relatively large geographic areas with low density in population and providers. It isn't as conducive to accountable care organization models. We put together a fairly aggressive patient centered medical home in the middle where we now have about 70% of Medicaid beneficiaries in a patient centered medical home. We also have Blue Cross and -- so we had Medicare. We recruited the state employees self-insured plan. Our hardest sell was to get Walmart corporate leadership to buy into a plan just for the state of Arkansas.We are reinforcing inputting in supplemental payments into primary care providers across the state. An example, a foreperson four-person clinic in southern Arkansas they're making about a extra -- they have restructured physically there clinic to be based around there for doctors. Each doctor has an advanced practice nurse, three LP ends and a care coordinator. They each wear different color scrubs. The patient come in and say I'm on the red team so the patient to -- increase the functionality and accessibility and the productivity of the teams.[Indiscernible]. For hip replacement the quarterback is the orthopedic surgeon and they are responsible for the 30 days before surgery and the 60 days after surgery. It is not capitated or bundled. Everybody gets their claims paid but the quarter side -- depending on how the team performs. We now have about 15 bundles.We are bringing on others as the year moves forward.

We did tie together -- until we passed the healthcare independence act. The private option act requires all carriers offering healthcare coverage participate in the payment improvement effort and were starting with the patient centered medical home.We are actively trying to integrate cost-containment efforts with insurance expansion efforts and that is one of the reasons we garner a majority of the Republican membership of house in the Senate to reauthorize this program on an annual basis. We have had two votes, one to establish and want to reauthorize the program and move forward. The federal government didn't tell us we could do this without a pretty aggressive evaluation strategy. You will see the logic model on the next slide. Effectively we believe by using the private marketplace we can successfully and roll through the state portal and other targeted outreach in a more effective manner than the traditional Medicaid program. Because we are utilizing private networks and paying private provider rates we will improve access to providers and services and improve prevention uptake and clinical outcomes. Because they are in private plans when they come to reenrollment they will not automatically drop off. There will be incentive based upon the carrier to reenroll and based upon ages to reenroll so we will optimize reenrollment. As an individual moves across the 139% poverty level, they stay in the same plan that we have potentially eliminated churn because somebody at 100% and on the -- plan if they get a raise -- there is no difference in plan depending on where the you are on the Medicaid private option or the tax credit supported plans up to 400% and beyond. You see on the next slide the four basic hypotheses that it beneficiaries with equal or better access to healthcare compared to the Medicaid p rogram. Equal or better outcomes. Better continuity and will determine a cost effective strategy that warns additional expenses because the benefits in care and outcomes for the beneficiary. I think we will see this could be as significant as the first time Medicaid turned to a capitated managed care plan that in the early 90s. Iowa has pursued a similar waiver with approval. I think Pennsylvania has a waiver under consideration. We have got several other states requesting additional support for how we achieve this. I would say it is not just the Medicaid advantage plan. This is the integration of our health insurance marketplace and our Medicaid program. It brings together rules and regulations of open insurance marketplace rules and regulations. It is a little bit of a challenge but we have worked through those.

[Indiscernible]. 120miles of undeveloped canoeing, camping and fishing. Thank you for the opportunity. I would be glad to take questions.

Joe, thank you very much. If you can hang on the line, I'm going to ask Cindy 2% and then we will open up for questions. It is a great pleasure to introduce Cindy Mann he was the deputy director at CMS and the director for the center and Medicaid and Chip services.Cindy has been a tireless advocate for better healthcare for low income people in the United States as well as an amazing partner with a variety of state Medicaid programs working on trying to improve healthcare. As a colleague, she has been a tremendous pleasure to work with and sometimes falls into the I'm just a country lawyer rubric, is also a tremendous consumer of health services research. Not just a tireless advocate but an amazing reader. Our job is to produce evidence and it is great to have customers who want this e vidence. Thank you for joining us today.

It is a pleasure to be here. Sorry to be a bit late and throw the agenda off a little bit. I want to thank you for having me and being interested in Medicaid and what is happening to Medicaid. Rick has been a wonderful partner. I am not just a willing consumer of all the work AHRQ does, but clamoring always for more and eager for the next analysis you produce. I think the partnership is incredibly important and we really evaluate. What you may not know in terms of the federal state p artnership, Joe and I were talking as I was driving in the car. We have been playing phone tag over the last 24 hours. He said I was on first and I will try and echo some things you say. Now that he had to fill in for me I will echo some things he said. He and the folks in Arkansas have been terrific partners to forge the way for a new way of delivering services in Medicaid. It is Medicaid and Medicaid dollars and protection. Medicaid provisions that govern what was going on, but the delivery is through the qualified health programs. It is not an easy thing to accomplish to bridge those worlds. Arkansas has done a wonderful job. There is obviously a lot we can talk about with the world of Medicaid. Rick asked me to focus on the issues around expansion and enrollment and I come at an opportune time because we just issued our monthly enrollment data report. For the first time we had enrollment data but I will get to that in a minute. I want to focus on the coverage expansions and other ways in which Medicaid is changing dramatically in terms of the application enrollment retention renewal process that I don't want to skip over a very important point. Right before that in terms of anyone focusing in Arkansas and delivery system reform, it is a very big priority for states across the country and a big priority for us at CMS to not just get more people covered and ensure they are covered for as long as they are eligible and cut the gaps in coverage, but make sure that coverage is high-quality and cost-effective and we are strong partner in moving the healthcare system forward. I want to make sure you all know that is important in terms of our agenda.

As everybody knows, the affordable care act anticipated between a marketplace the marketplace with the financial assistance available through the premium tax credits -- and the expansion of Medicaid everybody would have an affordable option to coverage.I think as everybody understands in this room but not so much in the public is Medicaid, while a strong player in the m arketplace, before the affordable care act did have a significant gap in its eligibility rules. A lot of people think Medicaid is therefore poor people. Those of us who know the program Medicaid was there for a lot of poor people but not therefore a lot of poor people. The basic structure of Medicaid had gotten built up through different acts of Congress and through different actions of states took on their own and left a hole in eligibility the affordable care act was intended to close. The whole is for adults and does quite well by children. The median income eligibility for children is 250% of the poverty line. Pregnant women are covered at a pretty robust level similar to what the children are covered out, but adults had a different story. If they were not disabled or elderly, the federal minimum -- and if you read the fine print you could roll back to the program in 1988. For childless adults there was no place in the Medicaid program for coverage before the affordable care act. As we went into the affordable care act we had a situation where parents with incomes below 63% of the poverty line -- not eligible. Parents were not [I ndiscernible]. Childless adults weren't eligible at any income no matter their situation unless they were disabled. As everybody knows the Supreme Court while upholding the positions of the affordable care act found one to be unconstitutional and that was the authority to penalize the state that didn't expand Medicaid.We are left with the gap existing unless the state decides to close that gap on its own. We have about half the nation taken that step. The federal government in the affordable care act said we will pay for it. For the first three years the Medicaid expansion is fully paid for by the federal government and the ratio of state federal share gradually changes so by 2020 it hits 90% and it never goes below 90%. It is a generous offer of financial support from the federal government and unlike any other [Indiscernible]. You can see significant federal support offered. As you think about states decisions to move forward, it isn't just the federal government is willing to pay for the cost of the newly eligible but states and local communities and healthcare providers are already paying for the care being provided to the uninsured. It is for many states a net gain when they move ahead with the Medicaid expansion. There was a study in Michigan that found the state would save over $1 billion over 10 years if they picked up the expansion.[Indiscernible].We don't have all states yet expanding. So far we have 25 states and the District of Columbia that made that decision. We passed expansion in New Hampshire a few weeks ago and passed the 50% mark. To give you an historic perspective when Medicaid was enacted in 1965, Medicaid is not a Medicare program. States decide whether they want to join the Medicaid program and if so they get federal dollars. When Medicaid was expanded -- created, 26 states jumped in. It took a while for every state to come in.[Indiscernible].We still have in 24 states adapt like the one I described. The states that have not expanded coverage not surprisingly are the states at the lower level of income eligibility.It is among the states that have not expanded the average income eligibility level for parents is about 49% of the poverty level. If you have a parent taking care of her child and works 20 hours a week at $7.50 an hour, she will earn too much money.[Indiscernible]. She is left uninsured. If she is a childless adult, she is not eligible at any income level. We have a significant gap in coverage. We have five states were for parents the income level is below 20% of the poverty line.

There is still a lot of work to do in terms of expansion. The good news is there is no time limit for estate to come i n. States are continuing to debate the question. New Hampshire joined the ranks of closing that coverage gap a few weeks ago. It is scheduled to go into effect in July 2014.

Let me say a little something about the private coverage option. Most of the states to their expansion, they just raised eligibility levels and didn't do a special waiver. We have three states of the 25 states that came in through a special waiver. The other states said we are ready to come in. That doesn't mean they are not doing unique and interesting things in terms of delivery system reform or consumer responsibilities, it just means there is enough flexibility they found to go their way. The three states that did their expansion through waiver our Arkansas, Iowa and Michigan. Michigan just kicked in A pril 1st. We did issue for the first time new enrollment numbers. We got data from 48 stands on enrollment.[Indiscernible]. It is for all parts of the Medicaid program and not for the new eligible. [Indiscernible]. We took out coverage enrollment numbers for planning -- we got data from 48 states. We will continue to refine the data over time. It's hard to look at an already existing Medicaid program and say, what does that mean?[Indiscernible]. We looked at baseline data and the states enrollment before open enrollment -- and compare that to their enrollment at the end of February. For the 46 states for which we had data for the baseline period and the February period, we found enrollment had grown by 3 million people. It grew more robustly among those states that had expanded.[Indiscernible]. Why would we have any enrollment growth in the non- expansion states? One as we expected some growth in the program projected at about 4% growth without any impact on the affordable care act, but also because is the way in which the Medicaid program enrollment process is operating has changed because of the affordable care act and those changes are without regard whether a state has accepted the new Medicaid expansion group.-- currently eligible people didn't know they were eligible or faced barriers in the enrollment process -- have been welcomed into the program. We do have data specifically from a couple of states that have been able to break it down. Washington state has found the in old 185,000 newly eligible adults but also among the previous eligible, 53,000 kids. Because of outreach and enrollment and the website, and the interest in coverage, they got more people. Those are under estimates for lots of reasons. Those are preliminary numbers. Let me identify a couple other things going on in terms of the enrollment. It is a new Medicaid program interns of enrollment. One is simplified new rules -- not looking at assets in terms of financial eligibility. The rules are largely aligned -- and that is important because one of the features of the new system is is that it is a coordinated enrollment and eligibility determination s ystem. People are not expected to know -- we don't need them to know. It is one single application for programs and largely the same rules that you go through the process [Indiscernible-Rapid Speech]. You may have heard we had a little problem with the marketplace on HealthCare.gov. States had problems with IT infrastructure so I won't pretend to say it worked perfectly or it is still working perfectly. It is one combined application and we are excited on the marketplace side. Going ahead with big challenges, getting to the finish line in terms of the simplified application. There's still lots of work to be done. We put out a 90% federal match for IT system improvements. We knew states couldn't pull this off with just their resources. The offer of support for IT system development continues through the end of 2015. Lots of work to be done improving the systems getting accurate eligibility. Of the big challenges is renewals and transitions. We need to make sure they are continuously covered -- [Indiscernible-Rapid Speech].

There should be no eligible person not enrolled in our view. The good news around -- that 3 million number is increasing today and it will increase the we have a lot of hard to reach individuals.We want to make sure we have access to care and continuity.[Indiscernible].Also of interest to AHRQ in me is to improve data reporting. We need to know where successes and problems are.Let me stop there.

Thank you. I appreciate your comments. I expect other members will have questions.This agency has been involved with development quality measures under the affordable care act for children and adults in Medicaid and has developed a set of measures which didn't exist before for some of his more vulnerable populations. Some of us are frustrated that different states are reporting different sets of data and looking at different sets of data in terms of assessing the quality of patient experience or quality and access in their Medicaid programs. Do you think we can look forward to a day at some point where there is a more uniform set being reported?

I think were moving to that end of moved toward that over the last couple of years. Congress told us to collect quality measures for kids and pregnant women and ultimately adults but made a voluntary for states. That being said I think the work we have done together to come up with quality standards and core measures has had a lot of resonance with states. We definitely have many more states reporting on those measures. I think we are moving in that direction. I think there is a lot of interest among states to use common measures. They keep asking us to collapse our measures and not hit them with different measures. It is never as quick as we would want but it is moving in that direction.

You mentioned about the -- effort. CM CS has been fielding on a cap survey for beneficiaries in all states and currently voluntary and currently going through pilot testing phase. The plans are to field a large-scale survey that would provide comparable information across states about Medicaid beneficiaries and managed care in fee-for-service and people with disabilities.Potentially big progress but the challenge is getting there.

While the reporting is voluntary we are trying to use all the levers to encourage states to come in. For example, we put out guidance on how states can move to a shared savings program in the Medicaid program. We said you need to have quality measures and we have the view of the quality measures. Were looking at Medicaid managed care regulations and looking at what quality components need to be in place for a contract to be approved in Medicaid managed care and quality is an important feature of that. We are in many ways in different directions trying to circle that wagon in terms of quality measures and reporting. I will say we are moving to revamp other data reporting in the Medicaid program. That is not going to be voluntary. We have authority to say Medicaid data is an essential part to make sure we are moving forward. That will be moving forward over the course of this year.

This is Joe. Not only the mention of standard data within program across states, but also standard quality metrics across payers within a geographic region. The providers are driven crazy by measuring the same thing but in three different ways. We need standardization not only across states that within region across payers.

Carol?

Thank you Jill and Cindy for your presentations. You said there were three other states looking at different waivers for Medicaid expansion or cover uninsured in the states would've not bought into the Medicaid expansion?

There are three states to accomplish their Medicaid expansions through waivers. The rest of the state stated through the state plan option.

Is there any interest or curiosity among those other states that chose not to expand their Medicaid programs to cover uninsured? To look at their programs? It seems like Arkansas looked at the financials of Medicaid expansion versus non- expansion and found there was a way to do that. Is there any curiosity or interest among those other states to develop other plans within those states?

Yes. It is not a sleeper issue, let's put it that way. It is a hotly debated issue in almost every one of the states that have not yet expanded.Some are actively engaged in debating it. Some expect to be more actively engaged next year depending upon election season. In almost every state, there have been studies and analyses about what the impact is.It is a front-page issue in most of these states.There is a fair amount of interest in the Arkansas type model and they will certainly be watching Arkansas closely.

I would just affirm that because we do have hospitals all these states and in pretty much all of these states there is discussion which points towards something like this as a potential option and there may be political reasons why this is a pathway which is more a tenable in some places. I expect to see a lot more activity in the months ahead. Jed?

I had a question for Joe, how are you measuring continuity of care in your new program?

We haven't got across the reenrollment process at the we have to metrics or two areas we will operationalize metrics. Continuity of care within the same provider network. -- maintain the same specialty access. The one that is probably more financially important, the continuity of coverage [Indiscernible].Crossing the income line and continuity of coverage across enrollment years.

Other questions from our NAC members here or on the phone? I will turn it back to the director for the next segment.

To kind of closeout this discussion around coverage expansion, Tom Selden who is the director of division of modeling and simulation in the center for financing -- 2% on work he and colleagues have been doing on Medicaid and CHIP eligibility issues. Work I think is quite fascinating and I would be interested in your comments and advice.

Thank you very much.I am reporting today on AHRQ very broadly and quite narrowly on AHRQ research regarding Medicaid and CHIP. AHRQ has had a long-standing support for extramural research on Medicaid and CHIP. These are four recent grants. There are other recent grants and a long tradition of funding extramural research. Last December, this past December, AHRQ issued a special emphasis notice that reaffirmed and highlighted our interest in these types of studies, in particular with respect to Medicaid and CHIP. It pointed toward studies of take-up access to care and churning.

AHRQ also has a very significant commitment tradition to intramural research on Medicaid and CHIP. I couldn't begin to do justice to all the papers produced on Medicaid and CHIP, so instead of trying, I pulled a few papers that make one key point, I t hink, and that is for people in the U.S. who were on the lowest rung of the socioeconomic ladder, health reform didn't just start in 2009. It has been an ongoing process of Medicaid expansions for this group and has been referred to as a patchwork. Each patch on that quilt is another opportunity to study and we have played I think an important role in providing research around those expenses over time. That will we have played we envision going forward, and I will get to some of the research we are doing in a moment.

There are two main core data sets at AHRQ. What Wesley Hospital discharge survey and when is he -- family of surveys. On the -- side, -- has been doing research on Medicaid readmissions. This chart shows readmission rates are substantially higher in the Medicaid population that among the privately insured for the uninsured, especially among non- maternal adults age 21 to 64. This isn't too surprising. These data are not adjusted for differences in severity and the Medicaid population is intrinsically a more difficult population to treat. That is not really the point. The point is if you're interested in hospital readmissions, you need to be studying Medicaid. There is another point that may be a bit more subtle. If you're going to study Medicaid readmissions from hospitals, what you need to do is have a data set rich enough to look not just at the fee-for-service sector of Medicaid, but also at the managed care piece. -- offers the ability to look at both and that is something that is common to both of the data resources, that we have a national perspective.

If I could interrupt, studying Medicaid readmissions, to highlight the need to actually do something, and we have a variety of efforts working with hospitals and small efforts with health plans a right try to figure out how to change this. The pattern here is very similar I have seen to readmissions in the Medicare program, driven by readmission rates -- but the question is what do you do? Some of the solutions would be similar to those in the Medicare program or that Medicare has used, but some are going to be different because of the challenges of dealing with people with very low social support, inadequate primary care in many issues that are Medicaid specific.

Moving in that direction, -- has been partnering with the group of 19 states to track both readmission rates and readmission policies and impart coming out of that and some other work is a toolkit, the crafting solutions toolkit for hospitals that was developed and tested in the six states and six safety net hospitals and this will be available early summer.

Over the past year or so, especially the past six months, my division has had an interesting and fruitful collaboration of sorts with [Indiscernible]. Very often researchers just produce their numbers and the policymakers try to use them but it is not often the number the policymakers want. We have been trying a more iterative approach where we produced numbers and they say we can't understand this, or we need to digest it more and then we go back a produce slightly different numbers. It has been a very fruitful partnership. One of the research products is we looked at the relationship between CHIP premiums and children's health insurance coverage. What we hypothesized and what proved to be true if there are two key dimensions on which the response to CHIP premium varies. What is your family income. If you have got a higher income you are better able to absorb and pay the higher premium. The other dimension is whether the parents have ESI offers. That provides a ready substitutes for the public coverage. What we found is if you look at the far right-hand bar, the far right-hand group of bars, a $10 per month increase in CHIP premiums reduced enrollment in Medicaid among this least advantaged group of kids. The other 150% of poverty where they do not have a parent offer to be as a backstop. In that group a $10 per month increase in CHIP premiums reduced public coverage by 7.2 percentage points and those kids are disproportionately becoming uninsured.

The second piece of research is taking a forward look at pathways to affordable coverage for children if we get to 2015 and decide as a country not to reauthorize CHIP. This is looking at CHIP eligible children. Some of those children will be able to go into the marketplace. There are pros and cons there. On the one hand you will have one insurance plan for the whole family.There is a debate about the comparability of benefits. That only applies to under half of all of the CHIP eligible children. More than half have parents with ESI offers so they're not going to be able to get into the marketplace was subsidized coverage. They will either become uninsured or placed onto their parents plans but in some cases the parents don't even actually take up the coverage now.These results resonated with -- and because CHIP premiums are associated with an insurance among lowest income children -- as a recommendation for 2014 to eliminate premiums for CHIP coverage under 150% of FPL. Because so many CHIP children would be ineligible for marketplace coverage, MacPac is recommending reauthorization of CHIP in 2015. One of the strong features of the medical expenditure panel survey is the richness of our health status information. When you couple that with all of our data on family structure and income and state of residents, we can look at different aspects of the ACA relevant populations to see what their health status is. In a paper that just came out I think it was last week in health affairs that Rick mentioned earlier this morning, we looked at pre- ACA Medicaid enrollees, excluding those gaining eligibility through disability pathway. We were looking at the nondisabled Medicaid enrollees and comparing them to the group targeted for the ACA Medicaid expansions. This is nationwide, but we also segment of the population by people in states expanding coverage and states that have not yet decided to expand.Across a wide range of health measures on the vertical access, you can see there is not a whole lot of difference. There is some concern out there that expanding Medicaid will bring in a -- population. We are not seeing that. If anything on a number of dimensions the -- our little bit healthier.

This was some work by some colleagues outside of AHRQ and looking at adults, the first group are those with severe depression and other psychological distress and comparing them to all other adults. If you look at the green bar, pre- ACA private coverage plays a much smaller role for those with mental health symptoms. Instead, they are more likely to be a public coverage. Those are the to box at the bottom of the column, and they are also more likely to be uninsured.

As you simulate the ACA w orld, we see both groups there is a large reduction in an insurance rates, but the percentage point reduction is larger for those with mental health problems. Similarly we see a larger percentage point increase in public Medicaid coverage.

I'm going to skip over our slides on Medicaid expansion in Arkansas, other than to say it has been our great pleasure to have been involved with that, and we look forward to continuing to work with Joe. Finally, I have got a couple of slides, I think Rick showed some of these results in an earlier NAC meeting. One of the long-standing interests of the division modeling and simulation is thinking about who pays for care and how we pay for care. If you think about it, you pay through your taxes enter premiums and taken out of your wages. You pay out-of-pocket and pay when you go and when you pay a private carrier and uncompensated care, there are so many ways we pay for care in this country. It is a very complex system and also very complex on who receives care. We are spending two points $7 trillion and there is not a lot of work done to sort out who is a beneficiary and who is paying for this stuff. We haven't quite got the finance equity piece going but we have gotten results on the benefits incidents side. To explain with this chart shows, at the bottom we have people enrolled in Medicaid and these are adults 19-64. I have deleted from this table, from this chart, adults in SSI, disability related Medicaid or Medicare. At the bottom you see -- they are receiving a large amount of public benefit. The next largest group are people with ESI because they are getting the tax subsidy. Between those two groups is what Cindy was talking about is the gap. Those are the people under 138% of poverty or under 400% of poverty and not having ESI. Those are the groups targeted by the ACA. Some of those still have yet to be targeted because of the not yet expansion of Medicaid.

Is a lot more expansion on Medicaid and CHIP.

Questions?

Can you go back a slide about mental health, pre- and post- ACA? I don't know if I understood this slide or not. Could you maybe want to again what this is saying?

Focusing on the left-hand portion of this graph, you have got people with mental health problems. Severe depression or psychological distress. The two columns there, pre- ACA and post- ACA, the post is simulated.

[Indiscernible].

We have only processed the numbers. This is simulated and what you see is an increase in private coverage, but you also see these sort of disproportionate increases in Medicaid and a reduction in an insurance.

One gratuitous comments, around the simulation, a lot of work is around trying to simulate what will happen and what would happen and is clearly fraught with uncertainties. Having the 7.1 million number announced for marketplace enrollment is for people who have been working on it, and I was in my last job and extremely gratifying start to this coverage expansion. One of the most amazing things to me is that 7.1 million people have enrolled but also the Congressional budget office estimate got so close to that number with the incredible amounts of uncertainty that were involved in trying to figure this out about what would the federal government do in terms of advertising this. Obviously the glitches with HealthCare.gov and tremendous uncertainties about how people actually behave. Either producers or consumers of this simulation, it is quite a triumph. It would take some credit in that -- who proceeded the job that Tom is then now is one of the main people responsible for these estimates.

That is very helpful.

I was going to make an observation about the early look of the health condition of the expanded population. I think it has been true that well over half of new Medicaid enrollees are supported in their enrollment by health system financial counselors. The patient gets sick and gets in trouble and comes to the hospital as an uninsured patient and we help them get Medicaid coverage. That hasn't happened yet largely for the expanded population. We are only 90 days into it. Potentially the sickest people that are now eligible have yet to be enrolled. As Cindy said, that will be a year-round phenomenon. The healthier Medicaid person showing up at jobs and family services and signing up for other benefits and being assisted to enroll generally are the folks likely to have been enrolled in the first 90 days as well as the self-directed persons who did it on their own. The sickest Medicaid patients will come out of our ER's. They may not yet be in the numbers. I would be careful about assuming there is not going to be a case mix index problem with the expansion population once it is fully loaded. In Ohio, which decided to expand on Halloween, not much time to get ready, 90% of the expanded individuals are still -- they don't have cards in their pocket yet. It is just an observation from the trenches.

I think that is a very good observation. What we are looking at their is really a more eligible population.

Again, it is simulated.

Identifying the group to be targeted.

I hope you're right.

It is a bit counterintuitive that most people, myself included, assumed the expansion population which kind of by definition includes lots of childless adults and some number of very low income childless adults, men who are homeless or alcoholic would be sicker.Tom didn't mention, but -- doesn't institutionalize people and likely under samples people who are very marginal and difficult to find.This is hard to know, but it is still quite different than general expectations.

I think there are also questions about whether some of those populations mentioned, could that qualify as a disability determination once they are brought into the s ystem.

Of the questions in the room or from folks on the phone?

Okay. Thank you Tom and Joe. Thank you very much for your presentation and time today.

Were going to move into our next item on the agenda. As an update for subcommittee on strategic directions.

[Captioners Transitioning]captions ]

At this point, I'm going to turn it over to Michael. I don't know if Helen is on the phone or not. Helen, I gave there?

Hopefully she will join us. Michael, take it away.

Did speak yesterday, just in case you can't get on. Speaking on both of our behalf and hoping ever present well. You have a document in front of you that you got earlier today. I will start for an apology of the short term notice. It's a single page front and back and we were making adjustments at 11:00 last night. The reason is we got this request to further look at patient engagement at our meeting in November, the fall meeting and holidays went in place and there is a lot .9 with patient engagement and how long do you wait before you start to talk about this. We did most of the work on this. There was a large scale supposing by the Betty and core foundation around patient information we tried get as much information as we good. Because you got it on short notice I will take a few minutes to walk through the slides and give you the context of what we are presenting. The first light for those of you that are new to the Mac the charge to the subcommittee for strategic direction West, for the strategic framework and we presented it in the fall.

If you look at our goal and our research focuses on overall health care system performance in collaboration with others in ways that want to engage patients families to enhance their health goals. It's been a deeper dive than that since we have been working on since the fall.

This sheet of paper, I don't know if it's the same as your slides.

That first slide, starting now will be very similar. Again, I you this slide for what would present the last climb with a few deletions, what is on your papers complete but just to make sure that the slide was not too overwhelming I deleted a few of the questions because the questions weren't the focus. There were a vehicle to help us understand what we're trying to do. The subcommittee in working through this issue of patient engagement struggled a bit and what we found we started to get hung up on was what people meant by engagement or activation or pop -- empowerment. I think the recommendation that we're going to make it's really better conversation because what we're trying to do is to facilitate a partnership with patients, clinicians and patients together we will talk about that. The overarching goal is to identify key barriers to patients and caregivers as well as similar barriers for clinicians who want to support this process and explore strategies to reduce or eliminate barriers to improve healthcare. We want AHRQ to fund research and quality improvement in ways in which we can meet the needs and wants of the patients and caregivers. There was a lot of discussion on engagement and in the end what we want is an ongoing conversation with the families and caregivers as well for clinicians. But we suggested was very specific conversations that should be occurring with not -- within our that enables the health care system to meet the needs of month of patients and caregivers. The first conversation is that conversation A creating research. These three conversations are equally important but we talk about this one first because this is a research organization and how to we get greater engagement involvement and whatever term we want to use of patients and clinicians together it's really a conversation about co- creating research. To try to make that a little more three-dimensional for folks, we have on their examples to consider when having this conversation. Things went as you're getting ready to put together a research proposal or an RFP or beverages are case patients caregivers involved in the process and have the thought that. An example of some of those break from the front in generating an hypotheses that are relevant and meaningful to them all the way down to serving on the IRB. Those with things we thought would help with thinking about having the patient actively involved in that process as well is our patient and caregivers to able to easily and effectively contribute to the research process. The list of questions is not exhaustive but hopefully gives you issue is that the but we thought to be conversations that could happen a priority to help make sure we're infusing into the process the voice of the family, caregiver and patient. That's the first conversation. The next one and actually as we start with the first conversation we had up there at this morning's presentation by the director and subsequent conversations talked about the role of AHRQ in producing and implementing research. The first one is really about producing. The second two conversations is about how we have the voice of the patient involved with the implementation. Just a way to frame it. The conversation about making collaborative healthcare management decisions around diagnosis and treatment. I will read a question or two. Our social and environmental cares questions addressed and is the patient caregiver and clinicians able to make decisions with a variety of healthcare data. Those a B questions be questions to make sure that conversation is effective. Finally, conversations about co- designing healthcare delivery. We develop the capacity and/or modify systems and processes to enhance system but in processes and what can we do at a system level to facilitate and make the process easier but that that there members of the snack in the room and there are a number of folks in the snack who are not in the room and so I went to open the floor up to those folks to add their comments but before he do that specific thank you to Helen. I'm a clinicians and I'm also patient depending on time of day and time of year that one of the things Helen said to me about engagement and part of the reason I feel comfortable moving away from the term was her feeling was that it's not that patient aren't engaged is that patients are engaged and clinicians as well-meaning as they are don't necessarily fan the flame and oftentimes dulcet. And I would agree and so the conversation really becomes the frame we think because to say you are engaged suggest yes or know and was activated and I appreciate that from Helen and also Roman for advancing help was a former member who came in over the last month who added some nice context to this. With that said, I will open it up for questions or comments.

Thank you, Michael and thank you to the members of the committee. I will start with one question I had and I didn't quite understand something in the second conversation. After talked about conversation and the bullet you have language about context training tools and making these conversations routine without introducing new route -- new routines and despair. I'm wondering where the new disparities came from and what concern was underlying in equity through this work.

It's a good question and one at the moment you asked I have wished you hadn't. This is a very specific question in this came from Victor who came from significant -- and hopefully for those of you on the call, I can't specifically remember the example but it's a bit of a new ones but I'm going to ask if Victor would follow-up with that unless someone can articulate it better than I am which is not at all. I think it's generally the idea was by virtue -- if you change the system have you been changed the folks who are now the haves and have-nots and I think that's very broadly stated and Victor which much more eloquent.

I've heard this another context and I'm not sure it's what Victor had in mind but the notion is if -- is physicians and other practitioners encourage a share decision-making model and if that model does lead to improvements in outcomes that may well be that people with more education can take better at Vantage of that and that disparities in outcomes will widen.

I understand that. The point I wanted to make as we see that in many areas early adoption and how innovation spreads it doesn't mean that innovation is bad.

First I wanted to thank Mike, I'm sure it was like herding cats. This is an area I feel passionate about and it was the root of my question is improving health and getting from healthcare delivery to improving outcomes really needs to involve patient engagement piece. I've been involved with AHRQ for a long time and I think AHRQ is been doing this for many years. James [ Indiscernible ] had a stakeholder advisory committee that had advisors on it and I was on it with Carol Lina and was actually the first person that change my thinking about patients and the importance in the decision process. You heard the million hearts discussion this morning. I think patient engagement is really an important component of that although was not implicitly mentioned. I had aside conversation that it's actually going on. There is a reference to an article by Suzanne Mitchell from Boston city hard up -- hospital which I think has a new hospital now.

It's Boston medical hospital. You talking about 20 years.

Patient activation level in 30 day rehospitalization, this is what we're talking about and I guess what I've been worried about is a new director coming in, new priorities that somehow this make it sort of lost and I think it's a really important component of what AHRQ does and has been doing and I hope that it is able to continue to engage in it and I really think that of all of the HHS agencies I can't think of a better place for this to really live.

We can reassure you of the importance of patients in making all this better. And to your earlier question, all of the work is around trying to improve health outcomes and the ability of patients to get what they need and to kind of -- the kind of challenge is figuring out how to do that and obviously cannot be done without involving patients in trying to figure that out. That is kind of central to what we do.

I think it's excellent. I wonder if the word patient is too restrictive. The research also pours over those were not patients yet and it speaks to also the prevention side of it which is something to think about in the verbiage.

Great point. Thank you.

I just wanted to add that we had a lot of discussion about engagement and definitions of patient and advocate and caregiver. It was a lot of different understanding about what that is. I think but we have tried to do in this document too and, as Michael said, the term conversation is really well-chosen term because the idea is that patients and anyone of us, medical consumers at some point whether you are an existing patient future or whatever, needs to be able to trust that the system is working for them and that having those conversations -- we don't define what a patient engagement it's. Every patient will define for his or her himself the level of decision-making my responsibility for that decision and ultimately agree to the care but it's going to very from patient to patient but the quality of the conversation is really what's important and patients need to feel respected, listen to, they need to be able to ask questions and to have honest answers provided and feel and this is a subjective thing that feel as though they are participating in their own care at whatever level.

Did use of the word consumer come up in these discussions?

Not really.

This one piece with emphasis on consumer servers or customer service rather but not really. I think we were thinking about patient advocate and somebody who is a proxy supposed -- spokesperson or caregiver for the patient and somebody who is either not the patient themselves but involved in that person's care.

Bruce's question was around the last statement, there our a lot of people who are really patients but we want to have involved in the type -- in the title label for t hem.

Not specifically but what we were talking about was having information available that's understandable so that when people get to that point they can understand it. (Operator Instructions ). To marry and then Harry.

I just want to where my quality measurement hat a little bit. I'm involved a lot of quality measurement work. It's a challenge really to measure shared decision-making and how well a clinician will address that etc. I would encourage HR queue and AHRQ do more research in that area in terms of how to measure that. Right now we and our measurement world we don't take patient perforations -- preferences into consideration. Sometimes some measures do but it tends to promote gaming. For example, some physician measures with a breast cancer screening, patient refused. Is that true? Or is it the clinician really did not exert enough effort to convince the patient the value of the screening and so on. It's fraught with challenges and is an area which is rich for exploring and researching. The other thing we do and another hat I wore as a QIO is in engaging patients the best method of how to engage patients and what patient's do you engage? Sometimes patients are self-selected because they are more educated and they can articulate more of their issues. Are those real the -- are those the patients that are representative of the population. Those are the kinds of things that are challenging us and it would be helpful if there's more best practices and evidence involved and how to engage a patient.

Very good point.

There is at least one question around asking patients one physician recommended treatment, I forget exactly the question but basically with information provided in digit of a chance to have a conversation with the physician? I'm not quoting the question correctly. I don't know if you've had experience using that and ensure that much more is needed really to capture this concept well.

And sometimes the measure tends to become a check box measure. Did the clinician to the assessment or did the clinician to that teaching and it becomes a checkbox.

This is the measure that asks the patients.

Harry?

This is largely in response to Bruce's questions and one other minor thing. First of all I think we were not necessarily thinking limited as patient even though that's the word we use. I don't like consumer because it sounds like our most important attribute is art function. I think the public. It's a matter of the health of the public and we hope to help them and prevent them becoming patients. This engagement needs to be done as a public need to have them understand what we're talking a bout. I would suggest potentially I was thinking the public even though we use the word patient may be considered to broaden that. The other thing would be we have conversation about this and I don't want to have that conversation here in any detail at all but just to make a point which I think the rest of the community would agree with. We say under recommendation we say we want art to fund quality improvement efforts when you think about the nations needs in the billions and billions and billions you realize we don't really mean AHRQ disposed to be going out there and quality improvement in general. Whether we are talking about doing research about or demonstrations of and obviously this small agency in the seat of quality issues and I think that's what we intended by that.

I appreciate that point. I don't think we were thinking to limited to patients but I appreciated Anne's question. Victor also is been very active in this space and could not be here in the phone -- on the phone. One of the things he brought up was as a point of background I've been involved with QIO for eight years now and still chair one of the groups and denominators and all that fun stuff one of the points that he made that I hadn't really thought about before is I him the clinician and I am being measured whether that box got checked how much am I going to care for the patient wants it done or not. Our measures for screening are based on population-based metrics. The risk for them to say no to rest screening they really not be an issue for them based on how they fit in their but now I don't get to check my box. It's an interesting thought in these conversations hopefully let us get to the page place with this becomes the patient's preference. Hopefully I worded that while I'm off. Just food for thought.

Other questions or comments either here in the room or on the line?

Is going to make a comment before it you're Michael. I do hope that agency does start to move down some of these pathways especially in its research formulation review process and those things that looks at what the core experience has been in that area because I think -- I'm not saying it's good or bad but I expect are looking a lot about the integration of patients into the various stages of the research design and review process. I hope that would be accessible to all of you here.

I would like to thank Mike and Helen and the members of the team for their work on this. It's been extremely helpful. As I read this and think about what we might and could and should do, I do have to say that the 2nd a nd 3rd conversations seem a lot easier to me to imagine how to arrange them and to get something really valuable out of them and then about the co- creating we split -- research. Part of Bruce's point is Macquarie's been very heavily engaged in that set of conversation for the last three years and there's tremendous learning to be cleaned from that but not yet and Mark worry is working on trying to figure out how the research is different as a result of this but they don't know yet and my first instinct is to try to wait a little bit more and learn from that while engaging in the conversations about delivery system design and certainly collaborative healthcare management in share decision-making which is -- which is been in area that we've done work on and we will continue to be working on. Would like to think about this more and I'm sure we will be following up with you while in thank you very much for your efforts on this. It's really very helpful.

Mike concluding remarks -- remarks said snacks started in July and ends when they hit the gavel. Angst while the folks who participated. The conversation from July until yesterday have been unbelievably rich and I'm very appreciative of that. The other thing is since I'm going to do it least one follow-up e-mail back to the members, much like the last thing that we did in the recommendation that we made there was either we agree to we go to great so I guess I would like an answer on behalf of the snack, this is something that you have to say yes we agreed we go to great or we think it was great and we will think about it later. Probably a procedural question.

I don't think we've done this before. Any way?

The last time we did take a v ote. Should we make a formal recommendation to the director?

Why don't you do this. Is there motion to recommend this report to the agency as our recommendations?

Just a point of clarification, with amendments or as represented?

I'm going with it as r epresented.

The conversation under a device meant. This to me is a living document but it's important to clarify that right now before you vote.

This is David have learned. I wanted to have a comment about under recommendation where it says fund research and quality improvement efforts, I agree with Kerry's comment that AHRQ does not have the budget to fund quality improvement efforts. Many of our healthcare organizations have larger operating margins than arcs annual budget. I think AHRQ needs to focus on research into this topic.

Harry?

I support that, obviously.

Let me ask another question now that we are in the palm -- parliamentary wormhole with the understanding we need to amend the language year to reflect arcs limited resources that it's not going to be QI for 300 million Americans, is there motion with an understanding to prove this report? Is there recommendation to the director?

So moved by care without understanding. Is their second?

Second?

Any discussion on the motion?

That would be when and amendment would be made.

Do want to make a formal amendment now?

Agreeing with his. I would see just we would do fund research or whatever research and if you want to state demonstrate quality improvement efforts I would be and comfortable with that but to fund quality improvement efforts is the on the pale and also beyond the possibility.

Can I make a suggestion? A friendly amendment to the amendment? One of the terminologies and sometimes these things work is actually the original language that I put in here is to fund research and to support quality approved meant efforts. Does that change it for you or not expect I would be more specific. Support is a big word too. I'm just trying to be crystal c lear. I don't think we can support or do from arcs space QI work. I'm completely free were fit. I would say fund research and demonstration of and that weight all the things that we talked about a really the demonstration. You really small scale but there for the nation. The environment can be voted on now to.

Let me see if I can move this. If you really want to get into Robert's rules of order now since we've actually made a motion and seconded the recommendation belongs to the body first of all what I will do is ask for motion on the amendment. Is there motion on the amendment?

Is their second?

All those in favor? Any opposed? Great. So going back to the original now motion now that it's been amendment I'm going to ask for vote on the original motion with the amendment. .

Any more discussion opportunity here?

I was just went to ask Rick to save little bit more about your concern over the first question and what that would mean for AHRQ and bow to we were going to get this body to vote on it?

More of just the thought that in sort of order and thinking about all of the things that need to get done that Merck Lori is heavily engaged conversations about co- creating research and bringing patients in and certainly we have conversations with patients in the past and others will know this better than I, some formal mechanisms and many informal mechanisms and my thought is that it would be useful to learn and get the benefits of learning about the results of Mark stories efforts before we go and try to either reinvented or copy it and that it makes much more sense to learn from the evaluation if McCrory is involved in trying to understand what is working and what is not working about what they are doing and it would make sense given we are couple of years into that experiment to take advantage of the learning from that experiment but we are not quite there yet.

The learning is not yet available.

If I could just comment on that and they think that's a great point. This is just asking to have conversation about it and I don't think anything in this language holds the and -- language -- anything holds agency to this work let me go back to Michael and then to Carol.

What you just described is exactly what this is asking us to do is to have the conversation and talk to McCrory. I would agree with you.

And just as an information point here and I'm sure you're familiar with this too, there our a number of research mechanisms now and the breast cancer world I'm familiar with the Department of Defense research program, many of their funding mechanisms require that community members of patients be involved in the generation of hypothesis and be part of that. The California breast cancer research program does the same thing. When I read this I think beyond the world of Tatian centered outcomes into where appropriate that engaged educated patients, advocates, whatever we want to call them can have input into scientific research with practical aims.

Other discussions or questions? Cindy?

You don't get to vote, Cindy.

I just wanted to try get a little more clarification from snack and others in terms of how they are thinking about this. Patient engagement is sometimes thought to be basically getting the patient to participate in their healthcare do their self-management work and can be doing what the clinician months them to do. What I hear is that you're thinking about patient engagement as being going more towards share decision-making that the patient actually has some authority I'm trying to be balance the power relationship. They also want ask if you are also extending that to patient engagement in organizations such as serving on quality improvement Moody's, serving on the safety committees, etc., just not a clinical encounter and finally a specific question which is AHRQ in the last year or so published a patient engagement guide and whether or not you're familiar with that and is part of this charged with saying do more things like that were take this further in some way? Are there some this -- specific thoughts that you have on that?

Mr. Chairman?

The thought this was yes to all of those things as recommendations. The more that the patient and the family can be involved even from the very upstream portion from is this a good idea from is this a good idea for research and is this something that you can understand for healthcare decision and it was his product that -- as broad as that in so you could figure out what is the best way to put that in and have those conversations with the things you're working on. Sherry?

[ Indiscernible - low audio ]

I think it's important as clarified by Rick I think it's pretty comfortable leaving the send but I must say that one of the important things for AHRQ and our service to art -- AHRQ is an advisory Council is not to get it confused in anybody's mind but what it if it says are and they think by doing this which is really taken out of the McCrory playbook and it's a good thing and I'm in favor of it. I do think we risk modeling that and they think maybe putting it at the end of this list might might make the point that we don't expect them to do what McCrory wanted them to do. I don't want people to think we are duplicating McCrory. As long as we are comfortable with them taking that the way they said I'm happy with that. The other thing is asking about consumer so now list when I was having these conversations I was thinking about the public and I would hope that something could be put in like the patient and the public engagement.

That would be accepted by the co-chair.

I think Anne's point a good one.

Are you folks okay with that?

Yes.

And I think this conversation is being recorded in there will be a meeting summary prepared so I hope the interaction we just had. Ended clarifications from the director and your conversation will be on the record and I hope that we ask in the summary we make sure that is included in there that clarification. We are not here to replicate McCrory and enough said at that point. Other questions or comments? Hearing none, we have a motion that's the and seconded. All in favor? Opposed? Okay. Harry. Thank you.

Thank you all very much.

Thank you very much.

Mike worked really hard on it.

I know he did. Ace seen some of the e-mail traffic.

We have public comment and nobody is signed up. Is there anybody that does want to make public comment at this point?

Hearing none? We will go now to the final wrap and NAC. Here this is where we ask people to make final comments and ask any questions they have. One comment want to complement the agency director and staffed -- staff are very focused meeting with a clear set of questions and I think and I hope it's higher-quality focused advice.

Thank you. And I felt like we were being engaged in a way that would be productive. Thank you very much. With that, this initial comment, whether other folks are final thoughts or questions at this point?

Thank you for being the first time here. I didn't know what to expect and I'm quite impressed and I can't be happy about the conversation about share decision-making. So thank you Michael and my friend Helen. I'm looking forward to the next meeting.

Likewise.

Others?

Michael?

I actually wanted to plant an idea for something that we could talk about it in an upcoming meeting. There was discussion early about measurement to the continuing of care. Anne brought that up. There's an organization I get some interaction with and interestingly enough it's a part of the Saint Vincent health group or medical group in Connecticut. The of the first certified click tickly -- clinically integrated network. I went and spoke to their group and what I was impressed with his what they are creating is the patient centered medical neighborhood. They are working with physician practices and they are in the stage and how I met them is to the home health organizations. There reaching out to find high-quality provider and it's a really interesting work and they've got to the point of submitting this new accreditation process. What also impressed me is they feel very strongly that the resources and tools that AHRQ survived with a big reason for their success so I think they might be a good laboratory for some of this measurement but I think hearing from groups like that and how they are beginning to look at this cross care continuum collaboration could be very enlightening for us. Even though they are not it point of measuring outcomes that they've got it in place. I know the of the 1st and only one at the moment.

I be happy to get you in c ontact. Really interesting stuff.

On reflection, I do of one realization is this is the first meeting I've been in in years were somebody said some app was appointed remake healthcare.

[ Laughter ]

We've heard that before.

Sherry?

I also like to thank everyone here some of the folks from AHRQ and everyone for participating. One of the things I could judge done after meeting is whether or not it helped them in their daily work and I think a lot of this is incredible and helpful across our membership. Thank you very much.

Just one quick thought. Found Patrick's presentation extremely good. I wish I had in our to listen to and understand everything he said. Can we get something similar from one see to see what new directions they are taking?

I don't know how many of you know Karen to solve low was relatively new director of ONC but quite and energetic person and has a strong agenda there and I'm sure she or maybe Jacob brighter would be happy to common share.

Are you collaborating with all of the?

Very heavily.

That would be good.

Other questions or comments?

I have actually -- Jamie Zimmerman has one comment and then I will close with thanks and closing comment. Jamie?

I will just use this fortuitous timing. I will take credit for but I did not plan for it. I don't know how many, there our some of you who come to our annual meaning in the past we used to have a showcase of the best of arcs work to basically help make sure that our work was being used and understood. Due to some budgeting the last meeting we held was in 2012 and the good news we announced is we will hold another meeting, probably in February or March of 2015 and the fortuitous timing is that in concert of federal register notice was released today announcing that we are looking into the possibility of cosponsorship for this meeting for nonprofit entity given expertise and health services research and track record in evaluating research impact and others who could add to our m eeting. I will forward this notice to everybody and if you could send them out to people who you think might be good to cold sponsor with us we really welcome that support.

With that sponsorship, does that imply shared financial bearing of expenses of the meeting? How would that work?

Yes. The devil's in the details. [ Laughter ]

Are we getting money or giving money?

And you get on the keynote. The weight -- once we receive applications we're actually going to have conversations with that -- with applicants and applicant and the good news is that the entity that partners with us can charge a registration fee so they won't incur any expenses and at the same time we will have money we are putting towards this meeting that will cover [ Indiscernible - low audio ]

This is something as we've done with SNAC and others and we are exploring.

If we're were potential cosponsors that did come with the check.

We would be happy to take that.

I want to thank you for being here. I know how hard it is to take a full day and for those of you that have traveled, more than a full day of the rest of your life. I very much appreciate the advice that you've given and they hope you feel that we are using your time well and I look forward to feedback on that and you all know how to get in touch with me and please do not be shy. I'm grateful and to look forward to seeing you four months from now and being in touch before that. Thanks and for those of you traveling, safe travels.

Thank you.

[ Event concluded ]