Event ID: 2468259
Event Started: 11/7/2014 8:19:06 AM ET
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I have not. But I have heard about it.
Your boss wants to start. Are you ready?
Yes.
Good morning everybody. Welcome. We are going to get started and we are a few minutes behind and it is great to have you hear all downtown at the Humphrey building. A couple of -- we have a number of housekeeping things but I first want to welcome you to the meeting of the national advisory Council for the AHRQ health research and quality and we have a pretty full agenda today and are looking forward to that and I also have some important guess with that -- with us as well. As opposed to our usual up in Rockville and [ Indiscernible ] I would ask that when people speak and use the microphones today that you try to be careful about shutting them off as soon as you are done because apparently for some technical reason if we believe them on -- if we leave them on we will cause problems with the webcast and as you know we are being webcast as per usual.
This is probably an older building and it probably has some little bandwidth issues. You never know. But it is a great monument to a great society.
[ Laughter ]
Jane is clapping.
It is still here hi Jane. [ Laughter ]. This is our last meeting for a number of our NAC members so for Jane this is her last meeting and Michael Johnson and [ Indiscernible ] and [ Indiscernible ] and David pence it is not going to be here and get -- Harry I gather you as well and myself as well. So we are all I know going to miss being active partners with the agency but we will continue to be its supporters and friends and advocates going forward. The work is so critical.
I know we are going to have a little bit of shuffling in terms of attendees today and I think [ Indiscernible ] is going to arrive around noon so he will probably join us a little bit late and we also have a new ex officio member attending for the VA for David Akin's and that is Doctor Bob O'Brien here so welcome Doctor O'Brien. Let to have you. He is a scientific program manager for mental and behavioral health in the office -- Department of Veterans Affairs Office of Research and Development so we are thrilled to have you here.
In addition to welcoming the members I would also like to welcome our visitors and those on the webcast. We have a fair number of people in the back. In terms of some housekeeping things towards the end of the agenda today cop for those of you that are heading back to the airport and probably most you or -- most of your the train station probably the best way is to hail a cab on the way out. So it is pretty easy to get taxis here. If you need other or additional help, I think that you should probably go to the registration desk which is right outside and it is being staffed today and they can help you as well.
For those members who are referenced, whose term is ending at the end of November, we are asked to have her picture taken with the director during the lunch break so we are looking forward to that as well. With respect to the public comment periods, they are scheduled for 1145 periods, they are scheduled for 11:45 AM and 2:15 PM and we would ask that those are planning on making public comments sign in at the registration desk right outside the doors here. As well.
Finally I will just mention that here on the eighth floor there is the Humphrey cafe. Right across the elevator back there so those of you looking for a coffee or beverages or snacks and meals -- that will be open until 3 PM. It has an incredible selection of carbohydrates.
[ Laughter ]
Really. It is like a carbohydrate smorgasbord. Being enjoyed right now as we speak.
[ Laughter ]
So with that said, let's go around the table. We will have our members introduce themselves. Including those on the phone. I will start and my name is Bruce a single and I am the CEO of America's essential hospitals. I will go to my left this way.
Hi. I am Janie Zimmerman it, the AHRQ designated manager commission for anything.
I am Sharon Arnold the deputy director at AHRQ.
I am carry cell good Dean of clinical translational science Institute at touch University.
Good morning. I am Andrea Elsner chief medical officer for the amount health [ Indiscernible ] company of companies --
Jeff what firm is of Kaiser Permanente and now a senior adviser for seeing -- economic review.
Good morning I am Mary and I'm an internist and chief medical officer for health services advisor group which is a Medicare quality improvement organization.
Good morning. I am Bill way. I am Executive Director at Merck center for observational and real world evidence.
Good morning. I am Paul Sherman the exec the medical director for the help plans for group health in Seattle.
Good morning. Chari Davidson. Vice president of the national business group on health.
Hello good morning Sherry Lane deputy chief medical officer CMS here representing Patrick Conway.
Bob O'Brien. From the Department of Veterans Affairs Office of Research and Development representing David Atkins.
There we go.
Good morning. I am Jane Crowley from Mercy health in Cincinnati, exec the vice president and chief transformation officer. Suck good morning everyone. I am Greg Baker vice president of pharmacy for take care health systems. Back --
Good morning Carol for Massachusetts coordinator for the national breast Cancer coalition.
Good morning. I am Henry Haynes from Cleveland Ohio. I am the president of Generale health professions of -- LGBT quality.
Good morning. Mike Johnson. Regional director and soon-to-be practice leader for the home health practices part of be at a health care in New Jersey.
Jane Retford Executive Director of the Connecticut Center for patient safety.
Good morning. Welcome. Rick the director of AHRQ and I'm really glad to see you all here this morning. Thank you for your continued work on behalf of the agency and thank you particularly for those of you who are ending your terms and not thank you for ending the term thank you for the work.
[ Laughter ]
More about that towards the end of the directors update. We have an exciting agenda today or exciting to me. I hope it is exciting to you. We are going to start with some general updates. We should introduce people on the phone as well.
No problem.
I think we have David Broward and Ann hundred on the line. Are you with us?
Yes. This is David Ballard. I and chief quality officer for really white health in Texas.
Great. Welcome. And Anna -- are you with us? Hopefully she will join us later. Just before we start the records update I just want to do one quick order of business. We used to have minutes from the July 25 meeting in your folders. I assume that you probably have seen them or review them. Are there any changes or edits or comments on the minutes?
[ Pause ]
Hearing none, is there a motion to approve? Motion from Harry. A second?
Yes.
Any comments? No?
[ Calling a vote ]
The minutes are approved and I will turn it to -- okay. We are now going to turn it over to Doctor Cronin for the update. Just give us a second as we deal with the PowerPoint here.
Yes. The technology is being dealt with and Charlie -- we just did introductions. Could you introduce yourself?
Health statistics.
Thank you. Welcome. So the department -- lots of activity at the agency and the department and certainly a [ Indiscernible ] of much in the news and Jeff Brady director of Center for quality and pre-med and patient safety will be talking about our safety work and we will touch briefly on that in his presentation. As you all know I'm sure we are eight days now away from the beginning of open enrollment and lots of activity with the department and some supportive working in the agency although it is not the center -- we are and evidence producing agency and we are producing some evidence around this. In the department -- in the agency, a very exciting last four months. And I am going to spend some time on general updates probably in the middle that. [ Indiscernible ] the assistant secretary of legislation will come and join us but unfortunately Ellen Murray is not going to be able to be with us this morning. But Jim will talk a bit about the events of the last Tuesday and what we might expect on budget and legislation over the coming years and I will spend some time on collaborative work that the agency is doing with a variety of parts of the department as well as some of you folks not in the department. And here particularly be looking for your advice and input into how we -- and what directions we should be working at strengthening and building our collaborative work and then talk a little bit about a very interesting meeting that we had last Monday.
How to more effectively pay for value? A project that we started with our colleagues at CMS. Spend a few minutes on where we are with the quarry and our work in patient centered outcomes research. I will talk at the end also about the big transitions -- this slide just acknowledges a few important but from my point of view less important transitions. Congratulations to Greg [ Indiscernible ] who is not with us today and Henry on new responsibilities and Mike Johnson who is not listed on this slide. One other transition to mention -- last week I read Fraser, who is the director for the Center for delivery organizations and markets announced that she will be retiring in next spring.
Irene has done incredible work over 20 years, leading the center, creating the healthcare cost utilization project which I think you are all familiar with and we collect 97% of all the hospital discharges in that country and make them available to researchers all around the country and the world. The creation of the quality indicators that are used by many hospitals as well as CMS and others. As well as leading a body of work on trying to understand how to improve system performance.
Just a tremendously talented group of people. We are beginning recruitment and if any of you know of people who you think might be good candidates to lead this division, please do let me know. Center. Not a division. Sorry. I always get that -- sorry. We will have more opportunities to fetch Irene and locker work but I wanted to acknowledge that transition here and also asked for any help that you may be able to provide on recruitment.
One other transition I have asked and I'm very pleased that record charting has agreed -- Rick has agreed to be the senior nursing advisor for the agency and this is a position that was previously held by Beth call is sharp who some of you have worked with and she left to work with the office of women's health a few months ago. And Rick is a nurse practitioner. As well as a PhD. He works in the set up for evidence and practice improvement. He will serve as a liaison to nursing groups and most importantly provide guidance to me on nursing issues.
So I am very much looking forward to working even more closely with Rick and congratulate him and thank you. I think he is not here today. Assuming this post. A very brief budget update. Probably know from reading the newspapers that we are on a continuing resolution through our early December. Jim a will be here pretty soon and talk about what we might anticipate after that. Obviously a fair amount of uncertainty but Jim knows more than the rest of us.
Under the continuing resolution, are appropriated funds are $371 million on an annual basis and we are expecting -- with some uncertainty -- to get a little bit more than $100 million from the [ Indiscernible ] trust fund and certainly being that -- the treasury has to estimate received from the tax that is paid or the fee that is paid by employers for people with employer-sponsored insurance and that process of estimation turns out to be a little bit tricky. So this number moves around a bit.
I wanted to give you a sense of the grant activity at the agency. Because I know that that is of interest to many people here and certainly of interest to me. So this pie chart shows data mostly for 2014 although for 2015 we have got estimates for probably -- what we will be spending from that T core trust fund and you can see that the grant activity is about $170 million with about a quarter of that in purely investigator initiated grant so these are grants that have a pretty broad program announcement that says we are interested in research that will produce evidence that will improve safety and quality and affordability and accessibility and [ Indiscernible ] and are 18 and other sorts of applications come in under the broad announcement so about $46 million in grants that are purely investigator initiated but another slice of about $33 million in grants that are targeted at producing evidence to improve patient safety and Jeff Brady will talk about some of those in his session shortly.
$24 million in health IT primarily grants that are aimed at starting to figure out how health IT can be used to improve both quality and safety. And then a large $66 million anticipated in FY 15 of grants coming out of the peak corp trust fund and I will talk about those in a few slides and then again later in the director's update. So I show this because in part I think that there is a fair amount of focus on that first $46 million investigator initiated slot -- slice and that slice has been fairly constant -- a little bit of fluctuation but it has not moved up -- much over the last at least five years.
But there are a lot of other grant activity at the agency and the other activity comes from a targeted announcement but still we have quite a lot of room for initiatives and creativity on the part of investigators. As usual, if any of you have questions at any time on the way through, please do ask.
A few minutes now on updates of a variety of releases and activities since both the last time that we met -- the state snapshots that are connected to the national healthcare quality and disparities reports were released and Ernie Mori will be with us in the afternoon -- actually he is here now but he will be talking with us in the afternoon about that QR national healthcare qualities and disparities reports and some work that we are doing on revising them.
The state snapshots get quite a bit of attention in a variety of states and I do not know if any of you have ever looked at them but I think that they are quite useful for providing information on how a variety of quality and disparities indicators look in a given state compared to national average and other states. So for folks that are working on trying to figure out -- what are the problems that we should be paying most attention to? Very useful resource for doing that.
In September Rebecca Smith who is at the university of California San Francisco published an article in the New England Journal that came out of a grant that was awarded under -- under the stimulus bill as part of our choice initiative reporting the results of a study that compared the use of ultrasound and CT scan for patients who presented the emergency department with suspected kidney stones.
As some of you probably know, CT scan is kind of the standard of choice here. This study is randomized trial and concluded that ultrasound as an initial test seemed to do as well as CT at identifying problems with much less radiation. So probably quite a bit safer. I show the slide in part because I think it is a very interesting study. With important results. But also as a reminder -- we have discussed this in the past but I think a useful reminder of out a shift in the kind of work that the agency is doing.
So this study was spent -- funded under [ Indiscernible ] as a said and with the enactment of the Affordable Care Act and the us Dalglish went of the core -- the patient-centered outcome research is -- this kind of work is not in the portfolio of the agency. So comparative -- this is kind of a classic comparative effectiveness or now he core study comparing pigment A to treatment B and our job and I will talk about this more at the end but just as a reminder, our job at the agency under the Affordable Care Act is to figure out how to effectively disseminate the core and how to train peak were researchers and but the responsibility of generating the core is per Cory now and I will talk about that some more at the end but I think that we are repeating because it is an important shift and this is a shift that is -- well predated me coming to the agency but I think it has taken a while to really socialize and make sure that people understand.
I am just going to say this because -- and I speak this from my heart. What AHRQ -- the studies that AHRQ has done and could do and comparative effectiveness are different than what is being promulgated at the Cory and it is wonderful and leave me anyone -- anyone who has a family member or has been a patient in our healthcare delivery system knows that it is -- it is desperately important for us to have advocates and patient and consumer input to research. That CENTCOM the -- it is not even the quality. It is just a completely different kind of research because of that input from the advocates at PCORI. That is my feeling and my observation and I just want to put it on record that I think we are losing something that we are not getting the scientific comparative effectiveness research that AHRQ has done so well.
I appreciate the kudos for AHRQ. I think that my sense and I am on -- I am on the board of PCORI. It is that PCORI started with very broad funding announcements. In part because they were standing up a new organization that was the surest way of getting started very quickly. The board and they have said this publicly. It is moving toward much more targeted approaches. They have a solicitation and will still -- assume that these funding the first round are part -- pragmatic clinical trials and beginning the work that certainly patient-centered but in terms of the nature of the work will have much more work that is this kind of comparing what happens with treatment A versus treatment B and one example and this is actually under the broad announcements but one of the other studies that came out of our choice initiative was work that compared -- a look at the effectiveness of the use of corticosteroids for patients with lumbar stenosis and I think I mentioned this at our last meeting.
That study that we funded looked at outcomes through six weeks. And PCORI has funded a follow-on of that for follow-on outcomes so PCORI has a very broad portfolio but they are -- as far as I to stand they would be very interested in your and others sends -- also funding quite a bit of work and I think I expected to be funding more work that will be providing information about the comparative effectiveness and alternative treatment options that should be very useful for patients and clinicians in trying to make decisions.
I wanted to -- I do not want to pile on too much but I just want to say that I think it is very important that you make that clear to the world and what the distinction is so it is not the sense of redundancy. However, somewhat of a nuanced ascription -- description of what PCORI does not do would be helpful and so for example in that private -- pragmatic file of whatever it is called -- anyway, whatever it was, for example, they only wanted to compare already in use FDA approved treatments or strategies. You do not have to do that actually. You can use more innovative things so I think there is a number of other places where you can compare to the [ Indiscernible ] research you can use things that are not already in general use and one of the things that is on the -- I think this is on the AHRQ website and it certainly was part of the FCC and CDRs comment is there should be a comparative effectiveness research on things that are off label but actually by definition the PCORI cannot use off label things really because that is not said to be a common use so there are areas where really important thing will be missed and NIH says that the [ Indiscernible ] does not do that kind of stuff either so I think that there is a -- there are some major states in that nation of CR that probably still should be targeted explicitly in -- and articulated.
So I guess -- we function under the direction of the Congress. And my boss the secretary. And so this is not a decision that I have made. This is a decision that Congress has made. They have said we are not interested in having you do comparative effectiveness research and they have created PCORI to do that. And for instance Francis Collins and I are on the board all along with 19 other people. We are working at trying to assure along with our fellow board members and the very talented staff of PCORI -- substantial resources that those resources are used to produce the kind of evidence that is needed. But I appreciate your point. I am going to actually -- we have got --
Just one second if I could. If people could just put their cards up when they want to ask questions that would be helpful but let's let it go little further and we will come back to questions in a minute if that is okay. We will come back to you. I promise.
Very delighted -- I am going to cut this down and we will come back to this but I wanted to take advantage of the time that -- of Jim who is the assistant secretary for legislation in the department. He has been that since the very beginning I think. Or close to the beginning.
The only confirmed person on the job anyway.
[ Laughter ]
Yes. I have learned a tremendous amount from Jim about how the Congress works and in some cases does not work. And Jim has done an incredible job managing HHS relationships with the Congress to the extent that that can actually be managed. Dealing with oversight over the last few years and I imagine that might be a larger part of the job moving forward after [ Indiscernible ] a little.
Yes.
Jim was in the staff in the Senate before coming to the department and I and my colleagues in the department have benefited greatly from Jim's leadership of AFL and I am delighted that he is able to join us this morning. To talk a little bit about what we might expect over the next couple of years and Alan Murray was scheduled -- the assistant secretary for finance and -- finance and something. The budget office here -- scheduled to be with us but she has got -- she can hardly talk this morning and has deputized to Jim or asked Jim to handle both budget and the legislature and which are probably pretty closely tied these days. So welcome Jim. Thank you very much for coming.
Thanks for inviting me. So as some of you may have heard there was an election this week which both simplified and complicates what I am about to tell you. It is simplifies it in the sense that anything -- now we are in the world of conjecture. I think that the new leadership is trying to figure out what they would like to do as well over the next several years. So I could spend days with you speculating as to it all but all all of the different things that they could be doing but it is not worth your time so let me just sort of say what I think is going to happen and what we still have is a lame duck and what some parts of next year might actually look like and what they might focus on.
First there are still a [ Indiscernible ] calendar and they do come back next Wednesday and that is to say the Congress. But the house calendar -- they are about 17 legislative days. So at this point, there -- they are zeroing in and they were schedule -- the house is scheduled to be done by December 12. I see no reason why they would not keep to that schedule. I think that there are a lot of folks who probably just want to get the your over and done with and there are a hold things that they do need to get through in order to be able to leave with a clean conscience come December 12. One of those things obviously is funding of the federal government.
There is a continuing resolution that takes us until December 11 -- the date before they are scheduled to take off so my expectation is that they will be getting that work done. The question there really is -- what are they focused on? Do they focus on the appropriations bill which is essentially taking all of the appropriations bills and federal policies they have got in those and just past those and then we are funded for the full year? Or do they focus on ACR? And then on the sea front, is it a short-term CR? Do they go from December 11 until early next year? Or is it a year-long CR?
Again it is really unclear. I think that the GOP has to make up their minds about what are they more interested in -- are they more interested in getting is -- clean slate so they do not have to worry about these things when they come in in January and take over management of both chambers? Or do they -- would they rather hold off and have more of a say come early next year on what is left on these priorities and thus sort of focus more on a short-term CR? These are all important decisions and I have to say that they once again will all depend on how badly folks just want to go home and call it a year.
Also on the appropriations side, I know appropriators want to get their work done. They have been working on these bills. So the question is how close are they bags to getting them all done. How close are they to sort of coming down to some final compromises that might lead to everyone just sort of holding hands and saying yes. These are the appropriations package and let's go to work and get these past. I think there is still a little more work to do that. That is going to slow things down a little bit but that is going to slow down just a little bit because on the very first day that they get back they will have a [ Indiscernible ] on the Senate side -- the full Appropriations Committee secretary testified and J Johnson of DHS testifying along with folks from DOD.
And a few other folks. It is going to be eight people sitting at a panel and our appropriators asking a series of questions about the very important emergency funding request the administration said that just yesterday I believe asking for a little over $6 billion to help us manage this evil a situation that we currently have. One is to really try to fight this thing at the sores which is what we need to do and also just help do what we need to do to continue protecting the country here. So there is -- that is not all. So in the days remaining they still could want to focus on tax extenders which is sort of a yearly ritual.
There are always a bunch of tax provisions that they are set to expire. We always have to sit around late in the your and try to figure out how to pass them and how to pay them. It is sort of an interesting exercise that you might wonder -- why don't we sort of past is permanently? Because these things cost money and in a lot of ways it is just easier to do these piecemeal and year by year. I know the White House has always continue to be a very -- in a broader sort of tax reform context to deal with these extenders but I just do not think that will be happening in December is what my senses.
Also out there there is still a defense authorization bill which they will need to get done. And the other big item on the fence I -- nominations. There are still a number of nominees and that we have out there. I think there is a desire on both sides to get as many nominees done in the time remaining on this as possible because what will happen is since this is the get of this Congress there will be a new Congress starting in January which means all of the nominees will be returned and -- after being nominated sent up again early next year.
Kind of a lot of work. So hopefully we can get some of our folks done and again, because of workload issues, I think our Republican friends probably will also try to be a little helpful on that front because it is more net -- work for them next or if -- if they do not need to do it then we should just go ahead and finish that off. Then there is January. I think it has been widely reported and it is not true that Republicans are thinking about -- what are they going to be doing? As early as next year.
I can, -- I can I think there are some conflicting pressures and the new Republican management will have to deal with and there will be the early desire to get bills on the floor and passed. That sort of speak to the base. Particularly as it affects the ACA. There have been more than 50 repeal ACA votes in the house. There will be another probably. Early next year. With the hope on the house side that that will also pass on the Senate side. Mitch McConnell was quite right when he reminded people that there were two numbers that he was very focused on. The number 60 and the number 2 -- the number 2 -- the number of years left for this administration and 60 -- the filibuster number -- the number that he needs to get to break filibusters so that was his way up I think reminding his caucus that it is not a slamdunk. Right?
We still have to work and they are making noises about -- and overtures about wanting to work and try to find places where things can get passed and sent to the president. So a lot of what they are saying is that the vote that is earlier this week was about peoples -- people being fed up with broken government and wanting to get things done so that means they have to get something done. Right? And that means that they still have to work with the Democrats to get something done. They still have to work with the administration to get something done. Because to be honest, I know that we just finished this election cycle but they are always -- already think about 2016. Right? It is a presidential election year and it is also a year that is at least from a Senate perspective, it is a tougher election landscape for Republicans in 2016.
They will have more than double the number of Senate seats up then the data -- Democrats will so they have a lot more territory to defend so again, I think there will be a lot of pressure to actually get something done and to actually speak to their base and to actually sort of highlight what Republicans stand for while at the same time still try to find little places or big places where they can get something signed by the president. There is a narrative out there that the -- a lot of folks have been sharing about the only time that big things happen is when there is divided government.
In this case the Democratic president and the Republican Congress has been hardened back to the days of the Clinton administration where I started my career as an OMB analyst fresh out of grad school in 1994 -- I was explaining to someone that I feel like I was in a career -- my career was born out of this world of the political back and forth because I showed up to OMB in 1994 fresh out of Columbia. Several months later, the Democratic majority in the house that was in power for 30 or 40 years had banished the resolution of the guy -- so I never really had and experience of the ironclad Democratic rule over anything in the house to be honest with you.
So it is -- this is sort of what I am used to a little bit. You know? That first year and a half I was dealing with the government shutdowns and I was also the FDA [ Indiscernible ] and as you may recall, the speaker get rich had a particular zeal -- a particular anti-Republic radio so he was making the FDA the poster boy for everything that was bad about the regulatory state so I spent a lot of my time defending FDA -- FDA working on that resolution and still wishing medical devices so that is to say that I am trying to explain to our colleagues in HHS -- this is not our first or second rodeo.
Rick mentioned that there will likely be more oversight. We have had the oversight. It has been pretty tough oversight for the last several years. I do expect the Senate to do a lot more of it as well. Although to be honest with the they have been in the game too. I think what is different is that now they've -- there will be chairing committees and they will probably be demanding more information and more documents perhaps. But I think that -- this department -- I have prided myself actually in being very responsive and being evenhanded with both sides and actually -- I have always been a big fan Arbor oversight to be honest with you and I think there is an appropriate use of government influence and power.
It is what the people -- the American people expect and good oversight is not -- oversight is not a bad thing in and of itself. So appropriate oversight is what I would like to refer to it as. But nonetheless. So that is really the gist of it. I think that for political junkies this is really interesting. Unless you are on the losing end of this. So yes. I am walking around a little conflicted because I am wearing my pretend of political sciences had and so this is really interesting and this is democracy at work.
It is also really interesting to get a sense of what the electorate was actually trying to say. Right? Because we have more Republicans and lots of surprises on the gubernatorial side but then there were some social issues on the ballot that were passed there were really -- I don't know -- just conflicting messages. Like for example the ballot issues on the minimum wage -- that one big -- not a little bit -- in several color red state so there were some interesting messages being sent and that will take us days to sort of try to decide for what it all means.
That is really -- I wish I could give you more definitive answers as to what is going to happen but I think that everyone is in the planning stages right now as to what they think is going to happen. All I know is that back next week I have got a hearing on Wednesday and I've got three Ebola hearings after next week as well so my work is not done and the departments work is not done in the department is never done and it is a huge department and the stuff that we do is amazing and impressive.
But we have two years left in this administration and there is a whole lot more work to do. I know that people are looking forward to just focusing on the work and continuing to try to do good for the American people. But in any event, I will leave it there.
I will take a few questions -- and then I am on off to a Ebola call.
A quick question. There has been talk about using budget reconciliation rules to maybe effect the ACA -- do you see this as a filibuster? What are your thoughts on that?
It is a topic near -- I do not know if it is dear to my heart but it is near to my heart because is Rick mentioned I was actually on the Senate Budget Committee and I worked for Ken Conrad for a little over 10 years so I have done a few reconciliation bills in the Senate. It is a tough process. It is not as easy as people make it sound. Yes. It is attractive because it is -- you cannot filibuster a reconciliation bill. It is time-limited. Very limited to the type of amendments that you can offer a but here's the deal. You cannot get to a reconciliation bill unless you have a budget resolution -- it is the budget resolution that provide to the authority and parameters through which you can have the reconciliation bill. Before I get to a reconciliation bill, they have got to do a budget resolution. And the budget resolution is -- explain to people when I was on the Hill -- it is probably the most political document that a committee produces which is sort of fine because it is just about numbers but the budget resolution is actually about policy. It is where a party says, Ellen used to tease me a lot about this because you guys -- sort of talk about aggregate. You do not really get into the details. And she was right. But it drove things. A budget resolution is listed as priorities -- it give you the big picture. Right? And that is why Paul Ryan for example has really used it to good effect as the budget care. -- Care. He is Mister vision. Right? He has -- he is focused on the government and what it does. And again you may disagree with it but he has been trying to be thoughtful about it and really has tried to get a handle on what his governor should do and that is what a budget resolution really does is provide you the aggregates but also gives you the highlights of what is important to the party and what the party and what the Democrats and Republicans want to focus on for the rest of the year. So the reconciliation is a tool that is in that budget resolution. There will be a desire to want to use it but the question is -- how do we use it?
What are you trying to pass? I think that it is easier to talk about repealing the ACA then it is to actually do it and sort of describe to people what it is that you are repealing. Right? For example, I think that Mitch McConnell was asked directly in Kentucky -- he said that we should keep the executive exchange or the website -- right? That is not -- it was not sort of a standalone sort of thing but it was connected to a broader sort of context so that is where they really have to sort of focus on -- and oddly -- maybe this is an opportunity. Right?
So if there are things and I think that all along I think that people have waited for the Republicans to engage on -- to try to fix various things about the ACA because the AC was not perfect. It did a lot. But any piece of good legislation can still between. So this may force a really interesting conversation. Right? What does it actually mean to repeal? And if it is not really repealed cut then it has got to be tweaking it or [ Indiscernible ] in some way that is actually more appealing and makes more sense to the states that these folks represent. So that is a long-winded way of saying yes. They are thinking about it. But it is unclear where they really want to go with it. And what the thing looks like.
Also keep in mind that it is ACA and is also taxes. This could be a reconciliation bills -- they generally are big and they can often do a lot. And touch a lot. So we shall see. But again, if it was not so serious that this is really interesting. But anyway.
[ Pause ]
Anything else?
If not, thank you so much and please continue the good work. Rick is awesome as to what he does. And that is one of the pleasures -- it is one of the pleasures that I have working here. At HHS. By and large I love the Senate. It was a great place to be. I think the idea of a Congress is a brilliant idea. It is a leap of faith. It is. The idea of a Congress is a leap of faith that we can go in ourselves. Right? For that, I will always -- I am always -- I love the idea of a Congress and I wanted to work. And I have a lot of respect for people who step into the arena to get it done. Just as I have a lot of respect for the people who actually on the executive side actually have to implement and do the work that the Congress has authorized us to do.
And doing it under tremendously tough circumstances and Rick has really -- he is a good example of the type of impressive leadership here and just impressive -- [ Indiscernible -- multiple speakers ]
Anyway.
[ Laughter ]
Sorry. Thank you so much.
Thank you.
I appreciate it.
[ Applause ]
We will continue the conversation that we were starting. I will let Bruce manage the flow.
We had -- I know that you had a question. I think you also have a question. Anybody else -- please put your cards a. We will start with you. But thanks. So Rick I want to go back to the role of AHRQ in disseminating P-core and you mentioned that spinal stenosis and corticosteroids and the question has to do with how active of a disseminator AHRQ is -- does it only say that here's the data and you decide what to do? Or would it perhaps go a step further and say that this practice is unaffected? Maybe wasteful or perhaps even harmful and these other things that we are doing to actively discourage its place in the delivery system?
That is a really good question. We have a variety of activities and dissemination now and I will talk more about some of them in a few slides from now. We do -- part of our effort here is through the evidence-based practice centers where we as the EPC's to review systematically review the evidence in a given area and there are many EPC reports every year. We then through the Eisenberg center convert the results of those EPC reports into clinician and patient friendly summaries. So we do in a variety of areas review systematically review evidence and try to make sure that that evidence is available to patients and clinicians and we also work with specialty societies or developing guidelines and trying to make sure that they have access and understand that evidence and as David Myers talked about in the last meeting and I will briefly mention again, we will soon be awarding grants to a variety of grantees and using practices to make sure that they are able to incorporate evidence so our role is I think much broader than simply having a study published and we are working both internally and with PCORI to try to flesh out exactly what we should be doing in dissemination. Because it is -- there are as you know many findings and one of the questions is which of them should be disseminating? And Bob Chaplin is the chief science officer and is leading an effort to try and develop a systematic approach to look at public health burden and the gap between knowledge and practice and likelihood that dissemination efforts will actually result in changes to help us prioritize and focus. But broader than simply having something college.
[ Captioners Transitioning ]
The chief science officer is here leading an effort to develop a systematic approach to look at public health burden -- the gap between knowledge and practice -- the likelihood that the dissemination efforts will actually result in changes to help us prioritize and focus. Try to get something published.
We are not only focus on disseminating messages to clinicians and petitioners we are also trying to work with other payers and folks with power to have a little more care. But our regulatory tools are limited. We don't pay for care and we don't regulate providers. We need to provide evidence and information and work with others to try and accomplish changes in the delivery system and that is what we are trying to do. Much more so than just -- here's the evidence -- go for it. We're trying to work closely with partners and we welcome suggestions on how to do that better and more.
[indiscernible] Thank you very much. I have been a reviewer of PCORI four or five times. I think what everybody -- I can talk to you more later about the experience, but I think what everyone is missing -- all the research -- how the care is delivered. We're in is delivered. It doesn't fit into any research framing people are used to. We knew that the community health workers and public health support makes a difference in the outcomes and yet when I was looking at your eye and the 5.4 million going to Frenchman care management, it seems that we need to enter quite dealing with sickness and better deal with hell. I have always appreciated the AHRQ research. We always get we talk about how people to implementation and somebody will say --
Intervention/is a part of the budgeting -- a line item to work the research. The line item -- in the present proposed budget for 2015 has gone away entirely. There is research on prevention and a lot of work on care management throughout the portfolio, particularly in the trust fund part -- the understanding about dissemination of p-core insistence and love this is around care management and so we provide support to the task force -- one of the many wonderful things that the agency does where prevention is front and center. Your point about medical school -- I will talk later 20 and a little bit about the work we are doing around training p-core researchers -- that not the same as changing the curriculum in medical schools, certainly an important point.
Hello -- thank you for your explanation of the situation that AHRQ is in. Many of us don't agree but those decisions have been made. I understand. I have a specific a question related to some of the programs that AHRQ has been before in this area -- like the evidence-based practice centers. Is that program and risk? Is a great program. I hope it is able to stay.
That program is an important part of what we do. Funds come from the program from a variety of sources -- some out of appropriated funds. Some patient safety for us. From HIT and some from other trust funds -- is a part of the dissemination activity to be able to synthesize and to systematic reviews of evidence -- this is the first part of the dissemination. We have redundant the EPC work and we will be a warning new rounds of contracts relatively soon. It is an important part of what we are doing.
I should emphasize -- make sure there is no misunderstanding -- our role in P-COR is a result of directions we have received from the Congress. Not choices I have made in the last year in the job for choices that Carolyn made before that, but we received bronze -- funds from the trust fund and stated that the -- this was to do training. We have also received appropriated funds but they are not to be used for classes in comparative effectiveness.
Those were purposeful instructions, I'm sure. Carol?
Thank you again. I appreciate this discussion. Learning more about the differences between PCORI and AHRQ although it is still have the in a lot of areas. To the question of dissemination of information, I received emails requesting from PCORI input on how they can better disseminate information. That struck me because I thought the role of AHRQ -- I thought PCORI was research and AHRQ was to disseminate findings. Can you address that? Is that something where they should be collaboration?
Yes. There is collaboration and clearly should be. Working closely with PCORI on both the dissemination strategy and the efforts that PCORI maybe making around dissemination. They had a contract that will be finishing up relatively soon to provide some advice to PCORI about dissemination strategies -- there is a meeting on December 10 that PCORI will hold. We are quite involved with them on the planning side. This is to get input into the contract -- the contractor will present some preliminary thoughts about dissemination. So, we are working closely with PCORI. I think PCORI is in the position of having funded 300 or more grams and brought announcements getting ready to find pragmatic clinical trials and target announcements. And they are asking -- when the results are available, what should be done in dissemination? And we are working with them on coming up with answers to that.
And is the goal of dissemination, then, -- being disseminated -- are appropriate audiences being identified to disseminate the information to? There, what is the implementation plan following that?
Does this pertain to AHRQ or PCORI ?
The dissemination and implementation.
All the above.
You point out the challenges. There are audiences -- many -- clinicians, patients, health systems, payers. How to get information into their hands in ways that they understand and use. The implementation challenges are clearly there. We all know the classic stories -- a 17 year gap between when information is produced and when it is practice. This may not be right but whether it is a 17 are 10 -- there is clearly. We are working on how to reduce -- narrow the gap.
I guess I want to suggest, then, in identifying the various audiences -- patient groups as well as public community groups as well as the medical and health services community that the messages may have to be different. But they need to be understood.
I wanted to make a comment. PCORI is a different animal. Created underrate certain set of political circumstances -- a different governing structure -- it had to go through its own web of from 0 to 60 and now 120 miles an hour in the next couple years rate is sensitive to this and he will carry it back and frankly I think some of these things are -- the nature of hell this is created and hopefully over time they can be rationalized. There will be bumps in the road and there will be gaps. Many times this -- things may not be as clear as we would like for them to be. We try to influence that is much as we can.
Thank you, Bruce. I was struck by your comments about your observations -- participating -- it struck me that there are different parallel tracks that PCORI needs to make sure -- establish -- as a part of the process and a part of their chunks of research that they do. Something like ultrasound versus a CT scan evidence. I'm not sure for that kind of study we need a bunch of patients weighing in. I don't want to throw out the baby with the bathwater, moving this work to PCORI. It's fine -- whoever does it, it just needs to be done. That said, how do we and how to different stakeholders influence Congress and make sure that they hear us because -- I don't think we let the politics of advocacy constraints the process. That is something that I think many of us are observing.
I would probably lose my job if I give you advice on how to influence Congress. I'm not supposed to say. I'm not sure if I would lose my job for this, but there are many ways to influence PCORI as well, as you know. And organization that is quite open to public input. I think that when you look at the portfolio it has been evolving over time, but as I said, the study we did -- we funded -- the use of article steroids for people with lumbar stenosis, -- they could easily -- I have looked at the portfolio -- whether they are letting this -- I would be surprised if they are not. They will be funding much of the kind of work that you suggest -- rightly -- is important.
Thank you.
If I could add a couple of things -- we will go to [indiscernible] and then we will cut it out there. PCORI have a Board of Directors publicly available. They are on there and make the decisions. It is not an agency way that AHRQ is organized. So I think that one could certainly talk to those individuals as well as influence the process in other ways. I think they are fairly transparent I have served on the review panels and I think that the patient voice is important and it has been there. My experience is that there is real science there, too. The level of science and the clear message that we don't do that science here, no matter what people think. I think this is central and critical. Well articulated. I don't think they see the patient voice and assigned as being contradictory and they also hold the highest standard and I think that that was well delivered and consistently delivered.
Mary and then we will go on.
Being a representative from the quality improvement organization community it would be remiss of me not to mention -- in terms of translating evidence and incorporating it into practice, you have QIO that are some the ground working with the writers on a daily basis -- a complementary effort for you to consider.
Thank you for raising them. I will talk a little bit about a variety of collaborations and ask for your advice on where and how to strengthen -- the QIO from July and -- we are doing some work there and Jeff will talk about is a little bit. Work we've been doing around safety both in the hospital and also now in nursing homes. We have an exciting new project working to improve safety and all and pressure ulcers in which the QIO be a central part. I am mindful that we have 45 minutes left and I have 26 slide. This is been a great discussion. I appreciate this.
If you want to show your slide -- [indiscernible]
[laughter]
We will move quickly. There is more discussion I would like to have.
This is a reminder an update -- at the last 18 David Meyer spent time discussing the funding opportunity announcement that -- interested in up to 8 grantees to work with small and medium practices to improve their ability to incorporate P-COR with that particular emphasis on improving performance on cardiovascular risk factors. We are currently reviewing and have a robust response to 2 funding opportunities -- one for the grantees to do the work, each of whom will have a substantial effort evaluation as well as an overarching evaluation we are reviewing those proposals. We expect to make awards in early 2015. Second, we talked about this -- again it is an important initiative. It is for the slide. We should a funding opportunity announcement in July saying that we are interested in to three center funding -- centers of excellence that with study what health systems are doing to implement patient centered outcomes research. This is a and to the previous initiative -- a book and.
This is focused on systems work -- delivered by health systems. This is important to figure out how to effectively disseminate P-COR to understand what systems are doing and which ones have been successful in what they are doing to be successful and how that relates generally to system performance. That announcement closed October 17, I think. Again, a good group of applicants and we will review those soon and aim to take awards in the first half of 2015.
I also want to mention briefly that we are working into merrily on -- into girly. Measuring health system performance. This is work that we will do with Medicare claims the data to try and define health systems and measure their performance on resource use and quality. I'm excited about this work. It is a fairly long lead as you can imagine. Difficult to do. I also think that the work we are doing will help us to a better job of managing and working with the centers of excellence to have internal expertise in this area. I want to provide an update on newly formed this summer a center for evidence and practice improvement. The goal here -- David talked about this by that of the last meeting. To have a focus in the agency on accelerating practice improvement and to the question -- management of evidence-based practice Center's -- as well as the support for the US preventive services task force work on health IT. This is exciting work on decision science and patient engagement and the division of practice improvement -- you can see the directors have been named and are a great group of people. We're conducting a national search -- a posting that closed a couple of weeks ago -- we will be receiving the actual applications soon. I've seen the names and they are a talented and exciting group of folks, I think. We look forward to that.
I see a number of [indiscernible] going on I will keep going and then Bruce is keeping track.
Since the last meeting the task force has been active as always -- I will not read through the list of final recommendations. [indiscernible] will be releasing the annual report to Congress and high-priority evidence Highlighting areas in which better information is needed to be able to make a good decisions about what services should be recommended as a capital a or B. There has been some press coverage on this recently -- the task force is in process of reviewing recommendations screening for breast cancer and I'm sure you remember the excitement in a 2009 when the task force made it recommendation. They issued a draft research plan I believe last spring and received mostly quite positive and some constructive comments and issued a final research plan in the fall. On schedule to be issuing a draft recommendation next spring. I am sure there will be more on they come out.
We initiated and Bob Kaplan took the lead on initiating a directors lecture series for thought leaders for stimulating discussion on leading health policy issues. The first speaker was David [last name indiscernible] a professor at Northwestern in the school of medicine. He has been leading the effort on promise at NIH developing patient reported outcomes measures and David gave a great talk on the use of [indiscernible] in research and even more interesting in clinical practice. These are measures that were developed for researchers. Increasingly they are used in a variety of [indiscernible] Is that on the website?
I believe in it.
Not yet.
It will be.
The directors lectures are webcast and we will send them out to the NAC members -- they are welcome to join. The 2014 health plan survey chart book was released recently. The headlines from this -- slow but steady improvement in patient reports of their experience with health plans over the last seven years or so. This concludes information from Medicaid and Medicare beneficiaries but not from folks enrolled in private health plans. This information is through MCQA. Experience reported by adult Medicaid beneficiaries continues to lead -- below that for Medicare but it has been catching up over the last seven years. The trend line has been for more rapid improvement among adult dedicate beneficiaries but still below that were Medicare.
We released the 2014 update on the national polity strategy recently. Reporting on private sectors work in this area. Particularly on measurement alignment efforts ongoing both within the federal government and the private sector as many of you are aware. A big area -- too many measures are similar to each other but not quite the same. Understandably this drive speed providers crazy at many of you can tell me more about that. We are working within the federal government trying to align measures and make some progress although there is still a ways to go on that.
Very good news -- recently we received a $2 million grant from the Robert Wood Johnson foundation to implement a medical organization serving as a part of the medical expenditure panel survey. This expenditure panel survey -- many households around the country. Then we surveyed the providers or a sample of the providers to get more information about the services provided and how much was paid for them. We have not asked other questions of the providers. Funded by [indiscernible] -- Robert Wood Johnson -- we will survey providers to understand how they are organized. Part of a solo practice? Larger group? What the ownership structure looks like and what the care management process looks like. They are quite excited about the ability to link that information to the household point where we know what you're was provided to begin to get a better understanding about the relationship between how providers are organized and the processes of care and what they look like and what kind of care is actually delivered. We are grateful to Robert Wood Johnson and quite excited about this initiative.
Briefly, we issue through all the healthcare organization project and [indiscernible] many statistical briefs. I will not track you through all of them but a lot of interesting information and useful information I think. The next five are from a [indiscernible] -- opioid overdose -- overuse. The rate of hospitalizations for opioid overuse almost doubled between 2002 and 2012. The pattern of hospitalizations for opioid overuse democratized quite a bit. In 2002 hospitalizations were much higher among young people as you can see in the graph -- 25 to 44 years old. Not shown on the graph -- much higher among men than women and also much higher in the Northeast and the rest of the country. That's not on this graph it was way over double in the Northeast. 2002 -- young man in the Northeast. Much higher rates than anywhere else. Then you can see here that the greatest rate of increase was among 45 through 54-year-old. A higher rate than among the younger folks. Also a greater rate of increase among the elderly and not on the graph the geographic footprint has been much more uniform. Hospitalization rates are still somewhat higher in the Northeast but pretty close and men and women are virtually the same. Democratization -- 2002 it was a fairly concentrated problem. The increase that we seem is frightening over the last 10 years -- a spreading of the problem to a variety of groups that were much less affected in 2002. Many efforts in the department and outside in trying to make progress.
[indiscernible] More than double, yes.
An interesting -- I think if you Google AHRQ opioids it would come up.
How many of you are familiar with the horizon scanning project? It is worth a couple of minutes. This is quite interesting. Worthy of some attention. We have a contractor that scanned the horizon by reading the literature looking at statements made by publicly traded companies talking to folks to try and see what is coming down the pike in medical care. Plus, devices, procedures -- drugs -- what might be there in a couple of years that is not there now? The contractor follows a large number of such items -- the notion is to follow them for two years plus marketing or post implementation as well as a couple of years while they are coming. There are few people in health plans that have used this information to try to anticipate where they need to make coverage decisions. More recently I have the contractor to try to use this information to see if they can produce some estimate about what the anticipated effects of the new stuff might be on spending. There is obviously a tremendous amount of uncertainty for many items -- what the update will be and the pricing will be. For decades we had a notion that healthcare spending has been driven by technology. Growth of technology. But at the micro level no evidence about what the relationship looks like. Again, we can send the website for this but I would be interested in feedback and we are initiating a small evaluation to try and get a better sense of whether this is useful or not. I would be interested in your feedback on this if you have a chance to look at it. Whether it is useful or not. If it is useful, how can it be made more useful?
I will skip to the next 2.
I wanted to spend some time on what we are doing in collaboration -- led to a few minutes of questions.
I will go to Jean and Michael first.
Thank you. I go back to page 6 -- comparative system performance initiative. This is really exciting. People are getting carried different places now with high deductibles they go to the walk-in clinics. Will some of this research provides information about where people are getting care and the quality of the care?
The question. The work we are doing intramurally will be with Medicare claims data. The 3 centers of excellence that we will be funding -- up to three centers -- may well be looking at those questions. Certainly of the centers in the work we are doing will try to understand about policy outcomes. Work we are doing internally with Medicare claims data is limited to what one can figure out about quality outcomes and claims data which is something, but limited. The three centers of excellence are much larger efforts. I expect this will be much more robust in those areas. As I said the application came up recently and we are reviewing is now to see what they are proposing.
Thank you. I will stay on page 6 with the slide below.
A couple of comments in a question. The idea of the center -- particularly the division of patient engagement is terrific. My observation -- maybe this leads to the question -- to be it is always patient and provider engagement when I hear the term patient engagement we have these discussions -- the question is -- is it a problem or opportunity with the MDG or engage were? -- MDG -- engagee or engage or? My broader question is -- what is your view of the move toward this kind of research -- more social science research? I will call it in our organization we have 3000 collisions delivery care to 3000 clients every day -- versus MPT's and of these great solutions --
What is your sense of how AHRQ will help in this area?
We are focused on implementation questions. Producing the evidence doesn't matter. What is needed is how to get information into the hands of clinicians and patients and get it used and change the flow of practice and a lot of the work that Jeff Brady will talk about the safety area -- deeply involved with these implementation questions. We'll try to figure it out the soft stuff has become behavioral economics and now it is hard stuff.
[laughter] A follow-up -- the slide related to the Robert Wood Johnson grant will it collect the contextual data -- this is exciting because it is moving in that direction. Thank you.
Let's do this -- I will go to Paul next. Then I will ask [indiscernible] and James to hold the questions. There is a fair amount to go through. All?
-- Paul?
Slide five -- maybe it's the way that it is. But I worry that sometimes we say we are looking at the quality of the system -- specifically dissemination of P-COR, you are presupposing outcome. Stated a different way, in addition to disseminating P-COR will there be a look at implementing this by improved care rather than defining --
Very much so. That is what we asked in the funding opportunity announcement. We are reviewing the applications but I would suggest that the applications will do exactly that. I
I want to talk a bit about some of the collaborative work and ask for advice. This highlights the importance of collaboration. Jeff Brady is when to talk much more about implementation safety. I will mention here that it is deeply collaborative and the bullets that we are excited about -- the numbers for 2013 -- this is not quite ready to be released yet.
Good news is coming up thing. -- I think. We worked closely on the technology assessment and I think it may -- in the interest of time -- I will not say more this -- I would be happy to discuss this.
The secretary and department is very focused on a delivery system. Clearly there has been tremendous attention over the last five years -- 4.5 years -- the implementation of the coverage expansion.
These parts of the affordable care act. But equally as important is the work on supporting transformation of the delivery system. Obviously this is an enormous task. The slide says that we are working with our colleagues in CMS and ONC and healthcare reform and other parts of the department, particularly around transparency and information issues as well as the development of measures.
We do some work -- I would be interested to hear advice on deepening the work with private payers. Much of it with the national business group on health and [indiscernible] Davidson is deeply a part of them. With other peers as well. Mostly on the trying to make sure they have access to and can suggest topics for the reviews at the evidence-based practice centers to and work on trying to have translational products that come out of them. We had some conversations and some work around the transparency question, particularly how consumers get better information about quality and price at the time they are making the decisions. We done more work on the policy side and the price side. We recently awarded a contract to work trying to develop measures -- consistent measures across the data bases. This is an area very much of work in progress.
We are working with NIH and a variety of areas, most recently planning for a conference on the science of dissemination and implementation -- to answer your earlier question -- there are a lot of people involved in this space in NIH and they put a lot of effort into this as well with any other partners.
-- Many other partners.
Let me go through the rest of this. I mentioned earlier that we had commissioned a set of papers on trying to suggest a research agenda about what we need to learn to do a better job of paying for value and not volume. This is the mantra -- we should do this. It is obvious. Our colleagues in CMS are working incredibly hard and creatively to figure out how to do this. As former president Bush said, it is a really hard a problem and there has been a lot written about this. The reasons it is our -- it is hard to measure value in ways that will -- if we paid for it to get is what we want. I talked previously about the apple pickers and the judges problem -- we pay apple pickers for performance -- every time they can get Apple we pay them. A federal judge -- the ultimate divorce is to pay for performance lifetime tenure salary unrelated to any think that the two. Why is that? How does this help us to think about medical care? We had a meeting last Monday downstairs here with Patrick Conway from the CMS and Sean Cavanaugh who runs the Center for Medicare -- CMS -- they were with us for most of the day. A fascinating discussion. I'm that we are working on trying to synthesize what the research agenda looks like. This will be -- the paper will come out in a special issue of the journal hopefully next summer. The last part of the presentation -- we done -- we done most of his earlier. Discussed the role in patient centered outcomes research focused on dissemination and training. We discussed that PCORI has a responsibility for funding patient centered outcomes research and we are working closely with PCORI as I discussed on these efforts.
One thing I think we have not mentioned is that PCORI has asked AHRQ and provided funding for AHRQ to manage patient registry to develop evidence about the comparative effectiveness and strategies for the treatment of uterine five ports. -- Vibrates. -- Fibroids. We awarded a grant to create this registry and we are excited about that. You can see the committee membership. We meet monthly with Joe Selby and the staff at PCORI on these collaborations. You can read this at your leisure -- this lists the kinds of investments we are making in training. 20% or so of the P-COR trust fund is used to make progress in training researchers to help better conduct P-COR. Exciting work there as well. A number of you have tensed up we need to stop in 10 minutes for other activities. My question for you -- this is around where we should emphasize other collaboration? The mission slide says we produce evidence but need to work with others to make sure that it is understood and use. We have 300 people and $70 million of budget -- this is a healthcare system that is -- the kinds of a strategic collaborations we should look at this would be most appreciated.
The question is before us -- think about that. While you do I will go to the folks that have questions or before. The patients -- Noel and Jane.
The way I think about Verizon it scanning that it is the first step of what health technology assessment agencies to in a five step process -- scanning, selection, assessment, appraisal, and implementation. I wonder if you are thinking about it in that context and if you plan on to helping people to the topic selection piece and if you are focused on groups in the US doing technology assessment like Blue Cross and Blue Shield and [indiscernible], for example. How you are thinking about positioning this.
Yes. We're trying to position this so that those working on technology assessment -- to include back to the previous conversation of PCORI are aware of what is coming down the pike and they should be paying attention.
Jane?
I would like to return to the issue of the AHRQ assessment or tools around health system performance. I think a relationship to the conversation earlier about hard science versus patient or consumer perception. This would go in the advice column. There are five or six, and rating systems today. I want to end of the expansion you would have U.S. News & World Report which is largely brand war position reputation driven. -- Or physician reputation treatment. I'm trying not to be judgmental.
On the other and you have proven -- data-driven. Cost per case, infection rates, hard science. Numbers. The public likes US news and world report. For my health is understandable to go and say we have been a proven top 15 in the country for as long as they have a rating is -- seven years or so. Nobody cares. They literally don't care. It doesn't mean anything. Yet the rating system that gets the public's attention and may or may not affect buying decisions and elevating and plan decisions and clinician decisions is the one that there is, frankly, no hard science behind. If we think ahead to the agencies mission of dissemination, we better not ignore in choosing how we will measure health system performance -- whatever black box explains this fairly obvious possible -- couple. -- Puzzle. Because if you choose to support this system that is accurate and measure all the things that I love but the public doesn't resonate with, then it won't help us. I offer this experience -- it is frustrating. Our day-to-day experience is that there is something about this that I don't get. Apparently it doesn't matter as much to people that infection rates and cost per episode and mortality rates and patient care experience -- all of that which has been vetted and on websites doesn't move hearts and minds the way brand or reputation or peer-to-peer references do.
While said. -- Well said. Let me assure, for clarification. The goal of the internal efforts is not to develop a government sponsored rating system of all health systems. We are doing preliminary work trying to figure out how we might approach this. So, and my first meeting here I talked about similar interests and mentioned that in the three and half years that I have been in DC at that point I heard countless times that figure is one of the highest performing systems in the US and I was willing to believe it. I had no way to do it. This meeting was on a Friday and on Monday have an email from people saying we are interested in talking with you about this. It was wonderful and friendly. I still in that space. I think would be better off if we had a way of defining health systems. I think there are 700 around the country. How would I do that? How would I do find them? How would we -- what are ways of trying to understand the performance? This is preliminary work. Your admonition to think about who and how it might be used is very important. We will take that to heart.
Briefly -- your colleagues at CMS are weight has to think about how they may define it. We have five star systems for almost everything. Either out there or in the oven ready to the banks.
Although not -- obviously there are rating systems for Medicare advantage plans. A variety of policy measures for a CEOs in particular. But not for health systems generally. As far as I am aware -- I am not aware of these.
Keeping in mind that the five stars and the comparison sites for the purposes of their comparisons within a care setting, I think there is definitely opportunity and value to put the pieces together and that is something that is greatly needed. Even in the ACO program where there is a system still there is the requirement to use measures that to a specific provider type. So, I think there is still room to do exactly this and the value of the product -- the synthesis.
Jane, to follow up on your question and you and anecdote -- the other day I went online to Hospital Compared to see if I could make a judgment about hospital quality. In Dallas. Given the recent events.
Just curious. People have opinions about it. [laughter] There was a lot of the data. I was rapidly overwhelmed by the quantity of measures. I couldn't begin to make any judgment about that. That experience -- I will never do it again. I have no better impression of relative systems in Dallas as a result.
Harry and then Michael. [participant comment - no microphone]
Even amongst the so-called science-based ones, there is frankly a great range of quality. For example, there was a magic out there whether people were being put on beta blockers for surgery. It turns out it kills people. There is a misunderstanding of the data.
There is a huge number of these things which become more and more important and I know we heard these stories. I think it would be a unique space for AHRQ even though it would be politically treacherous to talk about the quality measures -- the quality of the quality metrics. Nobody is doing this. Even the CMS that is a great interest in this ultimately they are not in a position to critique or lay out all of them especially when some of their own. That would be a special role.
I appreciate that comment. I went over quickly in about 40 seconds the discussion on the paper value project. -- Pay per value. Part of the discussion there is around the question of how to define value, measurement in ways that will get is what we want to -- better outcomes for patients. If I take your commented to heart, we are working on the research agenda and that is one of the possibilities as a place to go.
Great. They do. I will build off of James a comment because I completely agree. It seems that we anticipate or expect or assume that just because consumers and providers have data that they will act on the data. I think we all know that this is not necessarily a safe assumption. The hearts and minds comment struck me. Personally that I think about measures is that we want to measure what the provider is doing. Is an evidence-based? To have outcomes? I think patients and consumers, even speaking for myself, I expect you to do the right thing. I will look for it but I am going with an expectation. What really drives people to providers is how they do it. The connectedness. When I talked to our teams you've got to have confidence and connectedness. The patient satisfaction stuff is getting of the connectedness piece. I don't think it is more or less important, but how does it happen -- is a rounded up the clinical data or does the clinical data truly -- they just don't care? Because what they care about is the How these. This is the soft inside -- how we do this? We've got data about management of conditions. How do you literally sit down and engage the patient motivation and all of those things -- this is what I find more more is where the rubber hits the road -- it was the patient was. Assuming they do the right thing, and amplifies the difference. At least in my experience.
I agree completely. A four value -- pay for value -- the use of patient reported information. A new tour they are trying to coin -- PRI. Is it a -- it is a fascinating paper and very well done. Maybe some of the point that you may. Argument as well that in addition to the CAHPS types of survey information or [indiscernible] as you mentioned, bringing in patient narratives support. For a clinician is one thing to be able to look at the score of they are not -- if they are not going to give you much information like what to do about it. The patient narratives to provide information about what is really behind this is a key part of making progress.
": -- I would agree -- work at the University of Utah -- work that [indiscernible] is done -- starting to show the patients comments publicly -- what they are fighting internally is that the physicians performance improves -- most work 4 or 4.5. With the patients cared about was what the other people say. The pressure that that provided -- no financial incentives, just the positive impression of that provided -- they now have 25% of the physicians ranked in the top percentile. It is an interesting way to affect behavior.
Thanks, Bruce. As we talk about patient engagement and paying for value and James comments around what resonated with me -- we deal with a lot of large employer groups. We really try to talk with them about how they can work to decrease their healthcare costs. The one piece of medical information that I don't think it's out there and inside manner that we can find is where medication adherence provide greater value to the healthcare system. There are a lot of small pieces of information out there. If we can get the patients on their medication or teach them how to use the out my inhaler in a more efficient manner this will decrease the ER visits and increase -- decrease the bed days. From a global standard I don't think they can show where the adherence of things healthcare system of money. This would be a monumental piece of information to get out there for everyone to use.
Thank you. Jeff Brady will talk about some of this shortly.
Do you have one more slide?
Yes. Bruce listed -- those of you that have certain the agency well. I and my things. I've only been here for a year so I have to the benefit -- two thirds or more of your energy and effort and device. I greatly appreciate the advice that I've received over the last year and I know everybody has 124 150% day jobs. Taking a day out of the rest of your life three times per year to come here and the work that some of you do in addition to that is not easy. I am people. Grateful for your work. Thank you -- Mike Johnson, other things that shared the subcommittee for quite a while. Thanks to Harry for the work you've done on behalf of the agency. And -- Newell and jane. Last but not least, our esteemed chair -- this has been the chair for six years.
A long sentence.
I lost in the midterms. [laughter]
I did everything I could to try to convince Bruce to stay for a seven here.
-- Seventh year. I think that was enough.
Thank you for the work you've done. Fantastic. Sometimes difficult circumstances. Leading this group and providing advice to me at the agency, you've done a great job for us. By extension for the department and the American people. Thank you.
[Applause]
We have a token of our appreciation. This hardly begins to show our appreciation.
Thank you very much.
A card from your colleagues as well as something inside the car.
Thank you very much. I appreciate it. It has been a pleasure and delight and I look forward to be involved in the agency and all of you in various ways of our paths cross. I also want to thank the staff that made my job easier, especially Jaime Zimmerman.
[Applause]
Bruce came on as I came down and I greatly enjoyed working with you in trying to figure out how to lead that and transitioning to new directors and I greatly appreciate it working with you. I will miss you greatly.
We are working with the secretary on naming members to NAC and the new chair and we will share this information as we get it.
Is now time for a break. We will reconvene in about 15 minutes. Thank you.
[This meeting is taking a 15 minute break. Captioner standing by]
Get back to your seats. We are running a little bit behind.
We need to get going again.
We are going to get started and I will turn it back over to Rick for the next introductions.
Maybe. I'm glad to introduce Jeff Brady, the director of the Center for quality improvement and patient safety -- known as CQIPS. I rely on him tremendously. He has been in the job for about a year. A little after I got there. You will hear the work being done. We get about $70 million plus as a line item in the budget to work on producing evidence to improve patient safety. It's a big part of the work. I know you've heard about various pieces over the last year before. I thought because it is such an important part of the work it is good to have an organized presentation and I look forward to your advice about directions here. Jeff is a captain in the commission core and is an M.D. from the medical College of Georgia. He has been a AHRQ since 2006 and prior to that the FDA and a medical epidemiologist in the defense department and primary care in the Navy. I'm delighted to have him as a colleague and I look forward to his presentation.
Thank you, Rick. Good morning it is good to be back with you. It has been a few months since I last presented it to this group. Today my goal is to provide you with an update and the update is meant to prime the pump for discussion and feedback. This is something I look forward to hearing. We have many connections to the field both through funded projects and otherwise and this is a very important group to make sure that we are maintaining a focus on the most relevant research questions and in particular for the patient safety program things that can improve safety.
Really, very high-level overview. The programs are focused on producing evidence consistent with our agency mission but also making sure that the evidence is used. Ultimately we are seeing progress in promoting improvement in healthcare delivery systems and actually this is a good news story. We have good data to report at the national level. So, I think patient safety is an area where we are making progress. I will say more about that when I talk about the national goals. Really, these are the results of global solutions that research has shown are effective and various initiatives throughout the federal government and otherwise help to make sure that these actually on their way into practice.
As a reminder, the patient safety program at AHRQ is organized into 3 individual program -- general patient safety as the name implies is everything that is not healthcare associated actions. When I cover budget you will see that I -- we have healthy funding for prevention of healthcare associated infections and that patient safety organization program is something that you know about and I will provide you with an update about the progress we are seeing in that particular area.
I want to take a couple of minutes to acknowledge my colleagues. Does that leave the individual programs and also a colleague that is not new but you back to the agency -- Amy [last name indiscernible]. She came back to AHRQ after a productive extent at the office for health technology. I am happy to have her back and this sentiment is shared by many in the agency. She comes back even more valuable that she was she left. As well, another new member of the center team is Erin grace period -- she is watching and listening and may be connected in case there are questions in that area. Also Dr. [last name indiscernible]. He leads the healthcare infection associated program and he has a lot of experience. He has been responsible for the success along with his team -- the success we've seen in [indiscernible]. And my predecessor who is now actually a part of the staff that I have the pleasure to lead -- bill Munier. He is currently focused intently on the patient safety organization program. These are a few of the folks in the Center and these are the leaders that make it happen. Along with the teams that support their work. Before I leave this I wanted to acknowledge that Rick -- it has been a pleasure working with you. Patient safety is something that you had exposure to in the department in your prior role, maybe not the real focus of your work, but that doesn't just direct the agency, he actually means agency. It has been refreshing to have --
Don't listen to him.
[laughter] That was my next comment --
Again, a lot of people make it happen.
In a nutshell to put into context research program that we have focused on patient safety, it supports directly the departmental priority of improving patient safety and making health care more say. It is one of six specific priorities of the highest level of the national quality strategy. The patient safety in general and the centers specifically is noted in the affordable care act and many different things that we are currently doing and that we have the potential to do are cited in the act. Again producing evidence focused on healthcare safety and this is -- AHRQ was one of the first big entities on the scene when patient safety came into the national awareness. In general we are seeing successes that are documented with the sound of measurements and we are trying to leverage the success and apply it to future research opportunities. The problems that still persist in patient safety.
Varies dramatically here, -- schematically -- we had that portion of be able to expand this with our research program. For us in simple terms I refer to this as the upstream research. In patient safely it focuses on the identification of risks and hazards. We use this information. The grantees to the contract worker we support uses this information about risk and hazard to develop mitigation strategies and save taxes as they are called. Testing these and demonstrating that and developing them and some of the soft science is the term used today to refer to all of these challenges with implementation. This is very much represented in the research program. The central point is that we stay in this continuum and measurement underlies all of this and it is different for different stages and we try to be mindful of that. In some cases we overburden the every day delivery system with research level measurements. So, transitioning measuring along the continuum is something that we are keenly aware of it trying to make the link and make the transition. Again, just to give you an overview, every project I will talk about exists at some point along the continuum and some other projects are directly aimed at trying to bridge the different parts of the continuum.
When we think about where we are trying to get, no matter where we are on the research continuum, even if we are very early stages, just looking at to understand a problem, we always understand the problem better -- we are mindful of where we want to get to and these are two examples of success that the agency has enjoyed. In fact, the patient has enjoyed this based on following the entire continuum -- this is an example where AHRQ funded research to Mary at the behavioral aspects and implementation issues with the technical aspects of care and get this right and help get into practice and we ultimately followed the process all the way through to national implementation and we have documented results to show this. I think the entire country should patterns of on his back based on the development and use and application of this research. Similarly -- team stats while not targeting a specific problem is a topic area that we think is absolutely fundamental to not only patient safety the quality. Penetrated the healthcare delivery system and the team stats branded particular as one of the go two examples for teamwork and coordination in healthcare and and we find ourselves in a place where we have a fair amount of penetration into the system but we have persistent and this presents somewhat of a challenge for us in terms of allocation of limited resources -- where to we want to invest or in discovering other problems and where can we maybe the entire full scale national implementation some of our fellow partners in the private sector. Quickly, this is a reminder for me -- to make sure that I give you a good overview of the breadth and depth that underlies patient safety research. Many different issues. Putting on the audience -- there is a variable understanding about the depth and we tried to adjust our communication in that regard. This doesn't change the fact of the complexity of healthcare itself and the corresponding complexity of these solutions to safety problems We trying to be mindful and reflect this and all of our work.
A quick budgetary reference -- we had stable funding for the last few years. Based on the present -- the president budget we are under a continuing resolution of the president's budget reflects stable funding relative -- give or take a few percentage points relative to the funding in fiscal year 2014 and this is roughly how it breaks out according to the three major programs at AHRQ for patient safety. Again, a little less than half for general patient safety -- miscellaneous categories -- patient safety research. One highlight is continuing to try to shift the focus toward settings other than the hospital setting and that is reflected in our 2015 budget. I will say more about that. Almost half of the funding as I said is for prevention of healthcare associated infections and roughly stable funding for support of the patient safety organization program.
Now I will give you a quick overview of selected updates and examples of each of the three different programs. I mentioned in trying to extend safety improvements to patients in all settings. This is a summary of how that looks in our budget justification for the president's budget and 2015. We've been addressing as we done for other topic areas and other settings the full spectrum of the research continuum from discovery to implementation. For that I think as we done planning around this topic area we realized that although there are some pioneers in this setting other than the hospital setting, there is a relative terms of information -- good solid epidemiologic information about where the problems are. As we determine other parts of the program we are trying to strike the right balance between trying to achieve the immediate gains we can as soon as possible based on the things we know that trying to maintain some upstream focus so that we have a continuum of future discovery that will be the basis for future implementation.
Stay tuned. I can tell you that a fair amount of active planning and project development is underway. So, this will sort of rule out over the course of the fiscal year.
A real reminder that -- a quick reminder that as we try to shift the focus to settings other than the hospital or as we describe in the budget justification extending patient safety all settings of care, we are maintaining some degree of the focus on the hospital. This is not an area where we can say all problems are solved and let's move on and put a knife on it. Quite the contrary, patients still continue to experience harm and so we are -- at least what is represented here -- focused on implementation of at least two of these toolkits -- falls prevention as well as pressure ulcer prevention and another effort is to update the site for the prevention of BTE's. Maintaining a focus in the hospital setting. Another example that we continue our focus is in the area of perinatal and obstetric care. Jennifer Morrison the room. She the project officer for this effort and essentially what we are doing is applying some of the principles that were successful in comprehensive unit safety program appropriately adapting those to the challenges that exist in obstetrical care, a particular focus on patient safety of course. So, that is the heart of the project, again development of those solutions in a more thorough way. But relying on the same three pillars, if you will, that represent CUSP. Here you can see the three pillars -- attention to issues such as culture of the healthcare delivery system and particular the specific organization and unit. So, the science of safety, teamwork and communication, all of those kinds of principles that have helped move the needle in other problems. Hitting the mix right between attention to those things especially when you consider a clinician audience -- we can't afford not to appropriately focus on the more clinical aspects -- the middle column -- the middle pillar is the clinical technical aspects of the behaviors we are trying to change in the evidence that shows what should be done and the teamwork and culture and other issues -- attention to that actually helps organizations know how to get it done. One final point here -- with respect to obstetrical care, I think the organizations that have demonstrated success in this area have recognized a specific and particular -- in particular the world for insight to simulation. Practicing what they are trying to achieve in actual healthcare delivery -- practicing this in the clinical environment with the teams that will be expected to work together in order to accomplish all the evidence-based practice that has been established.
[participant comment - no microphone]
Sure.
So, in this area the structural aspects -- should a delivery unit have [indiscernible] on call or other kinds of structural models of healthcare delivered -- should a non-physician or nurse practitioner or other kinds of people -- a midwife -- do this -- are you studying this?
I will ask Jennifer to talk about this. I said that in general for all of these programs where we are aiming for national implementation I think there is a degree of balance in terms of how prescriptive we wanted to be. Obviously, we are cognizant of the evidence and what it shows that we recognize there is a variety of ways that organizations are organized. Jennifer, specifically --
Absolutely.
Jennifer Moore. A health scientist administrator at the agency for healthcare research and quality in place women's health and gender research. In response to your question, the teamwork, as you mentioned, is paramount and pillar of the CUSP program. As part of this, as indicated there is the ability to customize what you do in your institution based on your makeup of your team. So, some invitations utilize midwife and others do not. There is some variability in terms of the hospital engaged in this project. However we can capture the data understanding there are a -- the first agent Ray show is useful. Especially when the moment with the average -- understanding the makeup of the team as the scenario plays out and seeing if there is an opportunity to improve safety based on the teamwork and also the composition what the team looks like. Gee, do you have questions?
This is great. As far as they should safety goes, are you looking at the overuse of -- whether it is CT scans or cesarean sections were early deliveries? As a part of the patient safety rubric?
One of the specific points that I felt it to mention in the overview -- the laundry list, if you will -- diagnostic error is an emerging area especially as we look to the ambulatory setting -- the outpatient setting. Accompanying the issue of diagnostic error is -- what is the sweet spot of diagnostic testing?
That's part of it but I am also thinking about overuse of antibiotics in primary care settings. This is critical.
Absolutely. When I get to the healthcare associated infections section I will talk about antimicrobial resistance and some national organizations -- national collaboration -- the Choosing Wisely campaign. Specifically with respect to antimicrobial resistance, what is happening nationally and also about the AHRQ research. I will come to that.
One more question. We have a fair amount want to do.
I think that the perinatal safety levels are great. A great idea. How can we foster this? I just went online to search and you don't come up with an easy -- this is what you should be doing that this is how you implement it. How to get that translation across?
How can we help you?
Jennifer?
Is a timing issue. We are in the process of launching the pilot project in January. We are finalizing the evaluation implementation plan. That material is not available at this time because of that.
Okay.
Yes, as with the other projects.
Collaboration -- in the interest of time, we're not getting too deep but I can tell you that it is a challenge to pull various entities whether federal government or otherwise, I think we have some examples. This is a good transition to the next slide and more broadly some feedback that I would appreciate we get a lot of benefit from these collaborative efforts especially when it has a scope defying areas roles -- not so much specifically for agencies principles that need to be undertaken. That is definitely a good first step to try and not have to much overlap and also make sure that important areas are sufficiently covered.
We are not quite there with OBE but we have strong start in terms of -- on the federal side -- examining not only does project but how it relates to Jennifer is doing a lot in that regard. It is positive -- that is a quick summary. That is a major theme that we see in other areas whether it is battling antimicrobial resistance -- now I will talk about adverse drug event prevention. Last week the department released the national action plan for the prevention of adverse drug events. As I said the programs in the field benefit from this well-planned national organization of -- basically what the system's problems -- systems from a scientific perspective -- is really not a single target that we can focus on. The interaction of all these issues is another level of complexity. Best served by these kinds of efforts.
So, again, heavy focus on engagement trying to sort of establish and at least in a summary way what we know about preventive efforts at the successful and the questions is to remain where we need to focus research efforts. So, this is really just some of the organization that is a sort of helping to make this possible -- the federal steering committee and probably equally as interesting are the three drug classes that this effort is focused on -- the national action plan is focused on anticoagulants and diabetics and opioids. We are very much in sync with this a national effort. These are functionally the areas that are being addressed in the national action plan. I think for AHRQ, obviously, the role trials us to the research and unanswered questions; however, we do we go about conducting the research -- we are absolutely mindful of the broader context intermixed with the research questions are things like what is the role of incentives and the role of incentives. Incentives and oversight. Development of evidence-based tool. Again, this is a helpful -- this effort put into these kinds of organizing groups -- this will yield a lot of benefits in terms of managing the programs.
Then, we had already recognized somewhat contemporaneously the development of the action plan that medication safety was a topic that was right and presence in the early days of the patient safety movement. I think recognition -- and many other -- the case from a re-examination of the questions that remain and some of the opportunities for improvement. A quick summary of the funding opportunity announcement that is often active. We reference the national action plans -- very much in sync with that. This also reflects the comments that I said before -- focusing on all health care settings other than the hospital I promise good news. This is a lead-in to the good news. Already release -- the partnership for patients is underway. CMS is successfully leading that organization. The initiative. The reporting part of my professional career to see what put together the resources in the government and rallying the private sector as well. I don't want down the laundry list at CMS but suffice to say that a lot of folks in other government are working hard -- here is some of the list.
Schematically at least.
I think the involvement in the partnership for patients is about as part of the can be. In terms of representation of the healthcare system data released from the department -- backing me -- the baseline rate of 145 hacks -- this is as comprehensive as a measurement with support at the national level. In 2010 -- the most recent data that we released is a number that we see -- 132 1000 discharges. The range of 9% -- we are intensely working on the 2013 data. Indications just that this rate of improvement is persisting and me be accelerating.
It is good to recognize that success but it is equally important to recognize what it took to get there and that has been a fair amount of effort for a lot of individuals.
The medical liability -- you heard summaries of the research component -- the component of the program in the past. We are in the phase of trying to summarize the evidence in a usable format to support implementation and drawing from the findings that the demonstration projects that we started about 3.5 or four years ago -- the results that those have yielded. This is a challenging area as many know. There is a recent summary in JAMA with a nice overview of the decades of experience in the countryside dealing with this problem and I think again a bit of a bright light and success for what are labeled the nontraditional approaches to the problem with communication and resolution programs I is important to point out that this is not a problem we compare shoot a toolkit and expect to the hospital organization to follow through the front steps and at the end they have a nicely functioning medical liability system -- far from that.
We do have are examples of success and this is absolutely a good representation of a system problem that extend beyond the healthcare system but the legal environment as well.
Healthcare associated infections -- let me focus on the program. Just as all of the other programs have this -- in very simple terms -- reality of research for discovery and implementation, the initial appropriations help prevent healthcare -- they laid out the program ---based the work on for implementation and that is the comprehensive safety program -- we're still in the process of adapting and applying that to various HAI -- the list you see is in love chronological order -- as you can see, with CLAPSI the work is completed from the agency standpoint although I think is in terms of national implementation -- these still occur and there are specific areas that we are focusing on -- specific segments of CLABSI. It is still an active area of research that in terms of national implementation according to CUSP is completed and we are various stages of working through the problem. This is a simple reminder -- --: on that point of expanding the entire continuum -- were able to -- for various infections -- ongoing assessments of where their breast -- the research needed. C. difficile is a good problem -- we don't have great strategies to prevent this as we did for CLABSI. However antimicrobial resistance and drug prescribing patterns and attention to the environment -- these are things that show some problems -- promise. We are able to spend funding and all of these areas and make use of information a good package for prevention -- again, it is a goal -- a broad-based program that I think we are proud of.
[Captioners transitioning]Make use of information that we do have, even though it may not be a complete package corporate -- for prevention. It's again, a full -- a broad-based program that I think we're very proud of. So I mentioned, the combating antimicrobial resistance -- this is another collaboration I guess, at the highest level. This is coming out of the White House. And in recognition of the importance of this problem as a national security issue, the national Security Council has had a leadership role in formulating this plan. A brief history is just in September, an Executive Order was signed. We've been involved in contributing to the national strategy for combating antibiotic resistant bacteria. The area that we are focused on and this is where we are represented in the plan. In particular, on approaches to antimicrobial stewardship, as alluded to a minute before, we have for a few years now been focused on this problem and have -- I think an accumulation of the research findings that are at various stages of readiness for application in the field. A big set of that work is focused on the nursing home setting. And the use of anti-biograham's to help guide antibiotic selection in a more targeted way as well, attendance to issues such as standardizing antibiotic use for treatment of UTI. And so the stage that we're in is trying to pull all that information together in a useful way for nursing homes. Clostridium difficile and then finally as well in dialysis units. So let me move a little quickly here. This is a project that has the scope that is actually at the level of the entire program. We're at a stage and maturity level for the program where we've needed to take a step back, looking both retrospectively and prospectively, taking account of the body of work that we've produced, how it all fits together, again trying to translate that into a usable format for the field. And as well looking ahead to how we will solve additional research gaps. Several products that are already out from this effort to Journal supplements from some of the prominent journals in this field of infection control -- we're still working to synthesize the really important findings. Some of the highlights from the synthesis project, these are projects that you know about already. CUSP, reduce MRSA, really has changed the way that practice occurs with respect to universal decolonization for MRSA. And then focus on other issues such as glove and Downing. So home stretch here with the patient safety organizations program. I think this group has pretty good background on the program. I guess a key point that I'd like to make is -- that has been made before is the program is entirely voluntary but it affords protections and that's the draw for using it. I think based on the long-standing work that the patient safety organizations team has put into supporting this program, we're actually starting to see more and more recognition of the value of this kind of protection and trying to strike that right balance between protected space to actually learn about what's going on in an organization, maybe even what's going wrong in an organization or what could be better and actually making use of that information. So of course the common formats for measurement, but in terms of status, it's really pretty amazing to me that we have 84 active PS those -- PS Os, no federal funding, they are entirely independent entities. They reach -- receive technical support and -- from the agency in coordination -- I think it's pretty impressive, the list of PS those that are components of larger organizations -- PSOs. That is one model we see that is actually appealing to some organizations. Hospital Corporation of America, for example, Walgreens -- a relative newcomer -- but they have decided that application or the protections afforded help fit their operations. And I think will have an application to their work. Just a quick overview of the types of PSOs and the types of businesses. It's a fairly diverse group. I think that's ultimately something that's healthy for this program. In terms of interaction between different parts of the healthcare system. And similarly at a more specific level, clinical specialties are well represented throughout the PSOs that are currently in operation. So here are just some examples of the focused kind of problems and problem areas that different PSOs are undertaking. Clarity PSO is a general PSL. However, they've partnered with the radiation oncology community. This is an announcement a few months ago focused on issues related to radiation oncology. So that's just one example. Another is again -- I mentioned Walgreens and the Missouri Center for patient safety is the only one we know of that's looking at emergency medical technicians and their practice. So just a really wide breadth. I think the vascular surgeons, that's worth noting as well in terms of [Indiscernible -- low volume]. And so looking ahead for the PSO program,, the if oral care act section 1311 is something I think that community is eagerly awaiting. And this will be another positive shot in the arm for the program to sort of help pull organizations to PSOs and making use of the expertise that we know exists already. In that community. So this is where we started. Again hopefully you have a better understanding of these very general statements that are laid out. We are producing evidence and helping others use it to make healthcare safer. This is actually resulting in improvements in the healthcare delivery system. And ultimately I think it's the interplay between these national goals and very concrete local solutions that are attentive to the needs of providers at the point of care. So I think I've covered -- this is really intended as a jumping off point for the discussion. Again, I'm trying to list some of these examples of national coordination that helped guide not only our activities but our federal partners and in fact the entire system in some cases. National local capacity. I didn't mention in any detail a positive trend that we are seeing, which is increasing prevalence of patient safety topics. And professional education and training, maintenance of certification. I think that is -- medical schools themselves, patient safety is in some cases sneaking its way into the curriculum of those organizations. We don't really care how it gets there as long as it does. And again finally we are seeing results. Thank you for your attention. I'll look forward to your comments.
Thank you, really appreciate it. I'll start out with a question and then go to Gent -- Jed and Jane. You hinted at further acceleration of improvement in hospital acquired conditions. I'll ask a loaded question. Do you attribute that to the partnership patients?
I think probably the simple answer is attribution's very difficult and challenging. When you have something as broad as the partnership patients and other things that have a role in impacting safety, it's a very difficult question. I think it's a little bit of a Dodge but it's a nice question to have to ask. The most important thing is the results. I think that's a question we'll continue to ask ourselves and figure out what is the best science that we can apply to try to answer that question. I know it's something we've talked about a lot internally.
It's quite evident that the Partnership for Patients almost certainly is a very important part of the progress that has been made. And there other things going on as well. And it's difficult to figure out exactly what the attribution of causality is to various components. But it's hard to imagine giving -- given the timing of the progress and the energy that you know better than I that members are putting into solving this problem that the partnership patients is a really important part of this. I'd be interested in your answer.
We would like to think so. And I see improvement in our hospitals which we think can be attributed to to the AG and an partnership patients and the like. It's a big question right now out there.
Yeah. I'm going to go to Jed.
Thank you. Particular interest of mine, but I'll restrain myself to three quick questions. Has the legal statutory protections for information of PSOs been challenged anywhere?
Yes is the short answer. Bill can add to that answer if you would, Bill?
Yes. There have been several challenges --
Say who you are.
I'm Bill. I direct the PSO program under Jeff. In the Center for quality improvement and patient safety. There have been several legal challenges. I'm not an expert on them. The department doesn't get involved directly with them, but the first significant one was Walgreens was sued by the state of Illinois. And the State Department of Public health wanted to get a hold of their data on medication errors. And Walgreens resisted and the state sued Walgreens. Walgreens won in the local court level. It was appealed at the state level and Walgreens won the appeal. There has been no appeal at the federal level yet. So that was reassuring. There have been a couple cases in Kentucky which are less clear, but interestingly in one case where they followed the regulations very carefully and defined what was protected and what wasn't and so on, the case was upheld. Another case where they were less careful about defining exactly whether the material was in the protected space, the judge said, if you had followed the rule, I would have ruled that it was protected you didn't so it isn't. In a funny kind of weigh, that's actually not bad. So far, I think we're doing okay. There is still pending cases. One that has an ambiguous decision we're looking at. So so far so good. People are going to continue to try and he rode these projections.
That is reassuring. Thank you. You said you were renewing your VTE toolkit. And there's measurement in there. A lot of the VTE measures are quite controversial. What is your advice about looking for and measuring VTE occurrence?
I think that's a longer answer than probably we have time for now. I think the guide itself has a specific chapter focused on measurement. If you remember back to the graphic measurement -- that green bar at the bottom that is probably -- the width of that bar is probably not represent -- not representative of the role that takes in very -- varies patient issues. VTE is a good example. That's not a full answer but the components of the guide will focus on what are measurement strategies that have been successful. I think another look at -- so we take a broad approach to measurement in general. And recognize that it's dangerous to rely on one single measure. There's competing benefits and limitations of different measures. So I think the simple answer is that the guide attempts to lay all that's out for an organization so that they can at least make an informed decision about their own plan and what's available to them. I'll say that's another area that's maybe not specifically with respect to VTE and measurement -- I think this is more of an emerging area where more research is needed some of which we're supporting -- is better risk assessment for individual patients. I think that's been -- there are many opportunities to advance that particular part of the problem because it's really very much like -- as is also the case for hypoglycemics, this is the Goldilocks phenomenon. We're trying to get that right, sweet spot and I think risk assessment that's a little bit more individualized and considerate of individual patient factors will help to hit that target a little better for more patients.
And my last simple question. You have by diagnostic performance under human and environmental environmental factors, but me, that base for HIT kinds of approaches and technologies. How is that happening?
So I think certainly clinical decision support -- I think -- in trying to actually live up to that term, are clinical systems and IT systems in particular, are they supportive of not only the decision-making but the information gathering that leads up to that? So I think this is very much an emerging area where there are -- a little bit more order is needed to actually focus. I don't think it's a single problem, I guess. I think some more clarity about pieces of the problem in very simple terms, I think some of the leaders in this area, sort issues into cognitive and system-based factors. Sometimes I think that works very well. Other times that's an oversimplification. So I think the other challenge basically -- not what you asked about with respect to diagnostic errors -- but the continuum of safety and quality and really -- I think diagnostic performance if we want to put it in a positive light -- really is -- expands that intersection of safety and quality. There's some pure safety issues with respect to diagnostic performance. Other things get into frankly, some of the comparative effectiveness type issues. So I think by and large, the field need some clarity on how do we organize the prevailing questions related to diagnostic performance? I think I'll bridge from your specific question to a lot more, but hopefully that helps.
Jane, Bob, then Howard.
Thank you. I want to affirm, Rick, that the work that Jeff and his team do is among the best and most applicable directly to health system performance. And we really appreciate it. It's a lot of -- we could learn a lot about what works in dissemination from the specific Canada work in patient safety. Jeff, I wanted to ask you a wake up at night question about if you think of that HAC chart which is probably burned into your brain. So even if your prognostication about 2013 is right, we are still going to be worse than 10% of all hospital admission results in a HAC? So how do we get to 1? Or zero? But is it just a long slog through bundles around each type of harm and we just keep working at it? Or do you see something more of a breakthrough? One intent is still not acceptable. -- one in 10 is still not acceptable.
I'm going to try and answer. I think your reaction to the answer would be very helpful to me. For me, I think it's not exclusively but a big component of the problem is just shear capacity. And I've divided that into two dimensions in the past. Some of it is just time during the day. In particular thinking --
You only get 24?
Right. I'm not talking about my time. I'm talking about clinicians and provider time, trying to figure out what are the priorities of the organization? So that one is challenging enough, but it's certainly a consideration. I think the other is a knowledge capacity. And I think we are in some respects, addressing the problem on both of those fronts. And it actually comes together when we talk about -- there is a certain commonality across all of these problems. The soft science that we've talked about. Even those soft scientific questions are not absolutely the same across the spectrum of problems that we're dealing with. But I think there is enough commonality that that can help address some of the capacity challenges. Only the things that need to be different in addressing a specific problem should be different. From a provider providers perspective. So I think -- I put it into a general specialist kind of attention as well. I don't mean from a medical specialty perspective, but a specialized approach to a specific HAI for example. Is that something that the field can actually afford to do even? When we look at all of the problems that have to be dealt with -- at the same time, we have to be cautious because most of the problems do have individualized specialized issues that need to be attended to but it's really only those differences, I think, that deserved to be different in the solution. So I hope that makes sense. So when I do wake up at night, that's what allows me to go back to sleep. I think we're making some inroads into the capacity. I think the field naturally is figuring out -- that out too but we're helping accelerate it by having a relatively common approach to the common aspects of the problem. The implementation. I hope --
That's helpful. You asked for reaction. I agree with that relative to -- I see a sort -- SSI and BAS and CLABSI, early trauma, I agree with you. That there's -- we're developing capacity to more rapidly six or address those kinds of problems. But fully 50% of the harm is what I would say, frailty related. Falls, falls, pressure ulcers, and at least some portion -- I'm not an expert -- on medication errors. And I think that's a wholly different problem. Because if you just think about falls and pressure ulcers, it's not a secondary effect -- usually not a secondary effect of the good treatment we did or not a contradiction or an error in technique. It's 87-year-old people with three or more comorbid conditions at the end of their life in an acute setting with a lot of equipment around them. So my suggestion would be that we start to think about and maybe borrow from other settings, -- Mike is nodding his head -- he knows how to do this in a community setting -- but to me, if you take the 100 per thousand, and you sort it, they fall into two fairly different camps. And in practice, that's what we find. That downloads -- downloading the rules for how you avoid CAUTI and making sure that happens routinely is a very different problem than falls on the MedSurg unit.
Definitely.
Frailty is -- that's only going to go up, right? Surgical admissions are leading the hospital. The hospital is becoming full of comorbid medical illnesses. And that frailty problem is only going to get worse. As I make it to 95.
[Indiscernible -- multiple speakers] other people -- Bob?
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Can you turn your mic on please?
Sorry. I was ready to put that on too. More of a comment for you then a question. So again from the VA -- we do have a lot of interest in patient safety. A lot of work in HAI. One of the charges I had in being asked to come over here for David was to look for opportunities not only to partner but where can both sides leverage funds when we're working on the same thing? One of the things I want to point out is almost a year ago, we completed a study -- one of our investigators on adverse event reporting. I see you're working on your toolkit. And I'm going to I guess, offer up -- we have people working on this as well. When this study came out about a year ago, it immediately rose to the highest level for VA or VHA because it was of such interest and also set on the back of some events that had happened, so this investigator went out and jumped into it right away. And some really good work including developing a measure on appropriate disclosure. By providers to patients. So I guess basically I'm offering -- I can talk to you during lunch or after, but I can give you the contact information so maybe there's a way while you're working on the toolkit and you can benefit from the work that we're doing and bring the two organizations together on something like that.
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As recognized as one of the pioneers for communication and resolution -- I've got that right -- absolutely. The short answer to the whole number of things that you said. But I think we actually have one of our staff members, Noelle Eldritch, whom you may know, spent several years in the VA safety system, Rick's predecessor of course -- Carol Clancy -- absolutely. I think we'd love to continue --
Yeah. Still after a year, it's very hot stuff.
Yeah.
Up and down the ladder. So I think we could do that.
Thank you.
Harry?
I've always liked the old ARC adage about translating into practice. As a translational scientists I like to think we're not just translating from bench to bookshelf. As you point out in that spectrum all the way from research to the demonstration to practice -- I think over the last few years I've been coming to this meeting -- probably the most inspiring piece of work I heard -- the one you just alluded to, the malpractice work out of Chicago in the network. My impression is -- it stumbled in its implementation. If you pointed out, you can't just parachute down a little toolkit and expect it to happen. What are the lessons that we're learning from both the successes of that but frankly I think the disappointing implementation for something that is a great story about how art can talk about quality, human face and how it's improved interactions? It's a beautiful case study. And my impression is it's faltering in its implementation.
So I'll actually use this opportunity to go back to gene's comment about what I understood gene describing is something that's absolutely -- I was thinking what a friendly audience this is in terms of understanding the complexity of safety because I think that is one of our biggest barriers. I don't mean our ARC, I mean hour, the system. Appreciating the complexity of apparently simple problems. So for example, a fall is actually not that simple when you start to get into the nitty-gritty of what's happening. Patient factors, provider factors, nurse to patient ratios, the complexity just balloons. And I think the medical liability and in particular communication and resolution is another one of those types of problems where for understandable reasons, I think the way that this success has been described is really focused on apology. And that is the key part. Sort of the communication of what happened. The openness, those are absolutely foundational aspects of that approach. What's also necessary -- I have the opportunity to visit Michigan -- that's one of the other pioneers in the area -- and when you really see the system in operation, you start -- meaning the communication and resolution system, you really start to appreciate the complexity that actually starts with just understanding what in the heck happened here? To this patient? Was it progression of natural disease or was it provider misbehavior? Was it actually a systems problem? Or was it some combination of all those factors? So the point is I think that a first requirement for this to work is the ability of the organization to actually undertake that question.
Can I ask a little bit more? I don't want to see you dodged the answer but -- we know it's really complicated. We presented this -- there's all sorts of complexity. I've been involved with some of those. I want -- I know it's complicated, but really, there are levers out there and captive malpractice companies out there -- it would save so much money and certainly -- tell me a little bit more about what are the real possibilities of getting this implemented so you have that story?
We are working on this. I shared your excitement when I first got to the agency. Looked into what was getting done and this was presented -- this was really cool. We had underway at the time, a plan to try to implement these CCRP programs in four hospitals. That might be good, but if we need to learn more broadly, because you are certainly right. Trying to take the University of Illinois Chicago model and a bunch of other places to do this with mixed results, that we need to be more intentional at understanding the problems of the places that have tried to implement. So we have an ongoing project to try to implement in a dozen or more institutions. Working at trying to -- overcome some of the barriers that we have seen and develop methods that we could then say more broadly, we've been able to make progress here.
I encourage you to really look candidly at the details of that plan. For example, translation to public benefit is often translation really to the marketplace. So if you're not talking with the malpractice companies and all that, you're not going to get traction on this. I hope you're right on that.
Completely agree.
We'll go to Michael for the last question. If we could keep the response a little briefer? We have to move in -- [Indiscernible -- low volume] more than observation. You could follow-up on it it as you like. Two things, first, every time I hear a presentation, much to Jane's comment, I walk away feeling hopeful. Thank you. The progress is really impressive. I can't -- the other is you heard me say this before, I very much appreciate the extension of patient improvements into other settings that had -- happened on the NAC. So I want to make a shameless plug in my last time on the NAC. To make sure we continue to move into the home. And for a couple reasons. One is care is heading in that direction. A, that's where people want to be and secondly, it's less expensive. But when you take a controlled environment like a hospital or nursing home, control is a relative term -- you now take all the processes you put in place and add it to everybody's home, that's a whole 'nother level of complexity. But the care that's being provided, working at the VA for example, Tom and his team and home-based primary care, much more appears to be based on the stuff that he's shared being driven home and with good results. So speaking on behalf of my organization, home health providers in general, we'd love the opportunity to partner with the smart people at ARC to try to figure out that problem. When you're ready, we will --
Thank you.
Thank you very much. Appreciate your time. At this point we have no one who's been signed up for public comment. I want check to see if there's anybody who does which to make public comment at this time. Okay. Hearing none, we're going to head into the lunch break now. For those of you who are -- those of us who are departing from the NAC in November, we're going to have pictures taken with the director in the back of the room over in that corner there, the backdrop set over there. For lunch, there is the cafeteria right across the hallway here. You can go there. You also can bring the food over here. If you want. As well. And we are going to reconvene at 1:00 sharp. Thank you very much.
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All right. We are going to get started again.
I know that we spent a good part of this morning talking about making health care safer and improving the quality of healthcare. And I think we are going to continue that discussion this afternoon through the lens of healthcare disparities. We will be hearing from a couple of folks here about some of the departments efforts in this area as well as the quality of disparities reports that are really spearheaded by AHRQ.
With us to lead off this afternoon is Doctor Rosita Dorsey whose director -- office of minorities health. And we are thrilled to have her. She supports a number of HHS activities in this area including the action plan for reduce racial and ethnic disparities and is overseeing a lot of patient and provision to the ACA that relate to disparities and populations including my favorite section 4302 at if you do not know what that is -- I do not know. She was -- before this has she served as an analyst and the offices of assistant secretary for landing and evaluation and other people have worked there before as well so she comes with that endorsement and she also without going through all of her experiences was actually the IES officer at the CDC also in a prior time. So Doctor Dorsey is probably going to speak about 25 min. and then we will have questions. I know she has to excuse yourself after that point and then we will hear from Ernest Moy as well.
I would just add as Bruce said that she was in ASP when I was there and I had the great fortune to work with her and she did not work with for me that we got to work together some and it is a -- I knew her story and now doing even more important work. I also want to acknowledge that J Crossan has joined us from MedPAC. Excuse me. I'm sure that you are keeping the Medicare program living part. Welcome J. It is really good to have you here and thank you for joining us this afternoon.
Good afternoon. Today I will provide an overview of the office of minorities health and our mission and strategic priorities. I will also then discussed the Affordable Care Act and the health disparity provisions that are included and finally I will go over the HHS action plan to reduce racial -- and disparities. The office of minority health was created in 1986 and it is one of the most significant outcomes of the 1985 report of the secretaries past reports on black and minorities health. This landmark report was one of the first times where the department actually began to look at health outcomes by race ethnicity and got -- disparities were documented.
The office of minority health was a result of this report but more importantly or I would also say as importantly, when we think about the past since then, the national healthcare disparities reports that AHRQ produces are an ongoing mechanism that support what this report has done in terms of providing data and information on the reporting of disparities and showing where we are making progress -- progress and areas where we are stagnant and so that is also an important contribution that I wanted to mention and in addition 2015 marks the 30th anniversary of the report and so there are many activities that we will be doing in the office of minority health and -- to recognize that.
The mission of the office of minorities health is to improve the health operational -- racial and ethnic minorities populations through the development of health policies and programs that will help eliminate health disparities. We do that through five or functions, awareness, data, partnership the networks, policies, programs and practices, research car demonstrations, and evaluations. We have three strategic priorities at the office of minorities health and the first is to support the development and implementation of the provisions of the Affordable Care Act that address disparities and health equity.
We also lead the implementation of the HHS action plan to reduce racial and ethnic disparities and we also coordinate the national partnership for action and health disparities and the national stakeholders prodigy for achieving health equity and that represents our public-private partnerships and reducing health disparities and achieving health equity and the focus of all of these is to translate core minority health and health disparities programs into strategic activities and policies at the federal and state and tribal and territorial and local levels of the coordination that we do across the department is very important but also that is what we do with states and community-based organizations and other local partners.
This slide shows some of the impacts of the ACA on health disparities and health equities including data collection and the minorities health service infrastructure and also making health insurance more affordable. As part of the Affordable Care Act, section 10.3 the for of the ACA authorized the establishment of six agency offices of the minorities health and it elevated the national Institute of minorities health which was a center for an actual Institute and it also authorized the deputy assistant secretary for my narrative health to report directly to the secretary.
There is an office of minorities health within AHRQ which Francis Chesley is the direct -- director and within the office of minority health, the office of or dating policies of offices of minorities health and that is a pivotal way to facilitate some of the disparities policy across the departments and we have also -- it is also important as these offices were being established in terms of resources and making sure that there was a structure and foundation as they were being built.
Within the office of minority health, we also provide support and serve the Executive Director for the HHS health disparity Council so the health disparity Council is cochaired by the assistant Secretary for health and the assistant Secretary for planning and evaluation and it is comprised of senior leadership across the departments who work in the area of disparities and that -- as a body we coordinate departmental calls including the implementation of the disparities action plan which I will talk about further and again AHRQ is also a very important member of the disparities Council.
The disparities Council meets monthly. We have internal presentations and we also have external presentations as well. The next thing that I will talk about -- and I wanted to actually leave quite a bit of time for interactive discussion and Q&A so the last thing that I will focus on is the HHS action plan to reduce racial and ethnic health disparities answer the action plan is the first ever departmental disparities strategic plan. It is comprised of four secretarial priorities and five goal areas under which there are approximately 40 action steps in support of the plan.
The plan was billed on the foundation of the Affordable Care Act and it is very important. The new investment that were the department was able to make into the programs and policies that we support was critical in the development of this plan. So for the sake of time, I am going to focus on three areas and I think these are areas that would be of most interest to this group. The first and secretarial priority one which is to assess and heighten the impact of all HHS policies and programs and processes and resource decisions to reduce health disparities and so are secretarial priorities are designed to be crosscutting issues that are really designed for the department as a whole to utilize and to advance some of our disparities policy.
The rest of the action steps have leads and partner agencies. These are really activities that are designed for all agencies. So as part of this, these help disparity impact statements can inform future HHS investments and policy goals and in some instances can be used to score grant applications as -- if the authority permits and so as part of this implementation SAMHSA the substance abuse and mental health services administration actually piloted health disparity impact statements and for -- four grant programs in 2012 and it expanded it to new grant announcements in 2013 and then in 2014.
Let's -- what is different about this is that with these disparity impact statements, grandees -- grantees have to show at the time of application what populations and subpopulations their grants will focus on and how they will be measuring their performance and how that will be -- we tried some impacts which is very important as well and then also how does the work adhere to the national class standards and so I will talk about the national class standards in the next few slides as well.
It is really important that these disparities impact statements -- we are now able to provide increased attention to vulnerable populations and there is increased access to federal resources and involvement in federally funded programs for disparity populations and it helps in improving outreach and engagement and retention intervention prodigies and it also provides a way for us to use this data once we have it to really see -- are we aligning our resources to where some of the most need is?
The next example that I will go over relates to our national class standards. These are the national standards for culturally and linguistically appropriate services and health and healthcare and I believe that you should have a handout that describes exactly all of the class standards that we have sent out and I will not take time to do that here. But the national class standards are intended to advance health equity and improve quality and help eliminate health care disparities by establishing a blueprint for health and healthcare organizations to implement and provide culturally and liquid sickly appropriate services in health and health care.
We have 15 standards organized under principal standards which is to provide effective and equitable and understandable and respectful quality care and services that are responsive to Doug Wells cultural belief and practices and languages that health literacy and other communication needs and there are three areas -- government ship and leadership and workforce and communication and language systems and engagement and continuous improvement and accountability.
This slide shows the path of class. In April of 2013 we published the enhance national CLAS standards and this was an update to the original CLAS standards that were released in 2010. Since that point, we have actively been collaborating and working to promote the CLAS standards. Across HHS and academics centers and community-based organizations. And other federal organizations. As part of the release of the CLAS standards, we have released a blueprint that serves as a technical guide to assist organizations in the implementation of the national CLAS standards.
We also are looking to expand the research agenda. In 23 -- 2003, AHRQ assisted with creating a report setting the agenda for research on cultural competence and healthcare. And this was very important because it created a framework to guide cultural competence research. And that is something that we continue to want to expand. The purpose was really to examine the impact of cultural competence interventions on the delivery of healthcare and healthcare outcomes.
Through the adoption and implementation and varying healthcare organizations and conducting research of along those lines. Looking at the impact of implementation of the CLAS standards on patient clinical experiences such as satisfaction and patient adherence. And ultimately our long-term evaluation would be to look at the effects of the implement patient of the national CLAS standards on patient outcomes.
We are in the process of evaluating our national CLAS standards -- enhanced standards. We are in the process of -- actually we are developing an evaluation right now of the awareness adoption and implementation of the national CLAS standards. We have a federal registry that was out that was published on September 26. The purpose of this study is to look at a sample of health and healthcare organizations to identify themselves as being adapters of the national CLAS standards.
Based upon that car really looking at what it is that these organizations are doing at the leadership level and at the staff level to implement the CLAS standards and so we anticipate being in the field with this study in early 2015. The other project that we have is connected to the national ambulatory care medical survey so the the NAM CS which is shortly called is a provider survey -- it is a provider survey that is conducted by the national Center for health statistics.
We had two questions added to the physician interaction survey. On cultural competency training and the awareness of the national CLAS standards. We are also looking -- we are planning to have a special supplement on the national CLAS standards and cultural competence awareness adoption and implementation using the sample from the NAMCS. So we will have a complete supplement on that.
This is really important. Because what we would like -- this is a pilot and the first time that we have done anything but it is very important for us to begin to have some measure of assessment of the actual implementation and awareness of cultural competence and CLAS standards among providers who are not our normal stakeholders.
So we often will have these privilege and the opportunity to engage with stakeholders who are interested in disparities research but we rarely get a chance to actually find out what is going on using a nationally representative sample of folks who are not necessarily -- may not know about the office of minorities help so it would be really useful for us in our future work in promoting the CLAS standards and identifying -- are there areas of providers that we need to talk -- target and this is just a start and we certainly would want to do this more broadly and we want to use the information that we have learned from the various components of our evaluation strategy for that.
If our results from this pilot are not successful, we would very much be interested in talking to [ Indiscernible ] -- NACNEP by the component -- our initial questions is something that we learned that might be useful for that point of inflection is also down the line certainly once we get past the 2015 and complete our survey, but we definitely want to share those results with you.
This is our goal that is really focused on data and research. So the first strategy is -- increase the availability and quality of data collected in reported on racial and ethnic populations. And as part of this -- it is a multifaceted health disparities data collection. On strategy included in the plan. That component -- I do want to acknowledge the one who cochairs the HHS disparities -- Council -- I'm sorry -- who also has an instrumental role in that particular component of the brand and helping us to identify that. Along with Jim it who also cochairs the data Council. We also have -- a second strategy relates to research. And as you will see here patient centered outcomes research is an important aspect of that under the first action area.
I am going to talk about the data collection standards. Section 4302. So section 4302 requires the secretary of the Department of Health and human services to establish data collection standards for race and ethnicity and sex and primary language and disability status and AHRQ also has an issuing role in helping to lead the implementation and development of those and David Myers who is here -- he helps to cochair the subcommittee that led this effort. And again the data Council was also involved.
As part of that, we have developed new standards that were released October 31 and 2011. And our new data collection standards include additional granularity for race and ethnicity. We distinguish out native Hawaiians from Pacific islanders. We include seven additional categories for our Asian race category and we also include specific ethnic groups for persons who identified the Hispanic to select from --
This is also the first time that primary language is being collected and standardized way as a self-report measure in our major surveys which is very important for disparities work. Previously it had largely been an administrative variable related to language -- what language the survey was administered in and we rarely data analysis on that. But now we will have that data. Our standards applied to population-based health surveys and the response of the HHS.
With the data that are self-reported. And AHRQ -- the medical expenditure panel survey has fully implemented the new standards and I do want to mention that are disability status standards -- it is a measure of functional limitations that are also used by the American community survey. So now our data collection is also in unison with that as well.
And the last example that I have, it is patients that -- patient centered outcomes research. PCORP provides health care decisions by providing evidence and the harm of different treatment options and AHRQ PCORP portfolio is a part of the action plan and is something that we use and it is in support of the plan and implementation. And through that mechanism, grantees have been funded to identify potential strategies to reduce racial and ethnic disparities and shared decision-making in under resourced settings.
So that is the end of my formal presentation. And I welcome any questions that you might have.
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I will leadoff if I could. You spent -- you talked a little bit I think about measuring the uptake of CLAS standards. And adoption. Can you tell us a little more about how that might be measured and what things you might be looking at? Because CLAS is obviously a broad range of potential actions and goal setting and I'm wondering how you guys think about adoption -- measurement adoption there.
Correct. So we have -- one, we have a huge resource in our state cultural health website where we provide resources and tools and there is information that we are able to get when people come to us and look for information. Outside of that, some of what we need -- what we will do is working with our partners and HHS and looking at how these CLAS standards are being implemented. And I would say looking at the individual standards and what these standards include so for example how are organizations are infusing diversity in the leadership and there are challenges in getting this information because -- while we are the leaders in developing the CLAS standards we do not own the organizational data and so by collaborating with the organizations we can ask them to share what they are doing and then use that to develop models and best practices but it is a challenge for us to say exactly and that is part of why we are doing the study is to actually be -- how exactly are the CLAS being implemented but also CLAS because there are entities that are implementing cultural competence but they might not be truly at the CLAS standards because that is what -- how we frame did and so that is part of what we are also looking to do. The research agenda that was developed in 2003 was a great way to start with that. In terms of how do we measure some of these things? How are we getting data from researchers and how are we guiding them and how would, we try to publish that literature in major studies? But in terms of -- and that is something that we would like to continue to do. But there are many areas within the research agenda in terms of getting that kind of data. Where we can continue to build upon that. But the part of the reason why we are going through and developing this evaluation strategy and part of that is really an assessment of CLAS adoption implementation within HHS. It is that we do not necessarily have all of those answers right now to say -- to the fullest extent -- how has the CLAS been implemented outside of different examples that we know from states and community-based organizations and so for example we know that the CLAS standards were included in the navigator grant FOA. We know that they are included and different kinds of HSS programs that that is part of our challenge is how to manage that and say this is a number of organizations who have implemented the five standards or this is the fourth CLAS and the level of that implementation.
So just following on a comment to that -- so our organization as well as the American Association -- AA MC Catholic health ACH and others -- they are part of this national call to action on disparities and really HA is putting significant resources into this and fault -- focusing on cultural cover the and diversity and governance and leadership and the collection of [ Indiscernible -- low volume ] and data. We are think -- I think we could get these data as well and help you get it. Slow if any adoption of collection of race and ethnicity data. A lot to do with cultural competence and we are not really sure what that means. Really slow progress if anything around diversity at and government in leadership and that is a major source of frustration for many of us and perhaps not surprising that is where that [ Indiscernible -- low volume ] has been so I hope that whatever you do with here -- I hope that it helps to forward many of us who are struggling in that area about what to do next.
Absolutely. And that is ultimately what we want to do. We want to build a long-term evaluation framework that will also include these measures and these metrics that we should be looking at and tracking over time and identify different sources of where we can get that from so one source that could be organizations like that and we do have relationships with that organization. But that is part of where we are now. So we are in the CLAS management at least for 2000 we did not do this. And so we have the research agenda but really thinking about -- how are we going to systematically get the data and measure this? And then when we talk to our partners we can say -- this is the type of work that we -- would be most useful for us if you are going to be doing the research or two could share your data and then you can help us to tell the story and really track where we are making progress in those areas but definitely with the data collection that is one thing that we can identify -- our organization is doing this. For the language access standards, those are enforceable under title 6. In the office of civil rights and so those are much more implemented because there is a force behind them. Our first area was governance and leadership and workforce and that is where you get into diversity it of your boards and other areas and the engagement and continuous improvement and accountability and that is where the data comes in and then how to use that -- meaningful use of that data to make informed decisions. Throughout your organization. Those are enforceable and so we are continuing to look at two different ways to show the added value of why we want to do this and that is why the research again is important in evaluation strategy is important as well.
Thank you. Henry? Carol? Jay? No? Let's go around that way.
Having a lot of cards is probably a good thing because this is an important conversation to be had around this table nationally you I really want to thank you for providing the framework of what the OMH is doing currently with the CLAS standards and realizing that OMH also recognizes intersection Alecy as an important factor of looking at health disparities I was curious -- I am wearing my hat as president of farmer -- health professionals advancing LB GT quality and so this frames part of my question -- what is OMH looking at it terms of the future moving into 2015 and onward and terms of data collection? For sexual and general I 40 status from the things that we have begun to highlight and the AHRQ reports for health disparities and quality. So I think this is an important thing that has begun especially in the national health Energy Service -- survey we got some data back that we are starting to analyze more. But that is only identified some initial findings with sexual orientation only. There so far is not a variable that has been approved to look at vendor identity to my knowledge so I would like to hear more of that -- how it fits under section 4302 in terms of data collection or some other place.
Right. The office of minority health -- we definitely have a role in data policy coronation. In terms of section 4302 and the data collection standards, as part of that law, the secretary does have the authority to establish additional data collection standards outside of race and ethnicity and sex and primary language and disability status. To start that -- as part of that work or I guess I will go there first. The first error that we looked at was socioeconomic status and age and so our national committee on vital health statistics which is another -- it started with that. But I would say that when you look at at the time we looked at -- could we -- are we at the place to develop a data standard for sexual orientation and gender identity? We just were not there. The questions were not good and there were some issues. So we could not do that. So what we did as the department is we made a major investment to do some testing to actually get some questions. That being said, it takes a long time in order to develop a standard but to say -- so we recently got the first year of full data collection from the and hers and so we are expanding that and I think over time you should see -- could be be at a point where we can actually have a standard? That being said, data collection will continue for the office of minority health. For us and I think -- I did not say that this is for us and our statutory authority the minorities groups that we are charged to provide services for if you will in terms of -- in our work projects -- they are African Americans and Latinos and Asian Americans and native Hawaiians and Pacific Islanders and American Indian's and that Alaska natives and so that things they any data intersections would certainly have to tie into racial and ethnic minority population so we are interested in those intersection Alecy's and certainly the data do have to exist. We have in our grant program funded some programs that really would support particular vendor -- sexual minorities meant -- some of our grant programs that are targeted towards AIDS prevention and other work. We are also interested in this section Alecy of race and ethnicity and gender. Sex. We have an instrumental role in the my brothers keeper initiative and they serve as the HHS representative on that interagency committee. So to the extent that we can -- that this data are available we are very interested in that and in working with other entities to ensure that those data are available. And also the social determinants of health. So if you'll notice -- I did not get into this but if you're familiar with the CLAS standards we expanded the definition of culture so it is not just limited to race and ethnicity and language but it now includes many aspects of culture. And that includes sexual orientation and gender identity and includes disability status and other items.
I suppose my follow-up comment would be then since that there has been effort and commitment made on the part of the office of minorities health to become a more inclusive of these characteristics, that would certainly be wonderful to see OMH continue to work with and partner with other organizations to make sure that the output of the data actually happens over time and for example when I look at the webpage and saw the initial timeline for data collection and saw the 2013 and all of that was great but that was 2013 and we have not seen anything updated yet. With regard to sexual orientation and gender identity.
Are you talking about -- where to look? I am sorry. You said look --
On the OMH website.
Okay. And please be mindful that we are not a data collecting agency. So what we would have on our website would be -- and I can -- we can certainly -- but it is -- it would be based on what the organization has already developed.
If I could leave in here Charlie Rothwell. We are the data collection agency.
Yes.
[ Laughter ]
We were the ones that were funded to develop questionnaires and the questions and it is an evolving science if you will. I have been involved in this type of activity for over 40 years and one of the problems that we have had, whether it is race or gender or whatever is society changes as well as you look at how -- as far as how it wants to describe itself and what are the appropriate words and phrasings to use? And the questions evolve as we evolved as a society. And that is part of the problem that we are facing but we are committed to continue to be collecting this information and as we improve the questions, those questions will be placed on the surveys.
We are with you.
Thank you very much. I think I appreciate all of the work that your office is doing and I think it is incredibly important. To make sure that everyone receives quality care. So my issue is going to go -- my question Mike concerns go to quality. As we look to provide care that is evidenced-based and appropriate to the patient, I come from a background -- and advocacy background in cancer and all of the populations that your group has been charged to study are underrepresented if at all represented in clinical trials. So there is a real -- this insufficient evidence -- treatment evidence to apply to many people. So we are looking at the very definition of quality care evidence-based care. So my question is do you have any plans or do you have any ability to speak to the issue of enrollment or population enrollment in clinical trials on the development of questions? That would engage populations to participate more and to develop the evidence that would be appropriate so that they can receive quality care as well?
So one area that I can comment on that we have actively been working on is really working with the FDA. To improve the representation of racial and ethnic minorities in clinical trials. There is a huge issue in diversity within clinical trials and are those medications -- what we are learning from the clinical trials -- is applicable to racial and ethnic minorities populations? So we have been partnering with the FDA and also the other offices -- agency offices of minority health and so MHD has also been working with the FDA true the disparities Council to some of the work that they are doing with the data and also part of section 4202 to help them address this issue at least in terms of applications that they are receiving on clinical trials with a drug applications and medical devices. I also have been working with the FDA in terms of adverse event reporting. So there is not a specific field for race and ethnicity for some of the reporting which is also important and that is something that they want to explore as well so there is a field but it does not -- as a free response you could add race and ethnicity that is grouped into many other different kinds of descriptive characteristics for that particular patient but there is not a distinct field for race and ethnicity and that is something that they want to add and so those are some ways that we are working on that so we do identified that that is an issue and it is a major problem. We do have some coordination efforts across the department to help with that within OMH we also have research advisor who works in this area as well. In working with NRH and also the FDA and other partners in some of these activities so yes. We hear you. We also say -- with our advisory committee, some of the public comment that we received as well so it is an issue that is on our radar and we also identified.
Thank you. And I want to encourage you to really look seriously into that. Thank you.
Jay Thank you Doctor Dorsey for your presentation but more than that for the work that you do. I have a kind of philosophical question. Ice think about the work that you are doing in the area of disparities, how do you think about disparities of a process -- particularly causes of care versus a disparities of outcome? I have my own thoughts about that. For example, disparities as a process is probably easier to measure. They may appear to be more meaningful to pay -- fixing in a short period of time but looking at disparities and outcomes, may be an area that we will uncover things that are not known and therefore important. You went through the presentation and you talked about two areas of research. One having to do with the CLAS and then one having to do with PCORP and outcome research and I wonder if you are thinking about priorities for those two areas how do you divide them perhaps into let's focus on disparities are processes of care and one and let's focus on outcomes and the other? Or how do you conceptualize this issue?
I definitely would say that -- I look at them in the continue on. So the processes that are always leaving us to the outcomes and along those lines. It is very difficult to track the outcomes and see differences in outcomes. That is part of the reason why it is difficult for us to actually see downstream where we have made -- how we made significant changes in disparities and for many outcomes, we may not -- we are not seeing huge differences. That is part of the challenge. But definitely we are looking at the processes of care is important and some of the work that we are doing in particular with cultural competence -- we will see -- and should be able to see a more immediate impact of at least some of the cultural competence work as -- cultural competence in care on delivery of care to patients and having impact on the processes of care. So we should be able to see for example changes in hypertension screening or changes in diabetes screening. We might not see those changes downstream in terms of what is happening -- diabetes prevalence rates or even persons with diabetes -- are we seeing changes in amputation rates but those -- we have not been seeing as many changes. And it is harder to do. But I would say that we want to look at both. We probably look -- distinguish them out but both are important and we would be tracking both.
Just to add -- a question that was raised obviously -- it is kind of fundamental to thinking about how do we reduce disparities? We have not talked about social determinants and health I think everybody here knows that probably somewhat limited impact of the health care system on disparities. Compared to everything else that is affecting disparities but even so, even that somewhat limited -- obviously it is still there and thinking -- sort of figuring out how to at a minimum reduce disparities and process? It is not going to be sufficient to deal with disparities and outcomes. But it is kind of more in a control -- people in this room and the kind of work that we do. But building beyond that obviously is crucial. The expression of insurance coverage and the Affordable Care Act is a very good start but it is only going to be one piece of this. There was one very interesting study done -- I forget who wrote it but I'm DR published it. Or the working paper from the MDR. Looking at differences in infant mortality between the US and Finland and I think it was Auster. I'm not sure about the third country and it showed that for people with -- who were relatively well off on income -- infant mortality is very similar across different countries that it is for lower it income people where infant mortality is much higher and most unsettling is the -- in a lot of ways is it is actually postneonatal. It is not at birth -- there are differences at birth but a lot of the differences are between kind of that two weeks and one year. And how much of that is process of care? Probably some. But probably a lot of it -- other things.
If I could just pony onto bricks comment in answer to question. Rivka talked about the impact of the ACA potentially on disparities. And one thing that I will just keep in mind also that in addition to the think that it is overly around coverage expansion and the health center and measurement and everything else that we are talking about here. The ACL is also -- BAC is also a very profound distribution vehicle to a tune of about $2 trillion over 10 years and the insurance -- insurance of to these Medicaid expansions and other things finance often by impact on higher income individuals and this is not a matter of opinion but this is embedded in the law. I think some would argue that that distribution effect may be one of the most powerful drivers of health impact that the ACA eventually people we know of thinking of quality and health which is very profound.
Really thank you for coming. Especially at the last minute. I know that Nadine Grassi was supposed to come so I really appreciate that you did such a great job and like everybody else I really appreciate the work that OMH does. My question is really about the priority on impact statements. So my experience with grant reviews has been and our grant reviews has been that investigators have to address minorities. Check the box. Pretty much everybody gets that box checked. But some brands do a much better job of it than others but they do not get rewarded and the ones that just do the minimal amount do not get penalized so my question is, have you thought about how to use the impact statements to have a direct impact on the score of the grants?
What we wanted to -- so SAMHSA is actually -- it has it -- has been a pioneer in this area and we definitely want to use some of the work that they have done as a model. There are -- who provide grants and there are other agencies who are looking into this at the grants are not scored based on the health disparity impact statements and it is not just a checkbox but you have to show what the populations are that you are projecting to serve and how you are projecting to serve them. But then also how you are going to measure that but there disparity impact statements are also tied to performance measures and so there are some very specific pieces of information that grantees are required to report and then in addition to that, they also have to say how is this work going to adhere to the national CLAS standards? So within these 15 standards that we have an that addresses so many different areas and that is what the grantees have to do and when the reviewers are looking at the grant applications they are also given guidance as to how to coordinate those.
That is really great to hear because that has always been one of my sort of pet peeves about the grant review process and how does handle. So really great to hear that. Thank you.
Okay. I'm with health services advisor group which is a Quality Improvement Organization just so you can know my background. And -- we implement that the CLAS standards with precision practices so I have to questions. We are also involved with measure development -- quality measure development area. Recently -- we all know that we all want to move from process measures to outcome measures. And outcome measures are risk-adjusted and the risk adjustment has become a very controversial is you -- issue recently because of the adjustments of whether to adjust out the social economic status or the SES factors or not. It influences the rates that are providers are being held accountable to an safety net providers in particular are saying that because it is not risk-adjusted they are penalized more than the other traditional providers. So I was wondering is OMH -- do OMH have any research agenda into this area? In terms of -- what is the appropriate method to risk-adjusted to address health and disparities issues? Traditionally or usually when we shine a light on in area of problem in this case disparities, and help the providers accountable and make their data transparent cup by publicly reporting them or incentivizing them, it tends to get better. So one strategy I think to reduce disparities is really to make it transparent. Right now we report publicly that providers rate but we do not report their stratified disparities rates. So readmission or let's say aspirin on arrival -- what is the rates between a visit -- the difference between white and African Americans? That is not publicly available. So in order to do that, the data and the quality measure has to be in such a way that you can do it and make it transparent. So I wonder if you have any research into that or any activities in that arena?
We do not have -- [ Laughter ] --
My former colleagues in ASPE are working pretty hard on that and we at AHRQ are working with them to both do research and try to figure out what makes sense both on readmissions and other areas. As you know I think that it is kind of -- for process measures, as you said, it much less argument for the need for risk adjustment but as we move increasingly towards outcome measures, obviously a much tougher question. So there is quite a bit of work within the administration to try to figure this out.
Right.
I have a second question. In terms of the CLAS standards, I am not aware but maybe you can enlighten me -- if it has been incorporated into medical school and nursing school curriculum or providers accreditation standards such as joint commission or NCQA?
In terms of medical education, we have had conversations with certain schools and institutions but some of that is -- in terms of -- are they actually implementing standards as part of their cultural competence training? I don't -- I do not have the exact answer as to that. So I think that we had advise on the CLAS standards as it pertains to cultural competence but in terms of -- is this the exact model that they are using in their curriculums? But we certainly have had engagements with nursing schools and nurse associations and others to talk about the CLAS standards and how this could be used and adopted.
Thank you Doctor Dorsey. I appreciate your time.
[ Applause ]
Thank you.
I have the pleasure of introducing Ernest -- Ernest Moy and and I have had the pleasure of working with Ernest Moy and as you have probably figured out from a couple of hours this morning a lot of fun in this job although there are some stressful point to it but a lot of the fun is working with a great group of people and you heard from Jeff Brady a little bit from Jennifer and so today is a big day for the folks in the standard for all of the improvement and patient safety where Ernest Moy works. So Ernie has been spearheading our work on the national qualities report and disparities report. I think it has been for almost forever. Maybe not quite. Before joining AHRQ quite a long time ago, Ernie was the director of research at the AA MC. It has got his M.D. from NYU and one -- we are a little behind but I will take 30 seconds with an introduction and when I got to the agency about a year ago, one of these advantages of being a new is that you get to look at all of this stuff with fresh eyes. I have known the NHQ RTR forever and I think that it is a pretty cool document in a lot of ways. And I have come to appreciate that the state snapshot parts of it were part of the effort is used I think quite useful at the state level. The national reports -- I have a sense -- they are not so useful. It kind of comes out and it is one day of news report often and then kind of goes away. It sort of reminds us every year that disparities are large and have not changed much and provide some view of gradual improvement over time and quality and as you'll see I think some very interesting work on kind of the measures that get publicly reported and particularly those that are used for CMS and payment and improve much more rapidly than everything else and not surprisingly. But the question that I put to Ernie and his team is -- are there ways in which this report can be made more useful or more actionable? And Ernie and his colleagues have done some work trying to answer that and I think it made really good progress as you will see although I am not sure that we are fully satisfactory answer and really look forward to your input on how these reports can be made even more useful and higher visibility than they are now. So with that as an introduction. Ernie.
Yes. I think you gathered that I am on the seat in more ways than one and by update I think that needs help so this is truly an endeavor to get your input. Because we were undergoing some transitions prior to the current year but with as Rick Kronick mention we are going to make the reports quite different I think for 2014. We want to share with you some of our thinking about this and get your input and you can redirect us if we are going the wrong way or tell us to go in the right way but I suspect that not everybody here -- has heard me speak so I will give a little bit of background on reports. These are two reports to the Congress. Mandated in AHRQ reauthorizing legislation and this is a test for.
It is pretty straightforward and trends in the quality of health care provided to the American people and the disparities as a little bit more clunky -- healthcare delivery as it relates to racial factors and social economic factors and priority operations and way that we have interpreted that is that we track all of the quality report and we take the same measures and now look at variation and social economic status primarily but then across other population characteristics secondarily. So we look into the reports and you will see many race and ethnicity and socioeconomic disparities presentations.
Then a sampling of the other kinds of her prior to population differences that we can report on. AHRQ -- this is the report by HHS to Congress but the construction was led by AHRQ and from the get-go we have had many -- much support. We have a team that produces both the reports now for many years. And an interagency workgroup that supports the production and we get guidance regularly from the IOM. We have a single framework. We use the same data and the same methods. We Jews -- use exactly mad measures and focus on something different on quality reports and asperity reports but it is one point historically that each of the reports -- it has been a quality and good spirited report.
I will show you -- thinking that concept and the quality report focused on a snapshot of quality and asperity reports focused on disparities and the quality report looks at the traditional measures of quality and the dimensions of quality and look sad the variation across states and looks at variation. Disparities report looks at variation across race and ethnicity and socioeconomic status.
This is to emphasize the very critical role I think of this group in the quality report and disparities reports or around the periphery I have therefore -- four reports that have been repeated -- produced to guide the QR DR over the last 15 years but at the top there is the act because this is the primary nonfederal group that gives us input on the format and content of the reports and I'm most appreciative to the NAC and never said have provided so much help over the years.
On the left side I think -- left side. The two primary HHS guidance documents that we see form the structure report. We are structured around the national quality strategy for quality and around the disparities action plan it that we talked about for the disparity side or the do. -- Dispirited session plan goes beyond healthcare we tried to take the healthcare aspects of that and use it to guide our reports. On the right side you see the actual production units of report that we have better test and workgroup that provides us with guidance that includes representation from all through HHS. Then we have a support of many of the AHRQ centers that will do a call out to see him which is the home of the database and they have bent over backwards to help us with data for the reports including the production of special disparities analytic files and hospital data. Do not have great race ethnicity data and they do a lot of enrichment of that to get us through the files.
They also work with hospitals to enrich their collection of race and ethnicity data. Also to see packs which has included all of the quality measures in their survey collection and oversampling of subpopulations to allow us to provide estimates for a variety of populations that we otherwise would not to and of the bottom you will see our center. Because CQIPS because almost anybody in our syndicates dragged into the production of this report. This is -- I put this out there because the reports do not exist in isolation but they exist as part of the system and this is the system that I see that exists there.
Trying to improve care. We have the National Quality Strategy which tells us in essence what is important for us to improve as a nation. And reports tracking pension. Now we know what is important. What is going on with that? How are quality access and disparities changing over time at the national and state level? But of course this is also emphasized that the reports do not change anything but the things to change need policymakers and communities or providers to take the findings in the reports or other things and apply it to their local environments and the -- much of AHRQ roles to develop those implantations and resources that help communities and a providers affect the changes that are needed to improve quality and so again we emphasized that we see that our role is kind of a funnel. A funnel into the AHRQ different limitation resources and into the other intimidation resources that exist but we realize that we ourselves cannot actually if I change.
This is a quick snapshot of some highlights from the 2013 reports. You can see the very highest level summaries that we do. So we focus on providing folks on three different kinds of concepts. Quality and access and disparities and we try to summarize it in four different ways and one is how we are doing -- the overall status. The second which I think is very poor to because I do not think that this is allowed out of our reports is how is -- how are things changing over time? What are the longer-term trends for bottles of quality measures and access measures and for the concept of disparities? We also tried health targeting so we identified areas that seemed like they were improving and you do not have to pay as much attention to as well as areas that are lagging and areas that are falling further behind and I think it was mentioned that one of our findings was that CMS publicly reported letters -- constitute the lion's share of the measures that have been most successful and we -- very concrete so successes achieving 95% and it has been 90% measures achieve that and maybe you can say logically dictate that that would be the case. CMS -- of course you are going to make it better but we can actually demonstrated.
We think that that is actually one of those values that we can contribute by bundling or looking at entire measure sets of quality at a time. Okay. Now we are getting down to the meat of it. This is the old QR GR. -- QR DR. We have always had a number of pieces to this and I think that after the first report which there was -- I was actually involved with -- we went in there and said that write this report and everybody will love it and the policymakers love it in the providers and the community and researchers and everyone will love this one document and then we were told we were wrong because people want to see different things and so early this was a decade ago -- we broken up into different parts trying to appeal to different quality makers.
We have a highlight -- traditional reports and paper -- it is about 20 pages long and then to be a summary for policymakers and it is an explanation of that summary table that I should you. How are things changing over time? What are good areas? What Arbat areas? And then we have reports. Traditionally called reports themselves. These are the actual detailed findings and the targeted for these have researchers and advocates a providers who actually want to get into the information in a little bit more detail. To do this the last report in the 13 are 224 pages and the quality report and 207 pages in the disparities report and they were integrated so we are all referring to but -- it is almost 500 pages.
We thought that that was a problem. The third component is that we have everything out there so that people can use it so they do not have to trust us and if they want to dig into the actual tables or look to the measure specifications or know more about the resources, look at the variations and state snapshot we have it all of the web it is strictly three different websites. You have to know what is where and where to find it and this was a problem.
Now this is the new and improved QR DR and I will start about because that is something that we actually did. This is something that we already had in place even before the doctor came in and this was to take our three different websites and integrate them into a single website and now it was completed on December 2013 and I think that we now have a nice single website which lets you look across different measures and different levels in the nation and the state and go to the different data tables et cetera. In one place. I think that that is a component that we have successfully -- I should not say successfully but we have completed redesign although your continued input in that area is so -- certainly welcome.
What we are really doing now is redesigning the two top products and this is what we have thought about. The first thing was that the highlights because of that is what the policymakers want to see we think. And what resonates with them the most and that is the charge. The charge is to report to the responders to high-level concepts -- let us make that the reports. So that is the concept never 1 we are proposing to make the report to Congress and that we submit a paper and we do it early in the year so early and 2015.
We would organize it around the National Quality Strategy priorities. Since that is what the nation has determined to be important from a quality perspective plus the concept of access to care. The access to care -- we will create a separate set -- focus on not just the care but in addition to the NQS priorities. Then the third thing that we went through an exercise -- many of the team members of the QR GR went to an exercise with the HHS ideal lab and they've won a grant for the ignite project.
They did a lot of training related to design thinking and I know that they interviewed a number of the members of the net as well -- NAC as well as other stakeholders and ask them what works and what does not work and I think that the key finding from that was that people wanted to hear something more about the stories. Data dump or a summary of data even was not necessarily the most helpful thing but they needed some kind of organization around that and shows a good way of organizing things and so we are thinking as we move ahead that the highlights would include a key story or a story of some kind and then we would fold in the summaries that we have to support that particular story.
I will show you an example of what we're thinking about in a minute. Different chapters -- we have a lot of people who want to read those chapters and we continue to produce the but we are going to produce them as online only documents. They are going to focus on the statistical aspects so the reporting of data and then instead of having a QR and ADR separately we are going to switch them together and should have integrated sections that will be integrated section on patient centered care and then a single section on patient safety for instance and have -- instead of having two separate components.
This would be organized around the NQS priorities so anticipate there will be seven -- there will be access and then six in QS priorities. So how might this look -- sorry -- is so very quick look at our website. This is what our new integrated website looks like and we think it looks better and then I think it let the people get things that they want to see. This slide is emphasized that we have a new component which is on the left. So this is a series of analyses now that let a person at the national and the state level compare themselves to the benchmarks that we have established and what it shows is across everything in that copper are be a number of measures and in green where people are doing close to the benchmark and in blue where they are kind of in the middle range and orange were they are pretty far away from the benchmark and for a pretty -- how we are doing compared to the benchmark. You can get the exact same view for the state level. Back on the right-hand side is our old state snapshot.
We added these new components and preserve the old state snapshots the people of God and used to so you see the dial and a narrow and how a given state is doing average -- as well to the average of other things.
Has anybody here look at the state snapshot for your state?
I did.
[ Laughter ]
Did you find it useful at all?
Yes.
I would encourage folks if you have a few minutes -- I know that everybody is busy but if you have got Wi-Fi on the way back have look at the state snapshot and let me know -- does this -- is this useful at all? I think the national report -- it is hard to make it actionable. You can try to kind of raise the alarm -- the state snapshots I think maybe are a little closer to being actionable but I was giving a talk yesterday to the quality Association from a state that I will not name but using the data from the states snapshot showed a number of places where the state seems to be performing sort of at or better than the national average and quite a few indicators where there was pretty frightening differences between the fraction of folks in the state who long-term nursing home residents under restraint at 5% compared to 1% for the national average or the avoidable hospitalization rates for a variety of conditions work three times the national average. Whether that is -- that information then spurs action or not is another question. The state is a pretty big thing and what does anybody do about it? I was on the telephone. Yes. They did. But hard to know. It could have been. I will be interested in reactions.
Since you asked the question, while you are on this slide and I heard this before -- some others have this. This is my third part of the meeting. There is one thing right here that drives me nuts. So I will just say right now because were talking about comparing the state data. The green it which says you have achieved it actually includes 10% below having achieved the metric. So it is kind of mislabeled and the part that says it is close is as far as 50% off of that benchmark. So I think that one thing that needs to be fixed is we ought to make those categories -- the numbers match the descriptions and we all understand there are problems with the benchmarks and that is part of what that is probably trying to allow for some confidence interval space for. I think that if we're going to have people take it seriously it is to remind them that meeting the benchmark means meeting it and being close means within 10% and 20% and not 50%. Those are the metrics that we talked about earlier today and infections in ICUs. Being half off is not close.
I heard you. We will make the change. We are trying to be a little bit nice so that people did not have to see all orange. But we will be meeting.
[ Laughter ]
We will be accurate. Yes.
Push ahead if that is okay. I can give you an example of what we meant -- first we had -- one of the exercises that we had to go through was to align all of our measures with the national priorities and that is something that we did with NAMCS with our workgroup and I think it is pretty consistent with what the CMS has -- how they have categorized their measures and the -- after doing that I will get you an example of this story concept is so this might be one story that you have seen so since 2013, the rates of insurance among non-elderly adults have followed. I think that this is put out in a ASPE document and you can see the flat line use prior to 2013 and then dramatic decline and what the report can add to this is that we cannot comment about the 2013 because we do not have any data on their eggs at except we can comment on the flatness of the lines prior to 2000. -- Prior to 2012 -- prior to to a -- across a very broad spectrum of active secure measures there is not very much change so measures are better and some are worse but the meetings were all about zero other than for kids. For kids we did see improvement over the last couple of years -- up through 2012. Not for adults.
Here is another example. This is an example again from the ASPE report which shows that a disproportionate amount of the improvement in uninsurance rates were among African-Americans and Latinos. In 2013 relative to the -- I'm sorry -- 2014 relative to the prior period. But that disparity still percent. Then in the report again we cannot comment on the most recent activity but we can report that back in 2012 yes indeed that not only were their large differences in our insurance across different priority populations related to race ethnicity and socioeconomic status but across broad spectrum's of measures of axis of care they are were pretty evident disparities. So the color red is a proportionate measures that shows disparity against the population of poor Hispanic and black and et cetera.
I think that is an example of how we were thinking of cross walking a story with the summarized information that the reports typically generate and this is to emphasize that in the other part -- the electronic documents will still have everything else that people are used to seeing although we are planning on moving into a chart format and that we were thinking about our pages that have a series of graphics and then also they will be a series of bullet points underneath and they will be available as a chart as well as a PowerPoint slide for people to be able to download and use and so this is kind of the traditional view that you see for the quality disparities report and this kind of presentation will continue. One of the areas that -- undecided is what to do with the priority populations. So priority populations have always been somewhat unsafe -- unsatisfying and reports because none of the audiences for the priority population is a different advocacy groups or people are interested in material -- it is not very satisfied to have five pages on their particular population. So we want to give up trying to produce this very large section focused on priority populations and instead produce a series of electronic documents that focus on a single priority population and of course we have lots and lots of priority populations so we need to flesh this out over a series of year so every upcoming year using a couple of documents to focus on a couple of priority populations and then add to that overtime and we would still link to all of the key findings in the QR and DR.
We need help. Prioritizing. What priority population product should we begin with? What sequence should we do it? We have a lot of push to do something really to people's condition so that is something that we think we are very likely to work on in the upcoming year. So in summary, major design of reports 2014 reports should be very different and we are planning to make them different to what you are seeing in the past. We will still have a paper of document for policymakers as required by our lot and it will focus on key stories as well as a summary of our data and we have documents for axis care and lots -- each of the national quality priorities and then we will have a section related to the priority populations and then we will have our integrated website and we are looking for your input on this as well as opportunities to define it and to remind us that ultimately what Doctor -- the doctor chose to do is to make the reports more visible and actionable.
Trying to get it towards that but if you have more suggestions about how that can be achieved we appreciate it and we will put out some constraints that we have discussed in the past so in terms of timeliness of data that we kind of -- I think we kind of hit that. We cannot get more it timely data that what we are currently getting and then the other constraint --
Yes. So the ASPE thing is October 31 and a couple of days later and the major data that we have used was the latest release of the latest enhance release and they were just available at the end of September and so we are trying to turn this data around very quickly.
Yes. So the and EPS -- the 2012 would just available in September of 2014 and then for the and Magi as it is the first quarter of 2014 is available in September. The other constraint that I will put in terms of action ability is that we will often have to go down and is -- there is not much data that can be drilled down beyond the state level -- account is available for some data but it is very spotty.
I will put it out there for input.
Just sort of as you are responding to the request kind of one of the challenge is to think about is that for the most part had the data that are in the QR DR our data that have already been relieved. By some other agency or by us or by NCHS. There are some of the breakouts by disparities that have not previously been released. So some of the disparities work is new but it is also -- typically a year to have 42 years in arrears by the time we get it out.
A lot of the top line work has been previously released so part of the challenge is how do we synthesize -- Ernie has got the great fortune of being able to synthesize quite a lot of information and bring that together. But to tell that in a way that is really compelling and is not just -- it is the same thing that we heard last year. Quality is improving slightly. Disparity has not moved much. What do we do with that?
I can qualify that just a tiny bit so most of the quality stuff that we have has been previously produced. The disparities that -- some of the stuff is unique and as Mary had mentioned CMS has not put out the compared data broken out by party population so we have run away since and run and yes to get the nursing home and home health compared from the QA owes we get the hospital information and in the stratified way. And I'd does as far as I know this is the only place where that has actually showed up.
Ernie Carr a comment and a question to start out here. This goes to your comment earlier. I realize that you may not get your long press report but I would submit that I think that the report does live on during the year although that may not be apparent to you so I know in the next few weeks we are going to be doing a couple of webinars with literally hundreds of hospitals around some equity issues through the Partnership for Patients and certainly the AHRQ disparities report would feature very prominently and laying out the agency behind this. This may not be apparent to you but it is there and I think it is still really useful. In that regard. In many regards. I have noticed that you are merging the quality disparity reports and as you probably remember -- there was an IOM committee on this which spent hours of debating the merits of merger versus non-merger and many of us could have gone either way and I am wondering what you're thinking was behind why now actually going toward a emerge Sigel document.
There are two just one was operationally we found that having the separate quality disparate report -- integrated but separated is clunky and making them much more robust than they have to be if they were actually put together so I think that one -- that is an operational kind of answer. That is one of the reasons but that is not the only reason. I think that the other reason is that we think that as we move to an electronic kind of document, that having this stuff in easy proximity to each other -- I mean, you will not be having paper reports. It is not like -- it is like taking those and actually just integrating them in a seamless fashion. You can get a much clearer concept of then of what is wrong from both the quality and disparity report at the same time and we have not decided the name on it but we are not going to file the quality and disparity reports. We might just call it the patient centered chapter. Or patient centeredness document. And just try to make the two comments -- concepts so integral that people want and demand to see both of them before rendering of how we are doing. That is part of the concept.
Very nice. Other questions?
You and your team -- you do excellent work. I always look forward to this. The release of both the reports. At our company -- we use the data as a rallying cry to -- so to speak. Again, we have got to concentrate and have renewed vigor and focus to address address and we use the national and state specific whatever benchmark we have to compare and we compare our states specific data to see how we compare. That's Adcock -- that said -- our medical team or our economic team or whatever safety analysis -- I am always challenging them if they are sending out trans analytic reports to the business leaders, give them some kind of analysis. Give them some kind of recommendation as to where else to look and what else to ask for and so forth. So if you could make recommendations for areas -- that stick out to you. You are the experts.
Where we might look and try to gather more data so that they can drill down. I think that that would be helpful. Then are there not other data sources that you have access to so that if you do see something that looks anomalous or something that is not getting better -- isn't there a way to take other data sets so that you can do some of that drill down?
Do you mean geographically or just to confirm the differences --
To confirm?
And I think we take that triangulation approach does and so there are all different kinds and I know that they are not biased -- -- we also have statistics and the notion there is to try to create the true picture and so access is terrible in Philadelphia and it is not as terrible in Boston -- aren't there some other data sets or is there more data that we can look at to tell us why -- to try and start analyzing the root causes?
Yes. I think that we can start to try to go down that pathway. I think that earlier today that kind of came up as one of the things to highlight were the geographic regions that were changing because most of the geographic regions kind of stay where we are and the top 10 -- there are some that move and maybe some of those things would be interesting.
That would be very helpful.
Who is moving and maybe try to think about how they are moving.
Remember. -- We should be of clear about what is available and what is not. So we have from the database a pretty complete hospital discharge data. So to the extent that you can answer the question of why is Boston then Philadelphia different was hospital data? Fine. But limits obviously. We have in stock states emergency department data it useful for some things. We do not have and all payer claims database in general much less data beyond what is available for claims so there are serious limits to what we do.
[ Captioners Transitioning ]
This has to do with the chronic condition been -- Medicare payments -- the final rule them out last week. Looks like the payment level is going to be $40 for major beneficiaries -- you think about the panel size for an internist -- maybe 2 to 300 are Medicare that is a sheer is. 60% have two or more conditions -- that's a lot of money. Since we had -- yesterday when we look at [indiscernible] me have significantly underestimated the uptake of this particular incentive process -- at any rate it is robust enough to suggest that there are going to be some practices that are going for this and some that are not. Putting it to experience over the next couple of years might be a fruitful area of thought.
The agency has received a grant from the Robert one no doubt soon -- foundation -- spearheading the work to add a component to the provider part of MEPS and we will survey physicians to get information about what size practice and ownership and care management processes -- of imagine a low it is new -- the question has not been developed -- participation in the chronic care management please and be able to link that to the household component as well.
A good point. I and others are excited to to see the take-up of the chronic care management services and what it looks like.
Sherry?
I have two echo the comments from Bruce. Although it may not be measurable -- I will tell you that when we received -- we always order cases of the reports -- they manage. With an -- within a matter of hours. There is uptake and it begs a question -- who is the audience you would like to reach that perhaps we are not reaching? So, that's one question for you to ponder. Think also it's great that there is going to be more alignment with the national quality strategy because the policy levers are trying to drive according to that end with that in mind with the fact that the system transformation is happening, there is opportunity to look at exactly that. So, the concept of care coordination and those things that represent more [indiscernible] than disruption or disintegrated this , I think can be reflected in the report. You have that. But there is also real opportunity to call out what the population is and what it needs. What the population is comprised of -- you know, the chronic care warehouse and the multiple chronic conditions -- port can be helpful here. Again, very well aligned with the state snapshot -- you look at the state for the number of conditions you have and there is an estimated cost for the population, but it is just a number. Because it is hard. So, I think there is opportunity to converge those efforts anyway. But, if there is a way you can think of to capture not only the quality of care being provided but also what is left to do -- the disparity report is one way to look at them because it is an opportunity to improve this but there could be others -- I cannot think of them now. Still, great work.
Thank you for the comment. I will take the opportunity to sort of race maybe a screwball idea -- but, as Ernie said, one of the findings of the report, not surprisingly is that the areas with the most improvement in quality are the measures that CMS publicly reports or even more uses the payment systems.
One of the persistent areas in which we see hardly any improvement for many years is in the disparity. It raises the question -- this is a challenge to measure developers of which the agency is in part one -- whether there should be measures of disparities that go through the endorsement process, etc. That could be -- when CMS ask for public reporting and using a payment system, measures of quality perhaps there could be measures of disparities in quality and we were able to successfully develop them and get them approved, etc., I imagine that this could contribute to a reduction in disparities.
Just to respond, I would agree. Also, that the disparity that is apparent is your trending over time of is covered by what type of insurance and the fact that there are differences between states in the quality. Those are all opportunities to improve. I don't think it's all that screwball, either.
[laughter]
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So, it's important to us and we did make some comments -- thank you. We did make some comments to the household component maps -- MEPS survey we would like to see a question in the child a preventative supplement -- if a person has received an eye exam by an optometrist -- optometrist for ophthalmologist in the past 12 months. We look at reporting downstream effect of the policy, the Affordable Care Act for the first time in history list vision care as an essential health benefit for children. Because we link healthcare, vision care two medical care and we are not allowed to have standalone plans to exchanges, every state in the country and every level -- children from birth through age 18, get an annual eye exam and glasses benefit. It's huge. But, the problem is that we have no way to measure the impact of that. I just wanted to mention that. Say that we are ready, willing, and able to work with everybody here and at AHRQ in order to help get the accurate data that we need for policymakers.
Thinking. If you want to respond, you can.
You don't have to.
I want to make a clarification -- I can't comment on the MEPS question but we did not intentionally drop efficient measure. We shall this on alternating years. So, it's in one report and out of the next.
Thank you for the clarification.
Yes.
When I saw was out -- I thought it was a way to fix it.
[laughter] We still need to fix it. Because illegals and it candidly inaccurate.
We look forward to following up on.
Thanks.
Any public comments and this time? Hearing not as go back to the active discussion. Mary, you were up next.
Ernie, I have a couple of questions. On the priority population when you say there will be electronic documents focusing on a single priority population, what exactly what that consist of?
Right. That is one of those open-ended questions. We're thinking that people want more than the five pages we usually do. The question is, how much more can we get? A 10 page long fact sheet or going any where from -- duties [last name indiscernible] -- Denise [last name indiscernible] will produce a report for kids. It is likely to be somewhat variable. For these priority populations we are looking for people to work with us and so we are working with our office of priority populations research to see something they are interested in for multiple chronic conditions. There are some audiences that will give us some guys. So, anyone can give us guidance -- which relations and how much you think the population would want.
A second question -- this is different. A suggestion I should say. QIO has been using her state reports. That is one way for us to motivate our providers. We are assigned to one state at a time and so we use that? Of it. Now we are focusing on communities -- a smaller entity. If you can align -- I have to if you have kind of granular data at a community level, but that would be great. The second thing -- once you publish a report each year is you could make an effort to communicate with the [indiscernible] organization so we can have you or your staff present the findings to the QIO so we can be more familiar with it and so on. That would be one way to disseminate your findings and results.
Yes, coordinating with [indiscernible] is a great idea. In terms of more granular data, we have some but for most of the measures we don't. And when we do have granular data it is hard for us to access. For instance, the H Cup.
Charles?
Rate presentation I hope that you can come over and giving similar presentation to our staff. We are looking at how to redo and look at health the United States -- the secretaries report to Congress. Some of your ideas might relate. I also think there is probably -- close tie-in between the two activities. Also looking at how we do the publishing of vital statistics which has state level information in it -- we can put something from you. So, congratulations on that.
Just a general comment about what has happened this afternoon. We published in HRS the first winter information on the impact of the ACA and we are going to do that for the next quarters of this year and for ever. And by the way we have been collecting health insurance information on HIS for decades. There have been health disparities throughout this time and sometimes they have been [indiscernible] in many areas. The challenges it seems that people are losing sight of what we really should be measuring. Yes, there has been more coverage in health insurance. In the end, so what? If in fact people's practices don't change, both practitioner and individual, and in the end the health outcomes don't change, where are we? There in lies the challenge. So, I think these reports are going to be more and more important. As we take a look at really what the impact of health insurance is and -- because, if it hasn't had the impact that we want we are in real trouble.
So, I think these conversations went well this afternoon. I think they all dovetail quite well.
Thank you. You are asking for feedback about the recommendation. My feedback would be that I think the eye the lighting it up -- lighting it up for the measures and lining up access is a terrific idea. The circles I, most people are familiar with the Triple Aim but not very many are familiar with the quality strategy and say that none are familiar with the [indiscernible]. The more that you can type into these reports -- the more it will help people to see them in the life which I think is a terrific way to do it. Highly supportive.
At this time I will turn to Harry. Then also segue into general closing comments that you may have as we approach 10 minutes from the end of the meeting. Any questions you may have in wrap up or suggestions for future topics. I will go to Harry first -- your card is up -- I will segue into the closing.
Is that is where I think happy trails to you? [laughter]
Gene in important, this morning -- about including people from the military. First there is a disparity piece there and also the health problems are increasingly important in our society. In so many ways. This should be reported on -- traumatic brain injuries, post traumatic stress syndrome and the implications for individuals and society. These are not trivial and somehow they are being segregated out. You probably had to go to the try service health and all of these things to get when did but the more you look into it more you realize that it be underbelly of the national health environment that we really should be reporting on.
Now we are getting into more trouble. [laughter] I had a question -- somewhat of topic going back to earlier today. -- Off topic going back to earlier today.
As you think about the ACA impact, the library care about is going to expire and the initial reports are not good on possible extension. One reason is that we don't know what happened. I am curious about whether you have data on that or whether it expects to be asked about that in the upcoming policy discussions about that.
I'm not aware that we have any data at this point. When I was at my last job we put effort into place to try and get some of that data from working with one of the data aggregators that has relatively fast access to data. I'm not sure whether this effort was successful. It will eventually be data from Medicaid systems. But there is a long delay. There are problems with managed care data. The MEPS data my the eventually used -- I don't know if it has an identity in there. That's a bit tough. I don't think that we have anything now and to the extent of the question raised -- thing that I'm aware of that would be helpful.
Commentor closing questions as we come to the end?
Sure. We will get back to you. We will go to Jay and Newell
The Medicare payment increase of 10% is scheduled to sunset this year.
So, we spent some time yesterday on that also in thinking about it it was have to think about the purpose of it in the first place. Part of it was to stimulate care coordination but explicitly the med pack recommendation they gave rise to that part of the ACA was simply to try and improve the resources available to primary care to attract more talented individuals into primary care. I think it would be a mistake to say well, in order to justify extension of that we have to look in a short time and health outcomes or something like that when in fact, to be honest, there was more than one purpose in creating a. Our recommendation -- the plurality of the discussion which will probably lead to a recommendation next month will be to extend it differently, not as a percentage increase in the payment rates, but as a per beneficiary direct payment to the physicians.
Just for your information.
This is helpful to know. Thank you.
Newell? I wanted to thank Rick for the opportunity to be on this Council. I'm sure that I got more out of it than art got from me. -- Then AHRQ company. It has been a great experience. Also, to direct a comment to you, Rick, I suspect that you felt like we were really pushing you when you first came to the agency. And I think many of us care deeply about AHRQ. We were wondering who is this guy? Does he care about AHRQ is much as we do ? I think you still care some of that especially with Andrea's comments this morning. I'm happy to say that from the perspective you have passed the audition.
[laughter] I think that AHRQ is in good hands. At any rate, thank you very much for the opportunity it has been a pleasure.
Up to this point -- [indiscernible] . I will turn it back to you.
A few closing comment -- my thanks again to all of you and to those who are -- who I won't have the opportunity to think again at least in this setting for your work on behalf of the agency. To your comment -- I wouldn't have taken this job if I didn't care deeply about the agency. There are easier things to do. [laughter] maybe nothing that would be more fun, but certainly things that would be easier. I would close -- I got a lot of good advice today and I would remind those of you here of you questions -- request that I made if you would like to follow up on them place to. One is -- not that we could replace Irene Fraser as the director of the Center for delivery and organization but I am recruiting for a new director. If you have suggestions there, please along with me.
The closing question from the morning session was for suggestions about collaboration -- what areas we should look for to deepen our collaborations. If you have any follow-up on that, I heard from Mary about QIO. Please provide demo. I should've mentioned whenever more people here -- I talked a little bit about the investigated initiated work. We did probably two or three weeks ago publish a notice in general the [indiscernible] process is that we entertain these up to $250,000 per year for up to five years. The notice we published a few weeks ago said that particularly for grants focused on affordability and accessibility we are particularly interested in findings as quickly as we can get them. I'm thinking about the Bruce question about the Medicaid bump. We will entertain grants for up to $400,000 per year for up to two years. Less money altogether but more money per year. I would encourage you if you have colleagues in the grant getting part of the world to pass the word onto them.
That, my final comment is -- thanks again to Jaime Zimmerman for organizing this and once again to Dr. Siegel for his amazing work over the last six years.
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