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Town Hall Meeting at the AHRQ 2007 Annual Meeting
September 28, 2007
has time for a couple of questions and if you could come to the microphone.
Raise your hands and we'll bring you a microphone, I see, thank you.
Hello, Secretary Leavitt. Margaret
Stanley, Puget Sound Health Alliance. Can you give us a timeframe on CMS
crunching the numbers and sending them out to the local communities and what
kind of reporting that would look like please?
No, but Barry can. (laughter)
Very quickly, Secretary Leavitt, as I said earlier, would have liked
for us to have done this a year ago, but we will be announcing, probably in the
next day or two, the contractor that we are awarding to actually work with the
Chartered Value Exchanges to provide this information. It'll probably take
several months for them to get the methodology down, and I would anticipate
it'll be in the early Spring that they'll be able to have the beginning of
Nothing in this business
happens fast enough for me. (laughter) But we are making progress, and
they're doing it well and right, and I appreciate the care with which they're
taking, but hurry up, Barry. (laughter)
My name is Ragu Ram. I'm a family
physician in Buffalo, New York. I think we've done a wonderful job in this
country training our primary care specialties at value-driven health care.
Unfortunately, I think our reimbursement methodology doesn't share that same
value. What sort of approach can we take to improve the methodology that reimburses
primary care practices?
Let me just say,
I agree with everything you said and acknowledge that this is a chicken or egg
problem. Until we have information that begins to demonstrate the value in a
way that people can begin to follow it, the reimbursement system and a command
and control system won't follow it as rapidly, because a lot of politics gets
involved in it. And it's not just politics on Capitol Hill; it's politics
within the various professional sectors. And that's the reason that there's so
much power, in my judgment, in a system that provides information and leads
people to quality. Because people will pay for quality. And the system will
begin to change its macro-economic approach. I know this is frustrating...
it's frustrating to me. But, we're working hard to create an alternative to it,
and I believe once we do, those reimbursement changes, that macro-economic
equation will begin to shift. There's a lot of these. The primary care is a
good example, but there are a lot of macro-economic shifts that have got to be
made here. One of them is, "How do we deal with this problem, if the people
have to invest in the systems of electronic medical records, aren't the ones
who openly get all of the benefit?" Somehow, we've got to create a system
where those who make investment also get part of the value that comes from this
Now, I have confidence that
will happen. It won't happen, it may not be perfect or pretty, but it will get
there. So I guess I would say that my belief is the first thing we can do is
get this system into place, and the system will drive the equities.
Hi. I'm Kay Jewel. I'm a
physician in Wisconsin and a consultant. When you talk about the CVEs I'm
assuming that each one will be using the same measures, so they won't be
local. Will there be a national reporting? Or will it be local reporting?
In order to be a
Chartered Value Exchange, there are a set of criteria that's been laid out, and
we can talk about that in more detail. But if I just put it simply, the number
one criteria is you need to adopt the standard quality measures that have gone
through the process of the AQA and the National Quality Forum. And that's the
The neighborhood strategies
is we want you to do that in a way that, we want you to innovate to do it. We
started off with six—we call them the BQI's, Better Quality Information. And
you know, there's one in Wisconsin, there's one in Minnesota, one in Boston, one
in Phoenix, one in California, one in Indianapolis. And they're all doing it
slightly different, but one of the things we're now moving towards is all six
of them are beginning to use the same quality measures, and so if you're going
to have a Chartered Value Exchange, one of the commitments that you make is
that you will use those standards. And so we're using the brand of Chartered
Value Exchange as a means of knitting people's commitment together to use those
Now, we know that there are
people who are developing other ways of measuring quality that, and maybe that
need to be expanded, and so we want to create a means by which, in this network
of Chartered Value Exchanges, there's a way to advance those to where they can
be adopted nationally. Will we be doing national reporting? I'm going to ask
Barry and Carolyn to answer that—I think we probably will on certain measures,
and we'll start sharing information. The thing I expect this network to do—basically
3 things: 1—I want it to be a learning network. I want to have meetings like
this where we learn from each other, where we share technical data; 2—I want
it to be a means by which we innovate more quality standards; and, 3—I want
to make sure that we're all informing each other. And so, having the charter
and the brand of the charter, I hope, will begin to make clear a common path,
putting it together in the network will begin to create this synergy like we've
Good Morning, Secretary Leavitt.
I'm Kathryn Jones from the University of Nebraska Medical Center. Coming from
Utah, I know you appreciate the wide-open spaces we have there in Nebraska. We
have 93 counties, 22 of which don't have a hospital. So, I'm wondering what
the Chartered Value Exchanges will look like in our counties in Nebraska where
we have one critical access hospital that provides the care for all those folks
in that county, and how we'll use that Chartered Value Exchange to drive
quality of care for places in rural America where really, frankly, there is not
That's a great
question. I hope we can all figure that out together. I recognize the
difference between what goes on in rural communities. As you say, I've
governed a state where there were some communities so rural that you had to
order a haircut out of a catalog. And health care has to be provided as well,
and they have to go someplace else for it.
And, I think, ultimately,
what we're going to have to do is get it very simple and recognize that. But the
key to it is going to be the electronic medical record. Because those
communities, whatever health care source they have, making them part of a
larger system will begin to create some kind of pricing and quality measure
that doesn't exist now.
I think I dodge that
properly. Truth is, I don't know the answer, but I do think we can figure it
Good Morning. Louise Probst,
Business Health Coalition in St. Louis. Thank you very much. I wanted to say
on behalf of... communities here, I want to say thank you for your
leadership. The Federal Government is doing great work in health care, and
every opportunity I have, I tell people to hold on, because there's a lot of
good things happening. I also want to thank you for putting health care in the
broader context of what's going on. I also grew up in the 50's, and I know the
gift that I think our generation had of living in a world where you knew what
it meant to be American and we were proud of it, and so, I think it's important
to understand the impact of health care and other things. Now for my question,
which is technical. Since CMS has decided that it's going to measure the
quality of things centrally, will they also have a responsibility or feel that,
to actually share that data back with the physicians, or is that solely the
responsibility of Value Exchange? I assume doctors are going to be wanting to
come to you and get that information, I'm wondering if you had thought about
that? If you'll have a role in having the support line for physicians or how
that will work?
Barry, do you
want to respond to that? Or Carolyn?
Sure, I think that
obviously the Value Exchanges will be sharing information like this. But we'll
be able to calculate a national rate so that people could compare themselves to
that. We'll be able to have a regional rate—could be at a State, could be at
a local regional level and the local level. Probably initially down to the
physician group level, not to individual physicians right away. So we will be
sharing that information with Medicare information. The Secretary mentioned
Robert Wood Johnson Foundation efforts, which will align with what we're doing,
so we'll be able to combine the two to get a combined effort in the short
term. The Secretary has made it very clear in the long term, he'd like us to
expand and be able to offer information far beyond the initial measures that
we've chosen to do initially. And that will be shared with physicians, quality
improvement and other providers. It will be used for consumer choice, and it'll
be used to determine incentives to try to improve care.
Could I just
recognize that we're going to learn a lot, and the best opportunities we
haven't even thought of yet? And the market will begin to present new
opportunities, new ideas, and new innovations, and what we have to create is
this basic infrastructure and this basic network, and then, you know, I think
it's quite possible we'll, you know, you could start off with hundreds of Value
Exchanges and over time, it may, the market may say that doesn't make a lot of
sense. Now that we've created more trust in this system, now people have more
confidence in it, we might find Value Exchanges beginning to merge. We might
begin to see Value Exchanges making the very natural connection with
organizations for health IT, and many of them may say, rather that have the health
IT network development being separate, let's start merging those. As long as
we're dealing with common standards, then we can begin to see efficiencies.
Some of you have heard this sort of hokey analogy, but it works. I'm walking
through an airport, I think in Indianapolis, and there's a racecar that is on
display there—I think from the Indianapolis 500. And I thought to myself,
that's what people think I'm talking about when I talk about this system of
health care that will provide everybody with access to this powerful
information. That is, in fact, the vision. But in reality today, we've got
ourselves a little pile of wheels, a steering wheel, and a Briggs &
Stratton motor, and we're trying to build a go-cart just to prove we can make
this work. And once we've got proof of concept and people begin to create a
set of standards and confidence and trust, then it will begin to grow and mushroom,
and it will evolve into the race car. And it may be that we don't have as
many. It may be that rural America finds a different way to do it, but once
we're empowering the standards and driving the concept, we'll invent a system
that will be the most powerful system of health care on the planet, because
it's turning decisions over to people who care the most about the decision, and
that's the consumer. That's a powerful force, and it is the uniquely American
force that's driven our entire country to the level of prosperity that we
currently enjoy. And it's what is absent from health care today.
I think we have
time for one more question.
Hi, Secretary Leavitt. I'm
Georgine Stowt, a preventive medicine physician in Davis, California, and your
story about your colonoscopy precipitated a two-part question. One, did you
decide to get it? And, which one did you choose and why?
Yes, I did. And
so did my wife, and we ended up in different... I found one in Washington, D.C.,
that I was able to get under an arrangement that suited my purpose, and Jackie
did go to Utah and have hers there. And, under HIPAA, I can tell you no more.
Your story reminded me of a story
from my practice a few weeks ago, where a man I was treating for his obesity,
and he was doing very well, out of his own pocket, paying for it, of course, "I
said, oh now you're 50, how about the colonoscopy or the screening?" And he
shared with me a story similar to yours, that it would be $5,000, and he was
making a choice between dealing with his obesity or his colorectal screening. My
question relates to the vision of the future. Do you see a vision where
prevention will be prioritized and we don't have to choose among the various
valuable procedures and services with respect to our investments?
I believe that
once we have a system that provides a means of electronic connection, quality
measures, a way in which people can exercise judgments on costs, and
motivations for better quality and lower costs, we're going to see the market
drive us to that point. I think people will naturally see that prevention is
where the money is and that it will begin to move us to primary care
physicians. It will begin to move us toward more prevention. It will begin to
move us in a way that is toward lower costs and better quality.
I'd just like to say. I've
told the story about my colonoscopy a few times, and I keep getting new
information. You know, people come up and say, "You know, you can come here and
get it for a lot cheaper than that." But one employer said, we wanted
everybody to get a colonoscopy so we worked out a group deal, and we got it
down to just less than a $1,000. And then I had another person say that, "Well
I was in Japan..." And, you know, what they do in Japan is a little different
than we do here. They've concluded that they could, rather than have a
physician do the entire procedure, since it's all done electronically anyway,
they could have a room where they have many different monitors with a physician
monitoring all of them at the same time, and they're doing them for less than
$300. Now, I'm not here to advocate for that. I'll have physicians all over my
case. What I am... They've made a decision about value and cost. They've
concluded that, based on the risks that they believed were there, that it isn't
necessary to, that the risk of puncture may not, they've made decisions based
on that, and they're now able to give that colonoscopy that I was quoted $6,000
for, you know, for $400 or $500 dollars. Now, is there an economy in that? I
don't know. How will we find out? Well, we'll start gathering information.
Why don't we have it now? It's because it's all manual, and before it's
actionable, it's 5 years old. That's the system we're talking about, that's
the power we're about to unleash. That's the reason we're working so hard on
this hole. And we're just about ready to see it pop out, and all of you and the
workers and I look forward to standing side-by-side with you, laying brick by brick,
and we're going to make the vision come that the people of this country want,
and that's better health at lower costs for every American. Thank you.
Let me just close
with a couple of points. In our excitement about trying to figure out what it's
going to take and how can we support, centrally, local efforts at the kind of
innovations Jim just described, that you've heard Secretary Leavitt describing,
we can lose sight of the fact that Chartered Value Exchanges remain a very near
future-tense item. We will be letting all of you know when the criteria are
finalized. And the questions that I heard from Margaret Stanley, from the woman
from Nebraska, and so forth, I think are all critically important questions.
And I think the Secretary had it right when he said there's not a clear, easy
answer, but I think our collective working together to get these answers right
will be very important. One of the challenges that we will have centrally, and
we'll also need to get feedback from you on, is figuring out a framework in
which foundations supported investments in local technical assistance, the
Value Exchanges, the learning networks, and the quality improvement
organizations can make sure that their efforts are synergistic at the local
level rather than a set of tangled lifelines, if you will.
So, this is very much a
script in progress. I, myself, love the idea of a first AHRQ-a-palooza t-shirt.
We'll let you know if we actually get a chance to complete that idea. Thank you
for a terrific session.
Current as of July 2008