First Meeting of the Subcommittee on Quality Measures for Children in Medicaid and CHIP
Jeffrey Schiff: I'm Jeff Schiff. I'm the medical director for the Minnesota Healthcare Programs at the Minnesota Department of Human Services. I think I got here to be as co-chair for a couple of reasons. One is the medical directors for the Medicaid programs have been meeting for about 3 years in an organized way. And I appreciate the fact that both the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) have seen the value of the medical directors from all over the country as a vehicle for improving the quality of the Medicaid programs, so I feel somewhat honored to represent them. I also just want to say that this is sort of a historic moment as far as quality for children's health in the country, and I think both Rita and I are both honored and humbled to be sitting in these roles of chair and co-chairs and we hope we can fulfill all the expectations. I will turn over to Rita just to say hello.
Rita Mangione-Smith: Good morning everybody. I'm Rita Mangione-Smith. I am a general pediatrician by training. I'm at the University of Washington in the Department of Pediatrics. I'm also an investigator at Seattle Children's Hospital Research Institute. I came to become one of the co-chairs of this great subcommittee because of my main research focus which is really quality of care measure development. That is what I spend probably about 80 percent of my time doing, so I bring that to the table as experience in helping this group think through what are the major criteria we need to think about as we are trying to arrive at this core set of measures to be sure that we get the best possible set of measures that we can for this initial effort. I am thrilled to be part of this. It is a historic moment for child health quality I think in this country, and it is very exciting to be a part of it.
So I think we want to go around the table and if everybody could just give a brief introduction of who they are on the subcommittee that would be great. So we will start.
Barbara Dailey: Thank you, good morning. I'm Barbara Dailey, and I'm the director of Quality, Evaluation and Health Outcomes in the Family and Children's Health Programs Group at CMS. Good morning.
Doreen Cavanaugh: Good morning, I'm Doreen Cavanagh from the Health Policy Institute at Georgetown University, running the Center on Child and Adolescent Health and Substance Abuse Treatment.
James Crall: Hi. I'm Jim Crall. I'm chair of pediatric dentistry at the University of California, Los Angeles (UCLA). I had the good fortune to spend about a year at what was then the Agency for Health Care Policy and Research (AHCPR) and back when the original Children's Health Insurance Program (CHIP) legislation was being enacted, and I have worked to develop both quality measures and the work in the field of expanding access, particularly around Medicaid and CHIP programs.
Cathy Caldwell: I'm Cathy Caldwell. I am the director of Alabama's CHIP program, and we are administered in the Alabama Department of Public Health.
Ann Clemency Kohler: I'm Ann Kohler. I'm the executive director of the National Association of State Medicaid Directors and former Medicaid and CHIP director.
Kathleen Lohr: I'm Kathleen Lohr. I'm a distinguished fellow at RTI International down in the Research Triangle Park in North Carolina. And I think I'm here today largely because I serve on AHRQ's National Advisory Council (NAC). I volunteered because over the years, I have done a lot of research in areas relating to evidence-based practice and practice guidelines and quality of care and health status measurement and so on.
Linda Lindeke: Good morning. I'm Linda Lindeke representing 7,000 pediatric nurse practitioners in the National Association of Pediatric Nurse Practitioners (NAPNAP); they are in every State. In my day job, I'm in Minnesota, director of graduate study in the School of Nursing in a maternal and child health program (MCHP) center for children's special health care needs. I'm happy to be here.
Mary McIntyre: Hi. I'm Mary McIntyre. I'm medical director over at the Office of Clinical Standards and Quality for Alabama Medicaid, and I'm here because of my new role. We have been struggling trying to get some kind of consistency across payers when it comes down to health care measures. I recently convened the group that we call Alabama Healthcare Improvement and Quality Alliance that has basically involved State employees' insurance, Blue Cross Blue Shield, and a number of other entities with that one purpose in mind.
Paul Melinkovich: Good morning. My name is Paul Melinkovich. I'm a general pediatrician as well, and I'm the executive director and medical director of a federally qualified health center network of community health centers and school-based health centers in Denver called Denver Community Health Services. I'm also the chair of the board of the National Assembly on School-Based Healthcare, but I think the real reason I'm here is because I kept on complaining to Jim Macrae that there were no pediatric measures in the Uniform Data System (UDS) report outside of pediatric immunization. And so I got a call from one of his deputies saying, "We are putting your name forward for a committee," so—
Female Voice: Great.
Marlene Miller: Good morning. I'm Marlene Miller. I'm vice-chair of quality and safety at the Johns Hopkins Children's Center. I'm a practicing pediatrician. I also serve as vice-president of quality transformation for the National Association of Children's Hospitals and Related Institutions, a member organization of 200 children's hospitals across America.
George Oestreich: Good morning. I'm George Oestreich. I'm deputy division director for MO HealthNet, Missouri's Medicaid program in charge of clinical services.
Lynn Olson: Good morning. I'm Lynn Olson. I'm the director of research at the American Academy of Pediatrics. The Academy is really excited about the opportunities presented in the CHIP bill and happy to have a representative here. The official representative is Jon Klein. He was not able to be here today, but he sends his regards.
Paul Miles: I'm Paul Miles. I'm the senior vice president for quality and maintenance of certification with the American Board of Pediatrics. I'm a general pediatrician. I also serve as the Academy's representative to the American Medical Association's (AMA) Physician Consortium for Performance Improvement.
Xavier Sevilla: Good morning. My name is Xavier Sevilla, and I'm a full-time pediatrician. My practice is actually about 50 percent Medicaid and CHIP. I'm also here as the chairman of the Steering Committee of Quality Improvement of the American Academy of Pediatrics.
Timothy Brei: My name is Tim Brei. I'm a developmental pediatrician at Indiana University School of Medicine, and I'm a member of the National Advisory Council of AHRQ.
Phyllis Sloyer: Good morning. I'm Phyllis Sloyer. I'm the division director of something known as the Children's Medical Services Network in Florida, which is both a CHIP program and a Medicaid option. It also is the Title V Children with Special Healthcare Needs Program in Florida, and I'm currently the president of the Association of Maternal and Child Health Programs.
Catherine Hess: And I am not Alan Weil, the executive director of the National Academy for State Health Policy. But I am Catherine Hess, a senior program director there, and I, among other areas, oversee a fair amount of work, substantial body of work that we do, analytic work as well as assistance work around children's health coverage including working with all the CHIP directors across the country. And I will just add that for a long time, I was the executive director of the Association of Maternal and Child Health Programs when that program worked with the Federal Bureau of Maternal and Child Health to develop Title V performance measures, so it is fun to be working on these issues again.
Glenn Flores: Good morning. I'm Glenn Flores. I am a professor and director of the Division of General Pediatrics at the University of Texas Southwestern and Children's Medical Center at Dallas and also the chair of the research committee for the Academic Pediatric Association.
Padmini Jagadish: Good morning. I'm Padmini Jagadish, and I work at AHRQ with Denise in the Division of Priority Populations and of course with Carolyn.
Denise Dougherty: I'm Denise Dougherty. I'm the senior advisor for child health and quality improvement at the agency.
Carolyn Clancy: I'm Carolyn Clancy, the director of AHRQ. You will get to hear from me in a few minutes telling you how excited we are to be working closely with CMS on this. Let me just say that by virtue of our former deputy director and our mentor and spiritual guide to children's health, Lisa Simpson, I happen to know a lot about the early scripts for the legislation that was finally passed this year, so on some level we have been really waiting for this day as well and are really, really excited that all of you agreed to participate. Now you will get to learn what you signed up for.
Jeffrey Schiff: We also have someone on the phone. If you could introduce yourself.
Victoria Warren-Mears: Yes, hello. My name is Victoria Warren-Mears. I'm the director of the Northwest Tribal Epidemiology Center at the Northwest Portland Area Indian Health Board. I'm trained professionally as a registered dietitian, but I'm here representing the concerns of the Indian country today.
Jeffrey Schiff: Thank you very much.
Rita Mangione-Smith: So Cindy is not here yet, correct?
Female Voice: Yes, we do expect her to be here any moment. Cindy as many of you know is our new director of the Center for Medicaid and State Operations, and she is very much looking forward to being here. I think she is just detained.
Rita Mangione-Smith: So we might change the order up a little bit and have Carolyn speak first and then we will let Cindy speak when she gets here. So, will that work?
Carolyn Clancy: Yes, that is fine. Well, good morning everyone. Just before I get started, let me just say for people on the phone, I know that it can actually be a very efficient way, and actually sometimes you process different information because you do not have to watch body language and all that, but if you cannot hear us at any time, we are in a situation where we have to move mics around, please hit one of the buttons on your phone so that we know that you are having difficulty and that we need to be clearer.
So, I'm incredibly excited about this opportunity today, so I'm going to give you some opening comments from AHRQ's perspective. I'm going to warm you up to what I know is going to be a very visionary presentation from Cindy as well.
What I want to talk about is AHRQ's role in the Children's Health Insurance Reauthorization Act (CHIPRA) for quality and very specifically the focus and role of this subcommittee. And then we will have time for questions after both presentations. So, specifically our role in working this through with CMS, and I really cannot overstate how exciting an opportunity this has been for us. Quite properly, Cindy's presentation will have this delineated and described by the specific sections of the bill for those of you who think in legislatese [sounds like].
Cindy, I just got started so if you would like to go first I'm—okay.
Cindy Mann: No, I'm sorry, I got lost. [Inaudible]
Carolyn Clancy: Yes, I know, but I actually know exactly how you got lost.
So the specific responsibility that AHRQ will take a lead role on working very closely with our colleagues is identification of this initial core measure set. Now, just keep in mind for a moment that a lot of the work we have been doing in quality over the past 5 to 10 years, and a lot of aspirations when CHIP was first passed 10 years ago, have been idea- and concept-based, and there has been some work going. Now we have an amazingly short timetable to actually go from ideas to implementation because January 1st of 2010, the Secretary actually has to release a core measure set. So I think we have exactly the right mix of folks around this table of people who think in programmatic substantive terms, "How am I going to do that early in 2010?" And people who have more ideas than this room could ever hold for all the aspects of care quality that we should be measuring. So I expect our conversation today to be really robust and lively, and that is a terrific thing.
We are also going to be working on subsequent development of better measures, identification of an improved core measure set. I mean this short timeline means that we will have to make some compromises. We are not going to get everything we want in round one, but boy, are we going to set a foundation for future evolution.
We are also going to be working with CMS. There is a very specific provision in the bill that you will hear more about from Cindy for a very exciting demonstration program, and we are going to be working on the evaluation of that as well as working with our colleagues at the Office of the National Coordinator for Health Information Technology (health IT)—that is a mouthful—we just say ONC, not to be confused with cancer treatment, and as well as CMS on a model pediatric electronic health record and technical consultation.
So why did we eagerly step forward to say we would like to work with you and be a science partner in this effort? Well, clearly, quality is our last name. Again, thanks to the never ending efforts of Lisa Simpson and also our former colleague, Marlene Miller, and I should say that anyone who is a former colleague or visiting scholar, we take credit for your work for the rest of your career. Marlene can tell you about that, Jim. But children are a priority population for us in the highest spiritual sense and also specifically in our authorizing legislation so we take that very seriously.
We have had the opportunity over the past decade or more to develop and implement measures in collaboration with others from the Consumer Assessment of Healthcare Providers & Systems (CAHPS®) family of surveys through the quality indicators that are built off the Healthcare Cost and Utilization Project (HCUP) data or the hospital discharge abstracts that we collaborate with 38 States on. We have also developed some quality measures from the Medical Expenditure Panel Survey; now, these are for the annual reports that AHRQ does on quality and disparities. And we had the privilege of working with a number of you around the table or your colleagues on something called the CHIRI or the Children's Health Insurance Research Initiative, which was really a fabulous way for States to learn from each other. And I think that in turn sets a nice model for what we are going to be doing with these quality provisions.
One of the things that we have learned from our annual reports in the State snapshots that we release every year that are derived from the annual reports, is that even when States are really doing a terrific job, they often do not know why, which is pretty interesting. Those of you who have been following the practice variations conversations on the radio or TV or YouTube, whatever you tune into, Twitter, about why are communities different, why is Green Bay, WI, doing such a bang-up job? The short answer is it is not remotely clear that even communities or States that are doing a terrific job in terms of high quality affordable care know how and why they are doing that. And in this CHIRI initiative, actually States are able to learn from each other from practical operational details to other kinds of program features.
And we have also had the opportunity afforded to us through the Congress to be focusing a lot on quality improvement, both by evaluation of applications of health IT for their impact on quality and safety through our work on patient safety, our work in prevention and care management, and so forth.
This year, as a result of the American Recovery and Reinvestment Act (ARRA), we see very, very clear linkages between the investments and comparative effectiveness research and improving quality of care. Or to say it a different way, the infrastructure that we are going to need to rapidly conduct evaluations of alternative interventions for diagnosis, treatment, and so forth is going to be, in my view, precisely the same infrastructure ultimately that we will support—you heard it here—easy value-added assessment of performance that gives clinicians and health care organizations timely feedback. This is an imaginary idea in real life right now, but it is well within our sights and very consistent I think with the opportunities outlined in the CHIPRA legislation.
So we have a huge opportunity to move beyond identifying problems, and we in health services research excel at that like no others to actually transition to addressing and solving some problems and getting to a place where we have good metrics for accountability and, frankly, the endgame for me is improvement. The Everest of our ambitions is not more and better report cards. We know how to do that; we could probably figure it out without the CHIPRA legislation. What we need is better care so that no matter where kids get care, no matter whether they are transitioning from CHIP to Medicaid to private insurance and so forth, ultimately they know that whatever door they walk in, they are going to get high quality, affordable care.
So in addition to that, I do just have to note that we have some fabulous Federal partners. Now, many of those partners share our own sense of pent-up enthusiasm and longing for this day when there is clear legislative authority to focus in on quality, as well as expanding access and coverage for children. So I have listed them all here. I could not begin to possibly capture the sense of enthusiasm and passion among this group.
I do want to say that, today, our meeting is really to start what I think is an incredibly important public dialogue. A number of you were intensely involved in the legislation. Some of you were merely clapping hard when you saw it. Some of you have been working at the State level for quite a while, hoping and praying that this kind of umbrella and authority and freedom and space would be created to actually give you more space to do what you have been trying to push, sometimes from a fairly lonely position without a lot of support behind it. But our big opportunity today is to hear from folks who are not part of the Federal Government. So in the nicest possible way, I'm suggesting to our Federal colleagues that today is what used to be called in my father's family FHB—for family hold back—because we will have lots of opportunities after this meeting to debrief and so forth.
Now, this was supposed to and intended to portray very positive collaboration. It has a secondary feature which I'm not sure Denise intended which is to say that a lot of activity in quality measurement and improvement I would say until the past several years has been very similar to 6-year-olds playing soccer, right? Not very hard to find a common script in a real serious game plan. What is very, very different about this leg—or to say it in a different way, it has been very evolutionary, right? This legislation lays out a very clear game plan. Not surprisingly, it was informed by some very smart, dedicated people so that is not surprising. What is surprising is it actually came out the other end, but that is terrifically good news. So I think what I want to give all of you on the subcommittee the sense that you have very exceptional partners within the Department of Health and Human Services (HHS) who will be picking up the ball as well.
Now, the charge to this subcommittee is very, very focused. That can be good news and bad news. Again, the charge—this subcommittee expires December 31st of this year, the specific charter, and the charge to this committee is to identify the initial core health care quality measurement set for Medicaid and CHIP programs. I will tell you right now this means that everyone at this table is going to have something they want on that list that may not quite make it to the top cut. So I expect conversation and debate to be pretty lively.
I think you also have to remember that what you are making is recommendations to the Secretary. The Secretary gets health care in a really big way, not a surprise. She is a former governor and a former insurance commissioner and so forth but actually, the call is hers, and I'm saying this mostly to indicate that your job is not to lobby Cindy or Barbara or our two fabulous co-chairs, but to actually focus on making sure that we get the best possible debate here so that we can give her the best possible options.
In Federal Advisory Committee Act terms, this subcommittee actually reports to the full AHRQ National Advisory Council, which, by design, happens to be meeting this Friday, so the two co-chairs will present a report to the full council in the form of Kathy Lohr and Tim Brei. We actually have two members of it so just in case they left out a detail, Kathy and Tim will be chiming in. They too are very enthusiastic about this opportunity, and then that report in turn will go forward to the Secretary. There is going to be a second meeting of this subcommittee and so forth.
So this just shows the timeline here. Again, there is a second subcommittee meeting set for September 17 and 18. I know a number of you have logistical challenges. If you think that means you are off the hook from weighing in and our consulting you, you would be wrong. I will also tell you that as a subcommittee to a full Federal Advisory Committee Act advisory council, all of this conversation is in the public domain. There will be minutes circulated and so on and so forth, so remember that you are speaking for the public. We have not had reporters rushing down here probably because they are all distracted by things going on in Capitol Hill, but nonetheless, this is a very public conversation and all activities of this subcommittee are in the public domain.
So, the three charges to this subcommittee: one is to provide guidance on criteria for identification of this initial set; a second is to provide guidance on a strategy for identifying additional measures for consideration; and, the third is to review and apply criteria to the compilation of measures currently in use by Medicaid and CHIP, and you will be hearing more about that third task as our work gets under way today.
Our guidance to the subcommittee has been to consider measures in use by Medicaid and CHIP. Given the economic challenges confronting States right now, I do not think I need to elaborate on that, and I know that we have a lot of people sitting right at the table who in case our memories are short would be happy to chime in. States are not going to build new systems for this work by January of 2010. Many of them are going to have to let employees go. They are faced with making painful, painful budget cuts right now, so in saying "in use right now by State Medicaid or CHIP programs," we are considering an indicator of feasibility. This is going to be hard. Many of you can see measures that we could do if only we could update systems a little bit and so on and so forth. We hear you, and that does not mean that we will not get there eventually, but this date of January 2010 has kept our attention focused throughout and has really helped us focus the work that we need you to focus on today and move forward.
And I think it is very important for you to also recall that this bill includes $15 million a year for 4 years for extramural awards for additional measure development. Now, it is not really a secret for those of you who are close to the nuts and bolts of measure development to know that resources for developing these measures have been limited. In the larger world of quality, that is to say including grownups, there really is not an incredibly explicit funding stream for measure development.
Since the early days of the National Committee for Quality Assurance (NCQA) and so forth, what we have had are people cobbling together and identifying a little bit of money here, some resources over there, and so forth. There is no agency in government or even a foundation that says, here is our quality measure program. They may get motivated for a particular condition, area, or population and so forth. Over the past few years, the Medicare program has identified resources to support quite a few measures related to adults, and that is really a good thing but there is no way for most children's health care needs that you can justify as being relevant to the Medicare population, so that has been a real challenge.
So now we are going to have explicit resources, and I think this is fabulously good news, and there will be a Federal Register notice to come soliciting broad recommendations for priorities for the program. So in other words, January of 2010 is not the end of the road. It is the beginning of an incredibly important road. Again, the full NAC meets on Friday. The co-chairs will be reporting there, and our second meeting of this subcommittee is September 17th and 18th. If at any time you have comments or you think we forgot something, just E-mail firstname.lastname@example.org. Denise and Padmini monitor this religiously, and we will make sure that we attend to your comments. So if on the way home you suddenly think, "Oh, I knew I had an incredible idea, and I have been trying to verbalize it, it has been in the preverbal phases," that is the address, and we will remind you of that before you go home as well.
So, some questions that we have had to date, I just wanted to go over. First, are validity and feasibility core criteria for including as a priority? The answer is yes, and we think it is very important to be explicit about the evidence base. Can we include stretch measures? Now stretch, it turns out, is almost a Rorschach kind of term, it can mean a whole lot of different things. One of the challenges of course is I think we recognize that although we do not have complete comprehensive information about what every single State is up to, we do have a sense, and I think many of you have a much keener sense that there is a curve, a diffusion curve, if you will. Some States are doing a whole lot in quality for Medicaid and CHIP. Others have been slower in this area. They have been focusing on other issues or have not had resources or whatever.
As you are thinking about options for the Secretary, I think it is going to be completely feasible and potentially very practical for us to think about here are the must-haves. Everybody agrees these are the slam dunks that we want in a core set. Here is a richer set of options for you to consider, and here are some practical considerations that you would need to contemplate if you were to take on a fuller set. What is the right number of measures in the core set? This is up to the group. Now, I know many of you will think of this as a hundred would be a good starting point.
Just to frame some realistic expectations, when Hospital Compare first got started, this also started as a voluntary public reporting effort. I will say there were probably fewer advocates at the State level to make sure that voluntary became something that really happened, but the starting measure set was 10. Not only that, the starting measure set of 10 measures coincided with something that virtually every single hospital in the country was already reporting to the Joint Commission and CMS. The new, new thing was actually that this would be reported publicly, okay? So just, I'm not saying that we need to be in single digits here, I'm just trying to frame your expectations in terms of what have been some precedents, but it is up to the group.
And how we think about health care quality is something I also wanted to take just a few minutes to do some level-setting here. Now, there are many definitions of health care quality. I must say that when I start talking about health care quality with my family—and I'm the only medical person or health care person in my family, and I have a very, very large extended family who call and meet regularly with reports from the health care front, usually about what is not working—the minute I start talking about quality, I can see people beating a path to escape. Really glad you are worried about it, but please do not tell me the details.
So for those of you who spend your day jobs focusing on operational details that may range from how in God's name are we going to find more providers to accept patients in Medicaid for particular types of care to, "Oh my God, the governor wants another frantic report, and they wanted it yesterday, and they forgot to tell us," kind of thing, I just wanted to take a very brief rapid-fire overview in terms of how we think about quality.
The first definition here comes from the Institute of Medicine, and you can read Kathy Lohr into that definition, since I do believe it emanated from her cerebral circuits. "The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." Now, what is kind of said between the lines there is that we do not have evidence for everything that we think is important. And of course, we cannot say to patients of any age or population, "We are sorry, there is no study here. You figure it out." I mean we have to do the best we can.
In 1999, around the time that "To Err Is Human" and the series of reports from the Institute of Medicine came out, John Eisenberg came up with a definition that I use early and often, "Doing the right thing for the right person, at the right time, in the right way." Sometimes, I add "every time" to get the idea of consistency, and it does not matter which door you entered in through, but that is the definition that most people can relate to. My family can hear that, then they beat the path to the door.
Crossing the Quality Chasm published in 2001 came up with six characteristics or attributes of quality which made it a little less abstract for people: care that is safe, care that is timely, effective, efficient, equitable, and patient-centered. What I find really interesting about that is that these six criteria have stuck in a big way, so I regularly meet private-sector purchasers who say, "I want the IOM 6." Now, I would never ever test them in the moment to say, "Can you tell me what those are?" Because I think I know what the answer is. And you know what? It does not actually matter if they know what the six characteristics are. They know that there is broad agreement across multiple stakeholders that these are the attributes of care that we think are important.
Another way to think about this is structure, process, and outcome, right? Historically, we always thought if we had really good facilities and really well-trained professionals that quality would follow sort of like the river flowing to the sea. We have learned over time that simply having the best health care professionals, good facilities, and so forth is necessary but not sufficient. So licensure board certification, maintenance of certification, and so forth are incredibly important components that of themselves are not going to guarantee quality.
The processes of care, looking at what it is that is actually done to, for, and with patients, clinical activities, and so forth are very important and ultimately, what almost everyone cares about are outcomes or end results. Yes, people want to know that their kid with asthma is getting the right care, but they also want to know that they are not going to have to call in yet again this week because they have been up all night with a kid in the emergency room (ER), and they are still not sure if they are not going to have to go back later today. They want to know that their kid is not going to miss school again because of problems they are having medically and so forth. And I think that is kind of the end game for what all of us want out of health care for ourselves, for people we care about and are responsible for providing for.
Now, in the broader health care quality world, there has also been a growing recognition that we do not get to high-quality, affordable care unless we are focusing on a patient-centered or child-centered approach. And there is a different framework here that focuses on—it is often referred to as a consumer framework that looks at stages of illness and health, from staying healthy all the way through coping with end-of-life care.
In our annual reports on quality, we put the consumer framework on the left and the IOM 6 across the top. There is no perfect framework here, but I just wanted to give you a sense of how people have been thinking about quality of care. I myself think the more child-centered we can be, the better off we are going to be over time, both for this initial set of work and also building into the future mostly because from the adult world, most of the huge challenges we face, particularly in terms of dropping the ball and poor coordination, happen to be at the intersections and transitions in care from one setting to another, from the ER to back home, from the hospital back home, between providers who care for kids with special health care needs, and so forth.
So I do have to thank the subcommittee co-chairs in advance; they have already done more work, and they are going to make it sound very, very easy like they wake up living and breathing about this, actually thanks to our intervention these days, they actually do but I cannot think of two better co-chairs and I do want to salute their efforts. And again, we have the perfect blend of academic rigor, expertise, and intellect in Dr. Mangione-Smith and in Dr. Schiff. We have that plus serious attention and grounding in operational needs programs. So we think that is going to be terrific. I want to thank all of you in advance for the work you are going to do. I know you have already started in terms of responding to the Delphi survey and so forth. We are also going to be hearing from terrific paper authors, presenters, and so forth, and there will be ample opportunity for public comment, and we will be taking comments online after the meeting as well.
So without further ado, I'm going to put Cindy's slides back up and ask her to come up here.
Cindy Mann: Thank you.