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President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry

Final Meeting
Thursday, March 12, 1998

Consideration of the Commission's Final Report to the President

Secretary Shalala: If I can, while they're finishing up, let me see if I can gather from the commissioners anything other than editing, anything that wasn't included in some of the other chapters and let me start with chapter one, and see if there are any comment on chapter one that the whole groups needs to hear.


Commissioner Prado: I just want to ask you a question. If we just have minor --

Secretary Shalala: Then just give them to Janet.

Commissioner Prado: -- just give them to Janet.

Secretary Shalala: Just give them to the staff. For the most part, and I've given them my minor comments, anything non substantive, if there is something that was left out, actually a whole policy are that you think we've agreed on, do bring it up here, but any comments on chapter one.


Commissioner Montrone: Yes. Chapter one, I don't have a lot of comments on most of the chapters, but I do on this one. If you'll see back and look at the chapter as a whole, I question whether we're really talking about the state of health care quality and how good is care.

This is a chapter that is focused on the problems in our health care system by and large. The last time we had a discussion on this subject at the last meeting it was oriented around the executive summary which opened up and there were a number of us that thought it was really not complimentary enough about our health care system and the people working in this health care system and the accomplishments, and there was a request to make it more balanced.

And in the executive summary, in the first four or five paragraphs, it is that balance came into it. I kind of assumed that, since that was a summary of what was going to follow, that that type of balance would show up in this chapter, and it hasn't. I mean going through the first opening statement of this chapter for example, it says "While most Americans receive high quality health care from skilled practitioners, too many patients receive sub standard care." So we are disposing in a clause of the high quality of our health care and we're focused on too many patients received sub standard care.

I don't think short of, you know, a major overhaul, which I'm not suggesting, I'm just wondering whether we should at a minimum change the title of this chapter. It's a title that Morris says that what we're talking about here are the problems of the health care system.

Secretary Shalala: I need Janet to respond to that because they did do a rewrite of this chapter.

And can you respond to that?

Executive Director Corrigan: I'm sorry?

Secretary Shalala: Why don't you repeat your question, Paul. The point was that we had had some discussion at the last meeting, in fact pretty extensive, about chapter one and about making sure that we talked about the positives of the health care system. We did change the executive summary.

But Paul's point is that chapter one doesn't look like it was changed as extensively, and he's asking a question about whether the title is now accurate.

Executive Director Corrigan: Your suggestion is that we change the title --

Commissioner Montrone: Yes, care. If you read through this care is pretty horrible because we've focused on the problems. I'm not suggesting -- and this commission has spent most of the time focusing on the problems. So I'm suggesting maybe we change the title.

Secretary Shalala: Tom?

Commissioner Reardon: Thank you, Paul. I'm the one that brought up the issue on the executive summary last time about the tenor of the language which was changed I think is much more -- you know, it states there are problems, but we have a good system, let's improve it. That's what you're referring to in chapter one.

Secretary Shalala: I actually was opposed to changing the title, my reaction was sort of that we should actually build up the first page so that it is more positive about the context as opposed to changing the title. It seemed to me that we just needed it to be stronger. We sort of did it in a couple of sentences as opposed to a number of paragraphs.

Commissioner Montrone: Yes, I think if somebody could take a look at that and beef it up.

Secretary Shalala: Just take another look at --

Commissioner Montrone: And we have two sentences, if you get out of the Italicized. You know, the first two sentences --

Secretary Shalala: Every day --

Commissioner Montrone: -- say something about it and then we go right into the problem. The third sentence gets into concerns.

Secretary Shalala: All right, let's take that.

Any other comments on chapter one that are not editorial?

If not, we'll move to chapter two and see if there are general comments. I know some of you have given some specific comments on chapter two. Are there any other questions about chapter two, anything that wasn't included in chapter two that you thought that we had discussed?

If not, we'll move to chapter -- go ahead, Paul.

Commissioner Montrone: I do have one item. We do have a discussion in here about cost. We've had ongoing discussion throughout this whole document about the fact that if you bump costs up, you lose people. And I don't know that that is actually in the document anywhere, and I'm just wondering if we should say that somewhere. And if it's going to be said, maybe it belongs right here where it says where we talk about costs on page two. Can somebody --

Secretary Shalala: I think that --

Commissioner Montrone: -- indicate where it is.

Secretary Shalala: -- we've said two things. Number one, sometimes when you bump up costs, you save money. So there are both sides. You may have an increase in costs on one side, we said that in the consumer Bill of Rights, that there are aspects of the patient Bill of Rights where it may increase costs to provide certain kinds of information, but on the other hand you save money on the other side. So I think what you want is a balance statement in here and we should just make sure that in our re-read of this chapter that we have made, or of all the chapters, that we have made balance statements about that.

Anything else, Paul, on chapter --

Commissioner Pollack: Can I just build on what Paul was saying?

Secretary Shalala: Yes, right.

Commissioner Pollack: I too actually had a concern about that particular part of the chapter on page two. Change has been made and there is some improvement. I'm not sure I feel comfortable with how adequately it's improved. In that first -- in the second paragraph, the paragraph that begins both the number and share of those --

Secretary Shalala: Tell us what page you're talking about?

Commissioner Pollack: I'm on page two. Before there was a comment something along the line that people didn't choose to take health insurance, and that's stricken. And I thought we had some agreement, it's certainly been raised a bunch of times, that cost was a serious reason as to why people didn't opt to accept employer-provided coverage. And here we're far more neutral at this point where we say although the reasons for employees declining an offer of insurance are not well established. I'd like to say something a little stronger about cost being a significant factor at a minimum as to why it's not selected.

Secretary Shalala: Well, it certainly is a -- we'll make a note of that, we'll make a note of that. I think the point is -- well, we can figure out how to do that.

Chapter two --

Commissioner Pollack: I did have one more comment, I'm sorry.

Secretary Shalala: Okay.

Commissioner Pollack: And that is that, and I brought this up to Ann, so maybe it's resolved, but this is on the issue of managed care, and we did beef up our discussion of managed care in the chapter. The thing that I don't see anywhere in here, and it came out in the McGlenn report, was, you know, what I would call the hope of managed care. I mean we do have an enormous number of people in managed care. We kind of treat it like it's neutral. And the whole idea that, you know, managed care, if done well, really gives us a lot of optimism about how we can improve our quality. That particular thesis I don't see in here anywhere.

Executive Director Corrigan: Well, I guess only because this is a -- this was intended to be purely a review of the evidence that we have. It wasn't attempting to assert specific positions or --

Secretary Shalala: About any --

Executive Director Corrigan: -- about any aspect of the system --

Secretary Shalala: -- particularly organized system. It was just summing what literature we have at this moment.

Executive Director Corrigan: Well, my recollection of the literature, and there are some specific references here and there where data is presented that managed care data usually is better than the average for all Americans.

Secretary Shalala: The data?

Commissioner Montrone: Yes. You have --

Secretary Shalala: The data or the outcomes?

Commissioner Montrone: The outcomes of -- like you have some statements in here about certain prevention techniques, and you'll say, you know, like certain tests are being done, the average of the nation is 67 percent and under managed care it's 72 percent.

Secretary Shalala: That's actually a more subtle point of recognizing within the literature of where there are differences. And I thought we made reference to that actually.

Executive Director Corrigan: I think we do in the --

Commissioner Montrone: We do, but we never take that together and say look, you know, this gives us a lot of hope about managed care. If it's done well, this really can improve, help improve quality. It seems to me that that's what the data suggests. Maybe there is disagreement on that point, but I didn't see it.

Executive Director Corrigan: Well, the data on quality of care suggests that quality is about equal in various managed care settings to that which is in the traditional indemnity. I mean you are correct that there are some data to indicate that in the area of preventive services managed care appears to be doing a bit better. That's basically what we can say based on the evidence. Okay, we can make that clearer.

Secretary Shalala: This is an evidence-based report, so if we need to make it clearer, just make it clearer.

Herb, we're still on chapter two?

Commissioner Pardes: I just want to make a comment, if one starts toning this the other way, I am not so supportive of that. I'm no so persuaded about the optimism we have as to where we're going with our health system --

Secretary Shalala: I think that that was not the conclusion. The conclusion was to keep to the evidence, and that's all we're doing here.

Any more comments on chapter two?

Commissioner Pollack: Yes.

Secretary Shalala: Yes, Ron.

Commissioner Pollack: I have one more comment, and I raised this comment last time. I thought it was going to get corrected. In the bottom of page two in the section "Continuing concern about the cost of health care," and then continuing on the next page on health insurance premiums, we cite that health care costs have decelerated and premiums have decelerated. But I thought we were going to say something that there is concern that this may not be a long term phenomenon, and indeed we're hearing evidence, Ken Thorpe had presented a lengthy paper on this question and others have as well.

Secretary Shalala: Go ahead.

Executive Director Corrigan: We added on page three the first paragraph on health insurance premiums, we added in the sentence "In 1997 premiums for employers with 200 or more workers increased by 2.1 percent. The third consecutive year that a cost, the cost of employer based health insurance rose, lessening the overall rate of inflation and worker's earnings. However, it was also the first time in eight years that the percentage increase in health plan premiums was not lessened out of the previous year."

Commissioner Pollack: I noted that.

Executive Director Corrigan: We tried to get the most recent data, evidence, as to what was happening. What we have not done in this chapter is to put out people's projections of what's going to happen. We have stuck purely to the evidence. And I realize that there are some that are predicting that they're going back up, but that sort of moves us into an area that we were trying to avoid with this chapter. We tried to get the most recent evidence that we could, but until they actually do go up I think we're sort of crossing a line here if we start taking people's predictions.

Commissioner Pollack: Well, I guess I just want to just express why I raised this issue. Many people have questioned whether some of the savings that have been achieved are one time only savings, and I mean that's common in the literature. And my concern about not recognizing that that may in fact be true, and I'm not saying that it is true, but that it may in fact be true, I think would lead someone to conclude two years from now when the cost increases do occur, people will say ah-hah the reason they occurred is because, you know, some folks established regulations that saddled the industry with higher costs. And I don't believe that that, you know, that would be accurate.

Executive Director Corrigan: If we could just let Ann, she has an important I think. She was the one who reviewed a lot of this.

Commissioner Page: The '97 Peat Marwick data began with a preface from Peat Marwick that in spite of the predictions in 1996 that premium costs were going to rise greatly in '97, but that was not the case. And that predictions of '96 were not borne out by the facts in '97.

We also attempted to be cautious in this whole section because of the comment that was made by many commissioners at the last meeting, that we be careful how we portray trends and that sometimes a one year increase or a one year decrease was not a trend, but a blip, and so we did try to just stick to the evidence in where we are rather than where we might be.

Executive Director Corrigan: And what we had tried to do here, Ron, was to not try to characterize these data or go into extensive discussion about whether it's a one-time phenomenon or it is a trend or whatever, it was purely to try to state in as neutral terms as possible what we know.

Commissioner Pollack: All right. And I thought the way to achieve that is to say some, you know, is that some projections indicate that this may not be a continuing trend and that costs may -- something along that line, that doesn't say anything definitive, but makes clear that a number of researchers have projected that they will increase.

Secretary Shalala: I think that Ron has got a point because almost every analysis says something near that, and that is there is no consensus, but everybody is watching it, and that if you don't put in that extra sentence, it looks flat as if you've just taken a snapshot as opposed to understanding that the system is still shifting under our feet, and I think there is a way of -- let us look at that. And I'll look at it myself, Ron, as we're finalizing it.

Commissioner Pollack: All right, okay.

Secretary Shalala: Anything else on that chapter? Does anyone else have anything on that chapter?

I'd like to move to chapter three for any final comments. If they're just editing comments, please hand them in. I'm most concerned about whether you think the chapter reflects the final reading that we had on it.


Executive Director Corrigan: I've got Alan's comments.

Secretary Shalala: Chapter four?

Executive Director Corrigan: On chapter four, page 15 the top paragraph that begins with "Similarly" --

Secretary Shalala: Do you want to put your mic on.

Executive Director Corrigan: Sorry. Page 15 of chapter four, the very first paragraph that begins "Similarly there are limits," Alan --

Commissioner Weil: Janet, just to note, I gave you the blacklined version on people, what they have in their books. It's the top of page 15.

Executive Director Corrigan: Top of page 15?

Commissioner Weil: So they'll know where you're talking about.

Executive Director Corrigan: Okay, great.

This paragraph ends with the sentence "Given that science cannot guarantee that risk adjustment will be perfect decisions about risk adjustment will inevitably engender controversy with legitimate arguments for and against using methods with inevitable shortcomings."

Alan is suggesting the sentence "Despite these limitations the commission recommends that," gee whiz, something or other "testing and implementation of risk adjustment proceed as rapidly as possible."

Secretary Shalala: Alan, please?

Commissioner Weil: Sorry, I thought this fell in the technical category. This is a sentence that we agreed to last meeting that did not appear. On the blacklined version it's on the top of page 15 on what is in your book, it's the last paragraph on 14. And after that paragraph ends we agree to say, this is about risk adjustment, "Despite these limitations the commission recommends that development, testing and implementation of risk adjustment proceed as rapidly as possible." I think we agreed to that and it's just now being --

Secretary Shalala: Without objection.

Anything else on chapter four?

If not, we'll move to chapter five "Creating public/private partnerships."

Yes, Paul?

Commissioner Montrone: On page four we talk about the consumer Bill of Rights and Responsibilities, and we talk about strengthening the capacity of consumers and so forth, but we never talk about their responsibilities in that paragraph.

Secretary Herman: Say that again, Paul?

Commissioner Montrone: We don't talk about the responsibilities of consumers, and that might be a nice place to put it.

Secretary Shalala: Okay. Without objection.

Commissioner Montrone: And also on page seven I have one thing I thought would get dropped out, which it didn't, and we talk about the advisory counsel structure. And on the bottom of page seven we talk about private sector widespread adoption of its products and recommendations, and I didn't know what we meant by its products. It seemed like a strange choice of words, but maybe that's part of the art.

Secretary Shalala: Is he looking at another -- what, page seven, okay, toward the bottom.

Commissioner Montrone: At the bottom of the page.

Secretary Shalala: Okay.

Executive Director Corrigan: Well, one of it's products would be the aims for improvement. That would be a product, and specific goals and objectives.

Secretary Shalala: What's the difference between a product and a recommendation?

Executive Director Corrigan: Well, if you think of something only -- it probably isn't that significant, but if you think of something like the Healthy People 2000 document that, I guess it's a set of recommendations, it's also sort of a product, we can just leave it recommendations rather than --

Secretary Shalala: Yes, the word "product" is unusual in context.

Executive Director Corrigan: -- the word "product," okay.

Secretary Shalala: Okay, anything else on chapter five?


Commissioner Berwick: Madam Chair, could I just ask for some advice or comment from somebody on the size of the counsel we're proposing. As we've added people it's gotten to 16 to 20, and I just wonder if we have recommended something a bid unwieldy in size.

Executive Director Corrigan: I can tell you where it came from. It wasn't as a result of a detailed analysis. It basically was the size of PPRC and PROPAC in their earlier days. They did grow over time. It's probably a $10-$12 million commission. It was just sort of a rough estimate looking at others, other types of commissions, executive advisory councils of sorts. It was not based on a very detailed analysis of the work, and that would have to be done before it moved forward.

Secretary Shalala: Given the size of this one, it looked like a piece of cake to me.

Commissioner Berwick: Only if you chair it.

Secretary Shalala: Sylvia, we're on chapter five.

Commissioner Drew Ivie: On page ten I would hope that the consumer and patient representation would not be limited exclusively to organizations representing consumers and patients.

Secretary Shalala: Yes, I think we actually had made the point the last time, individuals and organizations, right. You had actually made that point before, so we need to clean that up.

Chapter six. Okay, Chapter six. Comments?


Commissioner Montrone: Yes, there was a sentence added to the summary in the front, which is a summary of the text, and when I saw it added, I figured well we added a whole section. That's "Seeking opportunities for consumer involvement in governance and oversight." So we've got something about consumer getting involved in governance and oversight, and then when I flip through the text --

Secretary Shalala: Where, give us a page?

Commissioner Montrone: On the first page, on the summary at the top there, Italicized summary.

Secretary Shalala: Okay.

Commissioner Montrone: Third line from the bottom "Consumers require help in making informed health care decisions, seeking opportunities for consumer involvement in governance and oversight."

Secretary Shalala: I don't know what you're looking at. We're on chapter six.

Commissioner Montrone: Oh, sorry, sorry, sorry. Six, I've finished with six already.

Secretary Shalala: Okay, you finished six, all right. Paul has finished six. Does anyone else comments on chapter six? All right. Chapter six, any other comments on chapter six?

Without objection we'll move to chapter seven.

Commissioner Montrone: All right.

Secretary Shalala: Do we have anything else on six? If not, we'll move to chapter seven.


Commissioner Montrone: Okay, I made my statement.

Secretary Shalala: Okay, we're on page one, the Italicized summary at the top.


Executive Director Corrigan: The sentence you're talking about is "Consumers" --

Commissioner Montrone: We're strengthening the hand of consumers, okay. We want to strengthen then to "Seek opportunities for consumer involvement in governance and oversight," it was an addition.

By the way I do want to thank the staff for the redlined version of this document. It really made it a lot easier to find these changes.

But there was one. This was an addition from the last time.

Secretary Shalala: "Seeking opportunities for consumer involvement in governance and oversight."

Commissioner Montrone: Yes, there's nothing in the text below that talks about this.

Executive Director Corrigan: It was a recommendation that was agreed to at the last meeting, to mention something about governance and oversight. It was not something that was considered by the subcommittee or reflected in the document, but it was agreed to at the last meeting that there should be some mention of it.

Commissioner Montrone: But this is a summary of the document. If we're going to mention it, then we should explain what we mean by that. And I'd like somebody to please explain what we mean by that?

Secretary Shalala: Peter?

Commissioner Thomas: I think I made the suggestion, well I know I made the suggestion that we include consumer governance and opportunities for consumers to become in the government structures of health plans and advisory boards and the decision makers in health care, and to have consumer involvement. And it struck me that in reading the chapter "Strengthening the hand of consumers" to not mention anything about that issue was a real oversight in my view. So I suggested that we include that at the last meeting.

Now, there was some language in the chapter that talked about that previous to my statement. And yet as I go back and look at it I can't find it. There was a statement or two in the chapter and I can't now find it, but I've been talking with Ann about this.

Secretary Shalala: Well, Paul is actually right. If we refer to it there, we've got to have a couple of sentences. We have to figure out a way to put a couple of non controversial sentences that doesn't lock in the --

Commissioner Thomas: Well --

Secretary Shalala: -- Peter?

Commissioner Thomas: -- I suggested a sentence or two, but Ann was informing me that because the subcommittee had not really looked at the issue at all in depth, that it was kind of difficult to then incorporate it at this time. And I don't want to put Ann on the spot certainly, but I'm hoping if we are going to have it in the summary, I would love to see some language in chapter that elaborates on it.

Secretary Shalala: It seems to me if the full commission agreed to it in the summary, then we can have two or three sentences that explain it in the text. So if the commission agreed to it in the summary, the full commission agreed to it in the summary, then we've got to find two or three sentences that we can incorporate into something else without going beyond what the full commission has agreed to.

Executive Director Corrigan: We can do that, we'll come up with a sentence or two --

Commissioner Thomas: Great.

Executive Director Corrigan: -- and find a place to insert it.

Commissioner Thomas: Thank you.

Secretary Shalala: Paul?

Commissioner Montrone: I think, I don't really recall the debate on that, I'm sure I don't remember a debate. I think Peter probably suggested it and it sounded fairly innocuous. But as I read it, this is not an innocuous statement here, I mean so I think that we should really --

Secretary Shalala: That is correct.

Commissioner Montrone: -- this is a powerful statement, so I think we should really focus on it.

Commissioner Thomas: Where does that leave us, you want to focus on it?

Commissioner Montrone: All right, if somebody wants to include it, they should draft some language.

Secretary Shalala: The sentence doesn't say, the sentence says "Seeking opportunities for consumer involvement," it doesn't say, it doesn't lock it in. It says "Seeking opportunities," which means that --

Commissioner Montrone: Okay, but the commission, this is a commission recommendation we're talking about.

Secretary Shalala: That's correct.

Commissioner Montrone: We're recommending that we "Seek opportunities for consumer involvement in governance and oversight."

Secretary Shalala: That's correct.

Commissioner Montrone: Well, what do we mean by that? Does that mean --

Executive Director Corrigan: It isn't a recommendation actually, it's above the recommendations and maybe that's the problem is that it's in that front end section, maybe it's something that needs to be woven into the text. We didn't mean to elevate it to a level of a recommendation.

Commissioner Montrone: It says "The commission recommends" in the summary, and most people are not going to read the text, they're going to read the summary. "Recommend several steps to strengthen consumer's ability to fulfill their roles and responsibilities. These include," so it is a recommendation.

Executive Director Corrigan: You're correct, and that's an error on our part. It should not be in that sentence because it isn't reflected in the recommendations. So basically I guess the question is whether you want something reflected about the desirability of having consumer involvement in governance and oversight and, if so, where.

Secretary Shalala: Peter?

Commissioner Thomas: I don't consider it an error. When I offered it at the last meeting I meant it to be a recommendation just like the rest of the statements are in that chapter. I think it's a critical piece to strengthening the hand of consumers, and it goes right in line with what the chapter is all about.

And what I'm suggesting is not that you have any kind of a mandate or any kind of directive that consumers be involved on anything, but it is a opportunity to seek inclusion of consumers on advisory boards, on internal review panels, on boards of directors, on policy making bodies, on all different types of decision making bodies that take place in health care. And it's an opportunity for consumers to get real involved in that.

Secretary Shalala: Okay, Tom?

Commissioner Reardon: And I'm not disagreeing with Peter, but what I'm saying if you would move that statement up to the sentence just prior to "The commission recommends," where they say "Stronger consumers also are better able to carry out their dual roles and responsibilities as -- and patient. One way may be as seeking opportunities for consumer involvement," etcetera. That would eliminate having to rewrite the text of the chapter and yet still include that statement.

Secretary Shalala: Peter?

Commissioner Thomas: Yes, it would. The question is whether it should be a recommendation. I'd like to see what other people think about having it included as a recommendation before I suggest that that's fine.

Secretary Shalala: Phil?

Commissioner Nudelman: Well, I also independently wrote some input on this particular topic because coming from an all consumer governed organization, I can't go home unless something is in here like this. I think it should be a recommendation.

Also, there is a comment on page seven in the first paragraph that says "A strong consumer voice also is needed in the government structure" --

Commissioner Pardes: What paragraph?

Commissioner Nudelman: Top, first paragraph. "Needed in the government structure of efforts to collect and disseminate information on quality," which also I think refers back to the individual or the recommendation. But I would love to see an added sentence or two that really talks about the values.

Secretary Shalala: I think that we agreed to this where it is, and that the only addition that's in order is whether we clarify it in the text so that we actually make sure that we refer to it further along in the text. People had plenty of opportunity to -- it was not innocuous in the way that it was raised, and there actually was some discussion on it. So I think that you're just going to have to find places within the text to refer to it. And it is not locking anything else.

Peter was very specific in his discussion. He was talking about seeking opportunities, not mandating on specific governance boards, and that's the way it ought to be treated in the text. It was not a mandate, it was seeking opportunities, and he was very clear when he made the presentation, that it was looking for opportunities to include consumers.


Commissioner Sebelius: And along those lines one possibility is on page four we talk about, in that first paragraph with reference to the whole Consumer Bill of Rights, the need for consumers to adopt a more active role with respect to their health care and we outline a whole series of ways that that can be done. Adding a sentence or two about the possibilities for inclusion in governance and oversight would be real appropriate I think in that paragraph.

Secretary Shalala: Wherever we put it in, it should not expand what was the intent of the full commission which is seeking opportunities, not are we reopening any major policy debates about what we've included in as recommendations. We're simply clarifying or adding to the language. So the staff is instructed not to go beyond what the commission has agreed to, and that is not a mandate, but seeking opportunities and to add language that is consistent with that.

I'd like to, if there is nothing else on chapter eight, I'd like to move to, or rather chapter seven, I'd like to move to chapter eight. Anything on chapter eight?

If not, we'll move to chapter nine. Again we're looking for things that we've agreed to that have not been included or the kind of thing that we saw before where we would need to add some language that's consistent with what we've agreed to. We're not reopening any policy debates.

Chapter ten, oh forget about chapter ten. We're coming back to chapter ten. Chapter 11.

Commissioner Montrone: Wait a minute, hold everything, hold everything.

Secretary Shalala: Yes, chapter ten, that's --

Commissioner Montrone: I'm still on chapter nine. Can I make a comment on chapter nine?

Secretary Shalala: A quick comment.

Commissioner Montrone: Quick, very quick, very quick.

Secretary Shalala: Okay.

Commissioner Montrone: On page four, this has to do with implementing the Consumer Bill of Rights of all things. We have this statement in the first paragraph after we say we're not taking a position that "It is reasonable to expect that they," meaning the private organizations, etcetera "could develop effective area of accountability," and then in the next paragraph we say "The commission encourages all health plans providers to move rapidly in implementing." Now, those two statements seem inconsistent to me, and I don't know why we kind of whimped out in the first statement, and why didn't we just -- I didn't realize that we didn't agree that there should be voluntary compliance, I thought the debate was over legislation.

Executive Director Corrigan: No.

Commissioner Montrone: Can you explain that then, that inconsistency there?

Executive Director Corrigan: I don't think it is inconsistent. My understanding is that there was an agreement on whether it should be voluntary or legally enforceable standards that's an issue that -- basically the commission's position is that it should be implemented, it can be implemented through a variety of different means, and it should be available and applied to all Americans. But there was not a specific position taken on whether the Bill of Rights should be embodied in legislation or implemented through voluntary means. But an encouragement certainly to move forward with whatever means we have available.

Secretary Shalala: Chapter 11.

Commissioner Montrone: Sorry, sorry. In the first, chapter 11, fourth line, the word "extensive."

Secretary Shalala: Chapter 11, page?

Commissioner Montrone: Page one, I'm sorry, page one in the summary.

Secretary Shalala: Page one, fourth line.

Commissioner Montrone: The word "extensive."

Secretary Shalala: I'd just take it out actually, I'd take it out.

Anything else in chapter 11? Without objection we'll move to chapter 12.

Anything in chapter 12? We do have some editing and some people have caught some typos and stuff, so just assume all that's been done.

Chapter 12?

Chapter 13? Any other comments on chapter 13? Anyone that dares make a comment on chapter 13?

Chapter 14?

Commissioner Montrone: I have a comment on chapter 14. On chapter 14, can I go ahead? Who is chairing this?

Secretary Shalala: Chapter 14?

Commissioner Montrone: Chapter 14, yes. We expanded on this year 2000 problem on page six, and I'm just wondering, and I forget who brought this up, but it was an excellent point that, you know, one of the real exposures, we have a lot of our portions of health care organizations are not really working on this problem. I'm just wondering whether we should bring that up into the summary. The last sentence perhaps --

Secretary Shalala: Say that again, say it again?

Commissioner Montrone: Page six, second paragraph, last sentence which was this whole area has been developed in the last draft "Perhaps even more disturbing however is that many small organizations that have not yet begun year 2000 planning may be unaware of how vulnerable their current systems are."

Secretary Shalala: Yes, that's fine. Can do.

Anything else in chapter 14? Chapter 14, any other questions?

If not, we've finished all the chapters except for chapter ten, and we're going to go to lunch and come back and deal with chapter ten.

Without objection we'll adjourn for an hour?

Secretary Herman: 45 minutes.

Secretary Shalala: 45 minutes actually, and then we're going to come back and we're going to do chapter ten, and we're going to have everyone's final comments.

(Whereupon, at 12:22 p.m, the meeting was adjourned and will reconvene at 1:11 p.m.)

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