himself. will it be for this quick >> before the end of the year we are going to take whatever actions. >> promising executive amnesty for many that are here illegally. as your senator i will fight to the amnesty plan. your tax dollars should benefit you. and remember, mary landrieu, barack obama, 97%. i will stand up to obama. i am bill cassidy and i approve this message. >> every morning i say a prayer for my kids. i just want him to be happy and do their best. bill cassidy is a doctor but he still voted to cut $86 million from louisiana schools to pay for a tax break for millionaires like himself. i don't know what kind of dr. would do that to my kids.

>> i am mary landrieu and i approve this message because louisiana children should never pay the price for millionaires tax cut >> i'm bill cassidy and i approve this message. >> a few words on obamacare. >> on voting with the barack obama 97% of the time. >> i am very happy to see the president defend what i think it's an extraordinary record. >> but if you dare disagree with her -- now you know what to do on election day. >> that louisiana runoff election between mary landrieu and congressman bill cassidy will be held december 6. louisiana has what is known as an open primary system where if no candidate gets over 50% of the vote in a the november election than the top two face

off in a runoff election. it will also be decided by saturday's runoff. coming up next on c-span2 the communicators with paypal cofounder talking about innovation and business startups. and a discussion on how medical data can be used by healthcare consumers. later on c-span to a look of posttraumatic stress disorder and a conversation on black friday and cyber monday retail sales and the economy. what does the title of starbuck zero to one mean? >> guest: it refers to any sort of innovation or doing anything new where you do the first thing of its kind, so the first word processor, the first first smartphone, the first car, the first plane. it has a connotation of the

breakthrough innovation that is a quantum leap rather than just a small incremental innovation. and my book is about how we as a society need to be innovating more and how to significant innovations that moved by a harvey's breakthrough companies. >> is silicon valley does that have a mindset? >> guest: is definitely silicon valley at this point is the center of innovation in the u.s. and globally. and number of companies google, facebook, amazon are significant ones and apple with the iphone. there's always a bias to make these incremental. sitka making successful it's all g. or go to one. most companies end up being more

incremental and much less valuable. that is copying things" is the title last. >> host: how is yours a zero to one company? >> guest: which was the first to combine e-mail and money which was a breakthrough idea then it turned out that to make the product products work you have to solve some tricky issues so that people could transact in a way that was fast coming easy and secure and was definitely the first company of its kind of grew very quickly and represented a breakthrough. it's often one sort of measure i get for the companies where you have in order of magnitude an order of magnitude improvement on some important dimension and so amazon had more than ten times as many because the next

biggest bookstore. paypal would send checks to seize power sellers which took seven to ten days to clear up and you got the money instantaneously which was a much faster process. >> host: where did you come up with the idea about electronic payments? >> guest: it's not to come up with the whole idea i was interested in this idea of the digital currency. how could it be shifted and we are focused on this intersection of cryptography and money. there are all these different challenges even if you come up with a new technology health of people adopted and then e-mail is something everyone already hand so we should try to link the money with e-mail.

something people are passionate about and they think about it really hard and in the process of that you really refine the business model and the idea and the great strategy. >> host: and a bbq right when i was running paypal in the late 1999 i was scared out of my wits. not because i didn't believe in our company but because it seemed like everyone else in the valley was ready to believe anything at all. >> guest: was a bubble in the late '90s and in many ways we are still suffering a hangover of that. a skeptical of technology and silicon valley but it was driven by realistic expectations about growth and cash flows and basically end up collapsing the next few years as nasdaq went

down just over 1,000. people often ask whether we have a bubble today and silicon valley. the bubbles in the tech stocks in the '90s were or helping them finance the last decade they are all psychosocial phenomena. we have a round of the order of 300 a year into today 2013, 2014 the public is far less involved and they are doing in much later. a much later. perfect as sarbanes-oxley, part of it is that the tech companies themselves don't want to go public. what happened this time is a long boom i would expect to go on for many years to come. >> host: you write the overwhelming importance of the future profit is counterintuitive even in silicon valley for a company to be

valuable it must grow and endure but many entrepreneurs focus only on the short-term growth. >> guest: we look at the future cash flow and included about three quarters of the market capitalization of three quarters of the value of paypal as of 2,000 one that came from the cash flows in 2011 and beyond. in the high-growth stocks most of the value a decade or more in future the investors and entrepreneurs tend to be focused on the growth variable because that's what you can measure how much did it grow over the last week or month or quarter. it's more important. the durability of the question of why do you have a permanent

lead and why will your company do something with near permanent value is an extremely important one. >> host: thanks for a cap capital venture mindset? >> guest: i wish i was a contrarian approach to the conventional wisdom. it's a fury to invest in different companies and to treat them as though they were lottery tickets of one sort or another. you are multiplying small probability that a big payoff and when you multiply a small number with a big number like that you typically end up with a small number and when you think in terms of the lottery tickets you will lose. so instead i tried to do over the years is only interesting

things with very high levels of convictions that ends up being a somewhat more concentrated approach and so instead of told him to put all of your eggs in one basket is a good idea to put your eggs in one basket that you understand very well. >> host: what convinced you very early on in facebook? test code that was something of a no-brainer they had to buy more computers to go to more colleges and people were skeptical of the social networking and they were not focused on the college market and so it was a reasonable valuation for something that had tremendous amounts. and i think that in today's context i invested the time insisted at the time when it was valued at about $5 million. would be valued at something like $100 million.

it's an acute sense of the hangover from the '90s. they are going to deliver a scalable product. i thought that was a good investment. >> host: where did this book stem from when you talk about the class at stanford? >> guest: does zero to one that came out of the class taught at stanford in the spring of 2012. i tried to convey everything i learned about technology, business, startups in a single course.

they host of them on the internet, 300 to 400,000 people. and we we thought that it be a great follow-up project to distill the notes and approve them and put them into the 200 page book which is what we ended up giving. >> host: on the first day of class would you want your students to know? >> guest: there is no single less. the overarching theme of my class and of the books that people should rethink competition. most business books taught you how to compete more effectively. mind tells mine told you that perhaps you shouldn't compete at all and as a founder and entrepreneur you should always aim for something like a monopoly that such a breakthrough that you have no competition at all.

we have competition for all sorts of reasons. we find it appealing to do things other people are doing a. starting a restaurant restaurant is a brutal competition. nobody makes any money. and the examples are these businesses businesses but often no one has even thought about doing. and like google and facebook and social networking and they end up being incredibly valuable. i try to get attributes from the contrary and questions like what great business is of the building and the intellectual question, tony something that's true that very few people agree with you on. this turned out to be a hard interview question because in the interview, people think of it as really brilliant and even when people have answers that most people don't agree with them on it is often

uncomfortable to articulate them and often a great deal of kurds to build some of the zero to one businesses. >> host: you return to that in zero to one and in one of the examples you gave it is god does not exist or there is no god and you say that is a bad answer to that question. why is that? >> guest: neither the answer that god exists or does not is a bad answer because those are two different sides of the conventional debate and there are a lot of people on that side of the debate and i think that the interesting answers are things people agree with you on and it isn't simply a matter of going against the conventional wisdom. it is an equally important to come up with something that is

true in one way or another. in the course of the book i think the example of the monopoly over the competition questions are underexplored. >> moderator: we are in the world people are very focused on the globalization and copying things that work. living in the united states or europe, the question of the technology is more important than the globalization. so i think that there are many answers to the question but you're never trivial to find. >> host: the best startups might be the different kind of colts. the fanatically wrong about something important. >> guest: i think a great startup is always united by the sense of mission with what the company is going to do that nobody else in the world is doing.

it's to be the first company powerful enough. it is an aspiring goal and no one in the world but it was possible and most people wouldn't think that it made sense to him. it is sort of like the colt you have some privileged knowledge or some insight into the world that is not shared by other people.

>> guest: the power law is the distribution of the size of the technology company. so if you look at the tech industry in the u.s., the top doesn't have a market capitalization of about $2 trillion they are probably as big or bigger than all of the other tech companies. and so, you end up with these radically unequal outcomes in terms of the company's highest. so it is unlikely to u.s. declaration of independence where men are created equal in the case of business not all are created equal and some end up being more successful than others. as a venture capital investor typically the case that your single best investor ends up being worth more than all of the others combined. and so this is a very strange dynamic and it's worth thinking through a great deal. and it is an application of the power law to the entrepreneurs of the founders is that it's perhaps not always the right thing to start a company.

it may be better joining the company. it is better off than the founding ceo of the startup in silicon valley. and we sometimes privileged to much and value the potential scale and we overvalue the scaling and so i think it is always worth thinking really hard about whether you will be able to build a great company or you might be better off joining another company that's doing something truly great. >> host: you spend quite a bit of time in her book on the. is it assisting, is it promoting this type of entrepreneurship? >> guest: i've been a big critic of the u.s. education system and focused a lot on the higher education where you have a runaway student debt that we have now over a trillion dollars of student debt.

i think that we have a bubble in higher education. and i think that it is -- i do not think that it is actually helping people do more entrepreneurial or risk-taking things. when you graduate with $100,000 of debt, you will take a safe and reasonably well-paying job to pay off your debt and you will be much less likely to do something entrepreneurial or creative or artistic which may pay less and ultimately create more value. so i do think that there is a big problem with the debt and a big problem in the way that education generally is somewhat overvalued. the analogy that i've given is the colleges today are in a crisis similar to that in the start of the 16th century. they are charging more and more. we have this class that is extracting just like "genesis of the catholic church had in the

early 15 hundreds. and we were told that it is the only way to go. you go to jail or go to jail. that basically if you do not get a diploma he will be saved and if you do not come in will go to hell. something for the modern equivalent of that and that's very wrong. we need to find a wide range of different things for people to do. i think that the post-education bubble will be a world that there isn't a single track, not a single path that there are many different things that people will be able to do. >> host: how significant was the bubble of the late '90s were the above? >> guest: it was extremely big and distorting. i think as it so often happens with these things, people learn a lot of things but they often learn very much the wrong

lesson. it was to try less projects so the aftermath of the bubble was to push us even more towards incrementalism. it was of course to discourage a lot of people from going into technology at all. business to consumer. in 2000's it was for the aftermath that people basically went away and so we had this enormous misallocation of resources and i think that we would have been better off with much less volatility. >> host: on the stanford class was that on the economic department, computer science department, which department?

>> guest: we did it through the computer science department. we thought that it would be -- this would be the best way to reach a lot of people that are starting these companies. there is sort of a rise towards the engineering product at the core of the new tech companies. although it was open to the people across the board and the university and it got a lot of attention far beyond the campus. postcode you are quoted in various places saying we got 140 characters. what does that mean? >> guest: basically it is if you think about the promise in the 50s, 60s, there are all these fantastic ideas people had about technology and it is a sense that something like twitter is not enough to take our civilization to the next level. so i've had this used more

generally that we are living in the era of relative technological stagnation. we've had a lot of innovation in the world of mobile internet and all those sorts of things. we've had much less innovation in the world whether it is energy, food production, underwater cities, flying cars, supersonic aircraft. all the kind of things people would talk to them in the 50s and 60s. and this is in a way that the work technology today doesn't mean rockets were flying cars. it means just information technology. there's been a narrowing of the focus. we've had a narrow innovation around this world of it. but i think that's too really improve the quality of our society we need innovation in all of these other dimensions as well. the hope is that we will have some widening in the aperture in the decade ahead and we will then start innovating in many

different areas. >> guest: at the company that i cofounded back in 2004. if the data analytics company that enables people both in government and large corporations to analyze a lot of debate to find national security threats or criminal activity, fraud canals with cybersecurity and sophomoric corporate context and it basically comes out of this idea that we had a lot of the problems of the world are not going to be solved by humans alone or by computers alone. what you have to do is figure out ways to get to the division of labor to the right between the two of them. so it's basically a way for the human investigators and analysts to work much more effectively with computers to analyze large amounts of data. and this is actually sort of a underexplored paradigm because

the dominant idea that we have in the computer world is that computers are substitutes for people. they will replace people in one way or another. the paradigm is much more. they are good at different kinds of things and the key thing to building a lot of great innovation is not progress the huge discount to replace people who. >> host: given the topic areas have you worked with the federal government on some of these issues such as cybersecurity? >> guest: yes, we have worked with the three letter agencies and various law enforcement and defense organizations and easy. it's always a very long procurement cycle to break into the federal space, but i think that after ten years they have

made a lot of traction and has impressive results. >> host: what makes you a libertarian and why do you do need to the republicans? >> guest: well, you know, it is always hard to fully characterize one's views politically. i did say that i'm socially more liberal and fiscally more conservative, which generally if you have a litmus test of the political issues become down a libertarian i would've different things. in general, i'm always a little bit skeptical about how much our political system will fix things. i think that paul spoke very important around this country. i spend most of my time working on technology which is a place where i think people can really move the dial and really make the difference. so i find the politics incredibly interesting in theory and i find it in practice to be endlessly frustrating, which is not even a very unconventional

view. >> host: does washington understand silicon valley, does it get in the way? >> guest: there are certain areas of regulation for the technology. one of the reasons that we have had this tale of the innovation in the computers which are relatively unregulated industry slow in other areas like it costs you $100,000 to starting a software company and it costs about a billion dollars to get a drugged up through the fda on average, that that tells you that we will have fewer companies and more software companies. so, i think that it is extremely important for what happens in silicone valley. i think that the two cultures are quite different in that they don't understand each other terribly well. i think washington, washington,p being focused very much on the process. it's dominated by lawyers and a

certain framework bring to ideas. silicon valley is more focused on substance and dominated by the engineering. so, you have a very different kind of mindset of how to approach things. one general bias people in washington, d.c. have is that technology is not that important. it's not something people are experts in. once i looked at the people in congress for 35 senators, congressmen, and a generous company be 35 of them had a background in science or technology were engineering and the rest of them are really clueless. they wouldn't understand they don't work when the wind isn't blowing or the solar panels don't work at night and so they are uncomfortable about science and technology and so in general it's something people want to stay away from here. >> host: in your book you are critical of the educational testing system. how do you grade your students at stanford?

>> guest: we have a test at the end of the course as well as a company that they would try to build. it's a, i don't think that you can avoid testing. i don't think that you can avoid grading if you're going to have an educational system. i think that it's become the problem when everyone has to do the same thing. everyone is evaluated in exactly the same way because the end product is not that everyone should be going to the same schools were studying the same subject. so i do think -- i don't know if we need to be greeting people as much in our society as a whole and putting quite as much weight as we do on the sat tests and all these standardized aptitude tests that are used to track people in these very homogenous careers. ..

>>

>> from the brookings institution this is two hours 15 minutes. >> we're going to get started. i am one of the fellows and managing directors here at the brookings his petition. -- institution. we have a packed agenda. with the people what to the web cast than those in the room if we're also recording the event to want to make sure we have items just a year ago. we will have a full reporting on the web site on the event page in the coming days.

if yes questions or comments wait until we have an open floor for questions and answers. we will actually have the session so we alaska ready to use a microphone. you'll also may submit questions through twitter you will see the #in case you'd rather use different media but if he were on line you can immediately download a couple of resources and once i finish housekeeping we will get to why we're all here today but the items that we have their available in the room is the first issue that is on the commonwealth fund website

with a topic that we are discussing. and we talk with you to realize there were so many tools around transparency even to us to talk about this on a daily basis a became overwhelming so we decided for today's conversation to put together aurora own online resource list. and we encourage you to send us feedback through the web site so we can get your take on how viable these resources are. so i want to start things off but i will moderate the first panel. but the one to ask what of

the vice president's that this would not have been possible without support from the commonwealth fund's in the work they have been doing on transparency has been instrumental what i hope this health care of the future. some comments then we will start. thank you. >> on behalf of the commonwealth fund for everybody here is in watching online. see we talk about transparency and i find myself saying what does that mean? and backward refer started to talk about transparent say it caught on in washington a long policy makers and i got the image we were talking about the

proverbial black box inside the of lucite box to call it transparency. but nobody knew what was going on. that will help address that is great to have a lot of data but we really want information. so we do have data is unusable for a man to in the right forum in the right context but to use it the way they need to. effectively and we talk about consumers in researchers and policy makers. and i am hopeful those topics we will be addressing today will begin to give us

some insight how we can use that data available to platitude goods used to make better policy and decisions with of reproducing the health care system i will not hold the position of any longer but thanks again and of the full route to a good discussion. >> with that let's get to the first panel. , lot summary can get the microphone on a new. -- hugh.

[inaudible conversations] perfect. for the sake of getting started like the introduction though weighing all the way next to be to the of last. from center of medicare and medicaid services, as charlie over here and also charles whole. lee had extensive bios in

packets as well as biographies that don't want to read those budget the goal of the panel was to offer a perspective from exactly what started a lot of this that cable route earlier this year on physician payments that was the motivation that was part of the data set wanted to explore what does this mean for patients and i will tell you we will have a deeper discussion around this topic not only from when i looked up myself that you can all do and how to access that information of that and even more importantly a 61 year-old woman who thought she had a cracked rib and her grandchildren were heavy at the time and she said if

the crackdown river said that is unusual but long story short she had lung cancer. not clear how it started but she said to are the best doctors for every tuesday? i gave her the sources said wednesday the difficult conversation of how much american and medicine and is not transparent and old to believe when important decisions get made day call together these resources the plo was all in these panels will tell you we can do better. so i will be that that. to probe what we started and

is really just the beginning so give us some background on what has been done with regard to your data transparency. >> it is great to be here. connection lee and a long love the center. [laughter] so i stayed high you have to view the exercise is true daypack to 2010 horror 2011?

intent to send with the entire department to identify all whole range of available data to me did not get the attention or publicity it deserves. with those first years were an interesting process. mid-80s and owen's could machine readable data geographical variation in data and that is not an all to diminish you hadar with

to say if they'd the books open and where do decompose medicare spending this is what it looks like it very granular ways. but where it started to get interesting to have years ago -- to end a half years ago with the transparency effort some folks may remember the release of that data.

but the same procedure often times with the same geographic area. chevrolet resonated with people i've known some certain economist that nobody has charges it ignores -- eddie more particularly if you are not insured gore well insured. the reaction and took us a little bit by surprise and it took them by surprise as

well. but with the hospital data there was a desire to keep building on this effort but to release the physician and data we were legally prohibited from releasing data that would allow anybody to identify the total amount of the reimbursement that stemmed back to the '70s than to and a little over i year-ago a florida judge overturned that injunction. and from a policy perspective to consider the release of the data.

and for public comment but in april the open data in with over 99 records it is a very interesting journey. we have shot our commitments over the past few years. so look at the track record it is highly unlikely we will continue.

>> just to be a clear not just a florida injunction but the discussions about whether the data should be released at all? not just a couple of years in the making that your new title is chief data officer. and as part of that are you increasing capacity? to explore not just the data set as well? >> ended is to maximize the data to manifest itself but

also transparency to make data available publicly with innovative ways to access more control. >> as her of the work we have been doing we have tried to find ways to help capitalize on what you have been doing battle will scrap outsourcing the different tools and private sector and public sector opportunities. i first want to say all of us would agree one of the best jobs to offer a zero

way to the web site. [laughter] land we said to use this website is that for understanding. as an investigator and a journalist and also as the category of researcher as well. is a great -- it's great to hear your perspective of. and you are working hard to lead the effort on futures transparency from medicare as well as the private sector. >> one of the unfortunate thing is that more data that comes out of more that you want. they opened one store then there are seven more.

that is one of the challenges. can i have talked to a physician's one thing i have been surprised about is how they're own practice compares to others they think they're doing right with the benchmark but there has been no tools are available they get one report card from united healthcare and the one from across -- blue cross. i thought it would be helpful to show the importance of putting caveat seasoned comparisons. because putting up prior data could be confusing in that is the push back that a lot of media organizations regurgitated what the government put out so well

before it put out its data the doctors were paid by pro public thought but doctors are a catalyst. they're not paid for what they prescribe. so we could get around it by going to the pharmacy with the advocacy on our behalf we talked about when doctors prescribe in medicare party which is the prescription drug program. is a lot of code and doctors and drugs prescribed in numbers can you just imagine? it really doesn't mean very much.

but if you're a doctor has experience is that the doctor you want to prescribe this drug? the with the plethora of data having access to is describing gore of a particular drug so we created a of a tool called for scriber checkup so don't assume you know, . so to look at the top for scrubbers of a particular

drug by specialty so go to our site to see the top of scribers within a specialty or a stage or a medication. but we also have the dash powered saw dissimilar is the specialty and stayed. but if you just release it in total that can be really confusing so we show you the percentage of doctors patients that narcotics whether you are a family physician that is a lower percentage than how the doctor compares to that purpose we have a mathematical formula the selection of drugs to put

them on bars so they're practicing in a different way. then finally the doctors drugs and what there ranks for other doctors in the same specialty and state. one of the things with medicare party -- data that we get to a disenroll about the millionaires and how much people got from medicare was not fair because some doctors spent a lot on of this drugs and when they use them again is it fair to say they are billionaires'? not necessarily if they treat a lot of medicare patients is that fair to put them head to head? so we looked at the

treatment tracker it is in context. we compare with in this a mistake and same specialty. see you could see the number of services per patient. when you see the red marks the doctors in the top 10 percent of their states and specialty. with the amount paid her service in unpaid per patient based on the level of services to the number of times for a patient and worth dash rate there were outliers and one of the takeaways is right now with the informational and it is a lot easier to find doctors who have questionable

practices it is too many variables we know right now. the patient may incur a lot of services we do see that on a the profile looking at a totality to see the complete context end of picture that is like that we think there's a huge amount of of france's just in the past couple years in this will lead to patients who are more engaged and even

with a patient to ask of they compare. who were those that were interested of the database right now? >> hospitals, insurers hospitals, insurers, medicare , we have heard people within the organization that our into raises a lot easier to use them there's. [laughter] they do get the first traffic of the data released to london to keep coming back and it is more

information comes out that this is key. does so the audience is are interested. >> talk about the pharmaceutical relationship since we worked on in the position open in pavement database has been a relief. we saw the technical problems to do the analysis already with that one particular one raising the common logistical problems as shown in the raw form. >> the assumption shows just because the government releases data, that is not necessarily the case.

with the drug company payments due doctors they relied do get a right to that is what they are releasing. the their spelling the names of the drugs wrong, listing drugs in multiple columns instead of busing gold columns touche duplicate the device as the drug and we spent months to sort it out. in the interest to spend the time to do qadarites rather than say over the next 12 hours simic that is the perfect segue for our doctor was a practicing internist in a leadership experience and as a side comment, we looked through dozens of letters sent to the senate

finance committee when senator wide been asked for public comment from physician groups and organizations on the topic after his parents a along with other physician organizations sent detailed letters that transparency is good. and the headlines that were threatened by. but when those headlines when live to understand why

they have millions of dollars of medicare charges it made physicians a nervous help people live together own pattern where in the end quietly curious but cautiously optimistic this is the right direction and. >> is the largest specialty organization with medical internist and a specialist and students. and i chaired the board

until last your aunt traveling around the country being thousands of doctors but my day job as a general internist i a.m. in the office and i see patients at the hospital. i could share with you if you put my colleagues in a room to talk about the data released for 10 minutes it would be nine minutes of silence. there are many issues for electronic house records data reporting on quality parameters budgetary concerns but i take they have but having said that data is important but it is important for doctors.

the example is perfect but with every patient that i see as a physician i have to make recommendations to move to the next debt. may be an x-ray or a procedure but it is clear the right antibiotic to give you better but if there are too, reaches the better one? which is the most cost-effective? you can use that example across every recommendation. so what charlie has put together changes that conversation to have nine minutes of silence but it is

so important for doctors to know what things cost. but the other parts of that budget we cannot make recommendations as a patient simply based on cost because the cost could be high but the outcome could be even better than and though low-cost procedure. so the outcome is important than the comparison needs to be adjusted. if you take care of lot of sick patients the cost is high but the outcome is very good. so your in your infancy.

this is great news for the profession for the american college of physicians we are encouraged by the data released an even more so with that i will stop. >> we have just one follow-up. but you will hear many sides of the issue. so what the concerns have been to date? >> they touched on accuracy. there is a lot of information out there.

benefited is inaccurate there should be a way for physicians to address what they perceived as inaccurate to make it more accurate. we have to access in an easy fashion if it is complicated it will use the news its utility. that one of the other concerns that was expressed that alluded to the fact releasing this data might be a way to redress waste fraud and abuse we can argue simply because costs are

high we have to not attribute that is fraudulent but to waste services. but by simply having a high cost may have to be careful it is not guilt by association. >> if anyone in the room has questions raise your he and so we can get a microphone to you. if anyone on the panel can respond, you cannot talk about future data or any action that takes place in the future but to date what have you done so far of the public side nor the private side? for medicare or medicaid?

>> first of all, they're both excellent and added important context. that we in in the infancy and this is a flow with area to appear with the data was are what it was not but it means we have very little control to choose to analyze in terms of the private sector you have hospital systems undertaking to use the of more transparent. there is legislative activity is seeking to

address or formalized pricing information and most recently the health care cost which is the agglomeration of regional health plans to announce a large transparency initiative that will kickoff to look at the data they have assembled from different health plans. i don't know if it will be exactly so our actions have had that trickled down. >> charlie reference to this but the commercial payers are looking at and quality parameters.

the day are insisting with the so-called quality reporting does not take into consideration, cost. it is not high value but i think the next generation of reports that are expected to turn into the pairs will be high value care. good outcome that a high value. >> one of the challenges. is wonderful they give the quit smoking devices to patients out of the programs it does not matter to me so

what you want to know if they have heart surgery they want to know who performs the most and how many are of live one year after that? we could not answer that today or tomorrow but that is a question want to answer. if you are a diabetic and it is under control i don't care if your other patients are i care about me. >> but at the same time patients are complaining about the high co pay, deductibles, be spent billions of dollars per year of marginal use in this conversation and release

gets us away from spending all of the extra of dollars we need to spend. >> no questions. >> it does come back to the co pay goes up the insurance goes up how can we provide high quality care? you have to factor in the cost with the outcome. >>. >> first i a congratulate you. have adu deal? and with the system with

that information. it is important. but it is rare for you can find their. so how do you judge the real system with that information? the with the treatment they don't ask for it.

so those are the charges. period to compare the patients to give it to the patients they can perform the procedure. then they say no they don't have it. >> we will try to wrap this up. >> so the mistake and assess it all the various recordings. >> and the other procedures. >> i understand.

>> thank you. this touches on a couple of things that the last panel may get into. the work started with the physician data and touching on the referral network with the next wave of data the tear triangulate the wage paid to of better picture on health care services. to you have comments on hospitals head is much more complicated than what we touched on. >> some of the end point talk about this issue is services that went out the door. at of pharmacy.

id to be paid to be dispensed and with the referral there are two different claims. the quality of electronic medical records it is when you try to adjust for things like that it is a long way. >> obviously a hospital offices in the er settings and it is so overwhelming to say why bother? lettuce leaves first it was the hospital data then with a physician in charges. because even the information on dialysis.

are there other care settings that we need to have better transparency? >> let me plug the, of publication. >> but what addresses this the first the physician did ask to be integrated with the pharmacy data in the isolated way. it addresses but you have to put it all together. comparisons are really difficult but until we get

into detail if we could never make comparisons. so hopefully one day we are moving in that direction. >> what has to date have you learned from the? and then i will kick it off. leg did surprise me that this was not important to my eight patients unnecessarily , but to my colleagues and they would

like to do get into that. but something that you learned from this process? >> i am a key part of the etfs is the physician data in on how few codes if before the start of the project tuesday the average said easy. or maybe a year -- or maybe more. there reza significant jump rebuilding 10 or 15 or less. the son were going through

those codes. >> i grappas of health reporter learning about the hospital regions are. and how you can of literally:one street over and the quality of doctors and it makes up the difference to look up the individual doctor. >> i looked up my data. i thought they were paying be more. [laughter] >> so i would compliment cms.

doing this for more than 30 years it was hard for me despite all that experience to make any sense of it. and i can imagine what the patients think how they figure out what is going on. as vivid that is a perfect segue. please join reid to thank our panel. >> and if i can ask the second panel? [inaudible conversations] we have dr. ginsberg that has extensive backgrounds to

have public-relations related to research in this area. >> end he will leave the discussion from the perspective of the policy makers. [inaudible conversations]

>> id we can start now. at the beginning of a conference to set the tone about transparency. there has been a longtime interest of mine and i believed the confusion comes from the fact we talk about it because of the aspect of sunshine. though republicans institutions or other institutions their operations ought to be a more transparent. son to be useful but then when they think further waiting physicians, hospitals, health plans and this panel is

about the three different audiences in what they can do. and a very distinguished researcher. it as an executive to talk about other data. with the need for health plan than with the policy background what can they learn from this information to help them with policy did the?

with that april data released. we will not dwell what was on the april release but what could be in future vises but they can talk about what they would like juicy to make them more useful. but it is not the only game in town. and he can go through the process to save time through the data use agreements to get the data that is behind the release. to end either can work with the entity and also has

another channel. >> but the first question with the charge of pavement is the big deal from the perspective of the researcher with had a couple of conversations and then salivating over the new data source. and gradually there is a much we could do with the data the research questions we would want more detailed micro levels then redo all the time. sodas that the data releases

not the big deal? not all. is the step forward. in number one of the release of the data that cms says the physician's right to privacy does not outweigh our right as a public to know what medicare is spending or buying. and then in place and to be paid by medicare. and by releasing this they said that the balance between the physician's right to your privacy is now officially tipped to know what is going on. so dave other things that

they have laid down a marker to say misgoverning a fall of hipaa it is a vast barrier reef you have to learn to navigate so that is the first important thing. second that it is useful because it releases more data we will see trent to combine it with hospital level. to get a fuller picture as

saying identifier to do combine the data release with that data. and private sector health plans will release data. >> then what's going on in the health care setting. >> it is us step in the direction to understand to make better policy choices and what they that be forget it is built through conscious effort.

and it has grown by such and such of a percent. began to devote significant resources with use of businesses it is that a resource that is built through effort and that is incredibly a valuable and the cms data released but in terms of where every are going next but to see the private sector is the black box. medicare starts to put the cards on the table but with geographic variation in some private sector it is more challenging to get a handle on that. in june to the extent to get

better structure is in the same format and then we compare prices and in practice patterns and an adjunct to fighting geographic locations. the most fruitful but also the most difficult. >> from the beginning the better serves the researchers needs any thought how that process could be streamlined? >> the data could be made it cheaper we pay taxes is for reasons of the federal government could provide services that should that have by higher marginal price.

the data is what should be made available even though it takes a lot of resources to produce that data once you've made one the copy is trivial to generate 1,000 copies of that digital a. the price could be made lower the turnaround time could be reduced it is the fact of nature at this point it is period others - - barriers for the others. ince i appreciate the comments of fund for sponsoring this and do talk about the issues and

limitations in the suggestions from where we go from here. but i really want to commend the cms for their efforts to promote transparency in the use of this data. with his refreshening an important with evolution over time it is an important theme in the have heard about this. it is useful to raise awareness. the pervasiveness that we see out of the data? frankly it is so obvious it is useful to bring a round of what things cost that is the basic information in there.

and it is what i call the coroner's grained view. useful for some but not for others but has volume i am not to practice any more of a general internist pilot the at my friends to see their practice patterns the u.s. expect a great deal of information from a senior population. it is important in provide in the current limited form but the most fundamental is that health plans have learned over the years it is more an exercise of hypophysis generation thing is to make a determination

about much of anything. you cannot look at the ride data table to say there is the al meyer let's do something. what you have to rich regulators around look have multiple data sources and trends over time said a further exploration and having a conversation you may find the al leiter is a referral practice this there the only ones to provide that in the region. the hypophysis generation is the way to think of the rock claims data. a lot can be done there requires analysis it doesn't

just put it out there but starting with a simple descriptive statistics standard deviations than there even read more sophisticated uses of claims data and the ability so there is quite a bit hough and it is an interesting policy question how much the sponsor does hers is having their raw data file. but in terms of physicians are in a state called for the most important attribute is the ability to make comparisons and and the

laughter have credible data to compare against a special save. that is what they have learned over the years my third suggestion or limitation is what they have learned is one releasing data is day good idea to have a service bureau function in the case of physicians to answer their questions for them to look at daewoo corrected if there are some errors they are very data congreve but they want the ability to drill down in ways that make sense.

this is a service bureau function like united health care we have the physician and portal that is open to all physicians in the network. this is an important suggestion. let me make some suggestions to go from here. the first is due cleanup the data in june offers some ball descriptive statements for the stakeholders added is reasonable for the sponsors to do even with the other analysis. second, the ability to combine data and data sources and thus set in this particular case it is the limitation and you can get the full picture.

that we may find the physician and expending a great deal of resources in the office to look at the total cost of care they're quite efficient. but you will live see that with to integrate and combine data sources. in the health care costs is a chair that is why it is so important to contribute data as the multi pair effort to bring transparency to the private sector market. and it originally started as a private sector trend data but as was mentioned once of parties got together and payers started to put the data together we can use this gore transparency

purposes. looking at quality instead of just cost of that is an effort that has been announced period deploy due in 2015. sova to use some up to be a medicare qualified to duty that is of good example from a different medicare program as well. there is a lot of opportunity this is the beginning of a new era. the current release has been useful eliot ltd. and others but it will revolve overtime if it moves in the directions the has been suggested already. >> but you got me thinking one of the steps for word is to go to the rod and analyzed data to a the

federalize data at the same time we are on track to have physician in value modifiers that will be fairly analyzed data provide -- alice transparency plans, any thoughts? >> whenever there are multiple initiatives it is an interesting and challenge her in the organization but that is why it is the greater opportunity to have a broader view of the resource saugh to use an internal and externality but the most important thing is moving beyond fairly rapidly just the raw claims release

into analyzed data the measures might be slightly different but has fallen as this is the domain without quality data so that any user cannot get the picture of quality information with the cost data is useful. that is a partial answer. >> so my a job is to shake of broader policy perspective to the u.s. congress and how they might benefit from the data releases have a right to start with the analogy above up black box. it is easy to value transparency.

we want to see more. but it are those residents that a do except a and embrace if we're ever going to achieve it. so physicians and providers need to get used to the etf to have a performance evaluated and the willingness to do that is dependent on how accurate or useful the data are and how they will be utilized over time. u.s. call for suggestions sent i have predictions. not that they will release more data but i will predict that they will. and in fact, the contractors will correct to those that

the media organizations have printed out. dave may well contribute to that effort and have the incentive that the information is available to a wide range of lookers they have the incentive to match up the national position of identifiers. i hope we have different kinds of providers in the future of the most importantly if we have that second date of release -- data release i will give you an example of how that could be useful. the idea of where i worked for several years took 2005

and 2006 data exactly the same database that attempted to identify beneficiaries to our high utilize hours of services. the correction is not perfect but we could identify a group that were high. then we examined those save beneficiaries. did they remade being high utilize hours? there is a slight tendency than we had those of monaco's that treated them given the of mix of patients then invade the that the doctors of following year there were twice as likely

to be a high utilize there i would be giving you a reference but it is the time seriously you cannot do with a cross-section. >> i worked for 12 years that gao i a supervised different committees of medicare and other health care spending. in case you are wondering what to they spent? anyone care to guess? then you get the same answer. i've looked at these news organizations reports of the data that is released as another source of

information. the b there are mistakes but when congress has much of its information from companies and betty our constituents with a vested interest and i remind you of the five top lobbyist, four of them our health care. and the fifth is a a a rp. said to have a different incentive in fact, that would say the news organizations our compliments, substitutes for the research that the support agencies do and i grant under contract.

>> ever also expect because they produce in give it is what could be investigated a greater depth there may be some benefit to ask questions that were raised to be investigated in greater depth to have the resources and capabilities to do that. so my bottom line is it is good and necessary as time goes on we believe it is an eternal part of health care reform. i've looked forward to the day were the database with not chess of reproduction of medicare and in the private

sector there is a huge amount of variation in. so not only to combine against different players to get a fuller picture to get the private sector data into the next to have all lot more opportunity to investigate meaningful differences around the country. >> and based on this release to members of congress and the likely shapes what they were asking congressional support to look bad or support policy wise do you have the sense of those directions. >> was that the only interesting thing i said?

[laughter] >> i don't know. but i did look up to see the hill did pick up the stories and reproduce them in their media but i cannot cite a specific instance where an issue was suggested to a member for and other agencies. >> it is the good time to return to the audience. >> wait for a record from.

and i am wondering what you would think of that's if they are important to have the market to visit of the day. tsa creation changed that? >> it is not of medicare issue but the medicare physician and. for what they can charge of course, those prices is more about private insurance. >> and that desires to have greater transparency but even though in massachusetts

there is a new law that requires so that is an interesting experiment to see that stay. from the consumer point of view what consumers want turgot is not what the provider charges as what do i have to pay? what is the charge to the benefit package that i have? and what does it mean to be? exactly if i choose option day or be. so that is increasingly

becoming available with that same transparency fame -- steve. >> was wondering about the raw data and what has been released. is it the same questions or is it hipaa or a combination? >> if you go through the process of the data use agreement, and you guarantee will satisfy all the data security safeguards, they will send claims data that has beneficiary identification in the coming age, sex, zip code, for the

of public release with those 11 or more. mckenzie the services. >> canada also provides that opportunity for different providers and beneficiaries. >> if sedgy is out of the bottle then what is best next for the cms data release? manchin a the modifier.

and with a wish list with the final output of the of modern fire calculations that is taking a the raw data that cms just made that others have been in talking about. so medicare can measure quality and efficiency including all of the services that they ordered a just what they provide themselves. so that would be a significant step forward.

>> it would be very useful but especially if they could correct the errors of the first release so the second year to make better comparisons over time. >> we have talked about the aba more comprehensive to link the data into have a more comprehensive view. with a the 360 view of who they are treating. >> the grouping data to look at how a physician looks at joint replacements or another well-defined episode of care.

>> i am with the of brookings institution. but what is this for the health exchanges? it hasn't so what my days of the interesting future developments with future releases? >> that is tough. if you can learn about prescribing patterns the exchanges may use that information. but they're not generally treating medicare patients and provided services with

the managed-care advantage program and then with the data from the commercial marketplace. but we have found these are different populations. and it is different from the senior population so to do a quality measure reporting may have different benchmarks love falls of performance. that would happen with the exchange population. but that is over time. >> i work from the did the

policy department. i have a of a quick question of a zero win the release of the old bin data there was the concern of the mosaic effect to a new release those defects you could read these personate identifiable information. >> this has not been brought up the publishers and to those the don't have a number of the above procedures or patients treated if ever buddy knows to that doctor is, then that is the motivation for that

claims requirement. . . >> the more risk there is of people being able to combine them in novel ways and kind of undue the privacy protections. and i would just say let's keep in mind