even though we have never met we have friends in, and your reputation in many circles is as high as i have ever heard. certainly as a dolphin fan i remember drafting a 1992 and i was sorry to see you go in 1996 when she may let you go. i appreciate your service both as a player in the nflpa and now for the leak. i do want to make two points about the nfl that are important in asking this question. the nfl doesn't just play for three hours on sunday monday and thursday nights. the nfl is a 24-hour, seven-day weekend ever that actively wants americans to admire and emulate the people of puts on the field. once are again people to wear and this is true of all i want to focus on the nfl pretty wants young people like my sons and they want to wear the same shoes, to wear their jerseys to buy the same and use the same products.

now they regulate what earphones they can use because the league has established a contract with one of the providers and i want him to wear those. this is an ongoing 24-hour endeavor. it wants people to emulate him look up to these athletes and they do. and that they can tell you being involved in youth football this is very sad but it's true. in some instances, the only positive male role models that many young americans today have happened to be professional athletes they see on sundays or at night on television. i think it's important to preface that because this is not just a sport that's played on a field three hours at a time. this has deep impact throughout society and there are millions of young americans who look up to these players and whatever happens or does not happen has a deep impact on them. for many of them it's the only male role model they have

unfortunately in many cases where people go wrong. that is why the rate rise case interested me. the situation with mr. rice involved someone at my sons personally admire. my sons came to admire ray rice and i'm not getting deep into the weeds that one of my sons place in a running back position. he's very quick so we look for someone on the national football league that has some of the same attributes that was ray rice and he looked up to him. a few weeks ago he wanted to know why the ray rice was not playing and i had to explain why he wasn't playing. the impact of that was extraordinary rate he's young to fully, and what it means that what happened or didn't happen had an impact on him and other young people across america because it served as an example of what happens in society and in life when someone does the wrong thing. that's why i'm so interested in the case beyond the horrifying incident. you stated the commissioner had

seen the elevator video but it didn't need to because in essence everything that happened in that elevator that the video showed had already been admitted to and testified to by mr. rice. is that correct? >> yes. and if i can senator again the commissioner stated he had seen the video and as i mentioned earlier i think anyone of us who had witnessed and saw that despicable act. >> the point is mr. rice whatever we saw in the video is certainly horrifying to watch but he told the commissioner that whatever that video showed he had already admitted to. is that correct? >> yes. >> not having seen the videos is the same as having seen it in this instance. you didn't need to see the video because they already knew what happened. >> inside knowledge in the beginning we made a mistake. >> i guess i'm trying to understand the process and you may have explained this already.

i know what happened to ray rice when he tested positive for marijuana. had he taken sudafed at the wrong time without a doctor's note. i know what happened. is this a completely arbitrary process for the commissioner zients punishment based on how he feels or a set model in place for what an action equals, admitted action. what is the criteria they used to determine the punishment? >> senator lee failed to impose the proper discipline. >> my question is how do we measure? i want to know what is the process moving forward i suppose as well but at the time out was the process of someone came forward and admitted always on the video that they punch their

fiancée in the face of an elevator by what measure y. three games instead of 10 and why six games as that of a full-year? was at arbitrary or was it something he looked to as a measure? >> he has tried to impose discipline, harsher discipline in the past it was appealed and knocked down. i think that shows the severity of what we know about these crimes. he went back -. >> appealed to an arbitrator? >> the players association appealed that offends and the discipline that was handed out in the past was appealed and knocked down. >> your testimony is that the player comes forward and says to the league i just punch my fiancée in the face and knocked her out and the commissioner decides i'm going to suspend you for a year the players union will file an appeal in that decision because one year is too long for someone that just punch

their fiancée in the face and admitted to it. >> the players association has that ability. >> and they have been successful? >> that's where we have our challenge. >> what is the criteria now? >> that's what we are developing. the commissioner has the ability to either impose or designate an individual to see the case and to hear the case. right now understanding and learning the complexities associated with it has been talked earlier about having internal investigations or were a parallel investigation with law enforcement but we are looking out again severe discipline. an august 28 letter to the owners and the players, the commissioner spelled out very clearly first offense a minimum of six games aggregating factors gives him or his designee the ability to impose more severe punishment. >> thank you very much. i wanted to comment before. i've never seen so many women

representing major league sports, professional sports in this country at a moment of high-profile importance for the leagues and i think it's a good thing. i think it's terrific and i would tell all of you to go back to the organization to represent and say you need to be at the table more often, not less oft often. i don't think i ever recall seeing this many women representing professional sports at a moment like this in our countries history so i wanted to make note of that. first i had a question to the national hockey league. in reading about the suspension of the player that occurred recently, think he's a defenseman for the kings and i will try to pronounce his name. i noticed in the article that the team was complaining because his salary was going to continue to count against the salary cap while he was punished.

i found that interesting because it creates a financial incentive for the team to not punish. my question to you yes or no does the league favor removing a salary count against the salary cap during a time of suspension and? >> initially when suspension was imposed it was determined by the league office that the suspension should be with pay so while the team continues to pay the player that money counts against the team's salary cap. subsequently we reached an agreement with the union to change the treatment for the teams perspective with a host of conditions so that it's no longer counting against the cap. >> so are you saying it is this true that all of you have cap so when someone is suspended for misconduct with pay that debt paid counts against the salary cap so the team isn't that being

financially punished for doing the right thing and? >> this was the discipline imposed by the team. with all due respect it was imposed by the league so the team doesn't have an incentive one way or another to act or not act. >> but the team could impose it and wouldn't still count against their salary count? >> only if they were choosing to pay the player during the discipline. >> okay. is that true with the other leagues? if someone is suspended with pay does that count against salary cap's? >> we just had our last two when we looked at adrian peterson and greg hardy. the team was penalized. there's a salary cap. there's an example of paid leave so the team is being punished because that is a cap day. >> i think you ought to look at that. i think you need to remove any disincentive there is to punish players who have had bad conduct

and the team is going to have that money count against the salary cap even when the team is not playing that will weigh in favor of a much shorter suspension for the team impose discipline. i will follow-up with qfr's on that. do any of you have a process in place to independently investigate the facts? >> senator i will answer that question. think as we talked about our recent case involving the player jeffrey taylor we immediately commenced an independent investigation retained to outside counsel including two former prosecutors one of whom had a sense of history dealing with domestic violence. >> nhl do have an independent press is to investigate the facts? your own investigators are pulling records and pulling 911 tapes all of that? >> as we have our internal process for conducting

investigations on all misconduct. >> mr. krughoff -- mr. tory as you noticed. >> i was fired. >> that always happens at after you leave the affection resurfaces, right? i wanted to get that in as a huge cardinal fan. does mlb have an independent investigation process? >> guess we do. it's not my department that we do have a department investigation. >> i would like to know what happened in the rodriguez case. i would like to know what the outcome of that investigation was. i would like to know if they asked mr. rodriguez said he paid the ticket for the fit that -- victim and a witness to go back to venezuela. >> i would have to get that information. >> we do so with their security department.

>> how many of you yes or no have an independent program for wives and significant others were employers are not allowed to attend whether it is a confidential here are the issues you are going to face, here are phone numbers you can call if you are in financial stress stress, here are phone numbers you can call if you have been abused. here are places you can go for help. how many of you have an independent program like that for spouses and significant other's? >> we do in the nfl, yes. >> nlb? >> excuse me. some teams have them. uniformly we don't all have them but it's something we are developing. >> i will follow-up with more questions on that because i want to make sure you get it. >> as michelle roberts explained we have been meeting with her family organizations to determine the best way we can

provide resources for them going forward. >> but you don't have an independent one now? and some of the articles i read the women were saying there was no place for us to go. the teams weren't calling us. the teams weren't reaching out to us. it was all about the players and what about nhl? >> our program extends to the players families and our program doctors have been accessed by players spouses and significant others. >> you have an independent program for initiation into into the league when someone comes? is there an independent program for the spouse of the player? >> to the extent that they exist they would exist at the team level. >> what about mandating reporting to law enforcement? do any of you have a policy at elite level that a coach is required for an assistant any team personnel as required if they learn of conduct by a player that is illegal in terms of a felony assault or is any

kind of assault that you are required to report that two law enforcement? >> yes maam we have been in place. >> right now if a player called his coach and says i was drunk and gotten a fight fight with my wife popped her in the face and i have left the house and she is called 911. when he calls that coach under the nfl policies that coach required to pick up the phone and call the police? >> that coach is required to do so. >> is a coach ever failed to do that? how long have you had that policy? >> that has been in place, i can't tell you how many years but he is required to call. >> i would like to know how many times coaches call. that's a question i have for the record. i don't have time to ask all of you that but i will for the record. i thank all of you are terrific people and want to do the right thing but you have got to understand the status quo is not

acceptable. turning the other way in thinking this problem is being handled by these players and their families out of the light many families are suffering. i think you all know that in your hearts. i'm going to keep following up and there will be more accountability in future and i will have a number of questions for the record. thank you all for being here. i will turn the record over to mr. rubio for more questions. if you venture questions and senator rockefeller's not here you need to recess the hearing because he is not coming back? do you can gavel out? i'm going to go vote now so thank you. >> and i won't keep you but i wanted to give ms. patterson the opportunity to respond to mr. vincent and his answer to my question outlined the role the nflpa has played in the past in players accused of domestic violence or other infractions.

what is the role and i wanted to lay the groundwork for mr. rice astray. mr. rice admitted to the facts to such an extent that we have heard here today that the league didn't get to see the video to know what happened. they have learned nothing new from the video they did nardi now. in a case like that what was the nflpa's role in supporting the player a rut world of a plan that process? >> first of all the players have the option to have us in attendance if they have a meeting or conversation with the commissioner so we support them in that way. if a player chooses to appeal after discipline has been handed down searches in the rate rise case we prepare that appeal and represent the player on appeal. i think it's worth noting for the record under the personal conduct policy that appeal goes back to the commissioner for his review of his own decision. that is what was different and the ray rice case because we fought for neutral arbitration. >> when the census is in the

past where mr. vincent outlined a reality where in the past his testimony as the commissioner felt limited by the punishment he could apply to mr. rice because of previous instances where he had instituted a punishment and have been successfully appealed. who were those instances successfully appealed to our mr. vincent you know the cases you are referring to when you outlined at in your testimony. >> the one that comes to mind is the bernie marshall. >> is it the one in south florida with his wife? >> yes, sir and the suspension that was imposed was three games and it was appealed and knocked down to two. >> that suspension suspension was appealed to an infant -- independent arbitrator? >> back to the commissioner. >> the commissioner lowered his own decision? >> actually was appealed.

the pa appealed it and in this particular case they knocked it down to two games. >> based on the branded marshall instance which i recollect was an instance where his wife was arrested by law enforcement authorities in that case because he had been stabbed in the stomach with the end of the bottle or something. my understanding was she was the one that had been arrested in the case although the facts have turned out to be something different. and he is clearly stated she was not at fault but in that case the commissioner's punishment was three games but on appeal from the nflpa in the independent arbitrator lured her to two games. is that the answers i was on his mind when he settle on the suspension? >> i wasn't involved in the ray right situation. >> what is it that the nflpa looks at one and make these appeals? what are the grounds? does the nflpa have a criteria

for things can go too far in punishing a player because they punch their fiancée in the face? >> we don't have criteria. first we have to see what the player wants to do. if a player wants to appeal no matter what our vices we have the duty to do so. we represent him in that appeal and move forward. and the rise case it was no matter of the length of the suspension. it was the arbitrariness of the second suspension. we felt mr. rice was in that double jeopardy situation at that point because there was no new evidence that emerged. so there are different grounds. i hate to say that it's case-by-case. >> i understand the distinction in the rise case and the sense that he had received one suspension and when the video came out and the world saw what the commission commissioner knew they had additional suspension and they punish him twice for the same thing already knew about. my question is moving toward god forbid tomorrow we awaken to a new ray rice case in a player decides to appeal i guess your

argument is at that point the nflpa has the same obligations as a lawyer were to a client to defend them irrespective of what one's personal views may be about their conduct. what we don't have is an established precedent in which we know at some point there is an appropriate suspension that is unavailable. we don't have that set yet. that is what you are working on now. >> that is exactly what we are working on. the commissioner spell that out as august 28 letter. a minimum with aggravating factors allow him to impose more harsh and severe discipline. >> i would just like to say to some of the earlier points we would like that policy to be collectively bargained. one of the senator said we know what happens if a player has marijuana in his system or we know what happens if basically there is a drug policy violation. this is one of the reasons why because there is inconsistency,

because neither one of us can give criteria for what happens next. that is why we believe this policy needs to be collectively bargain. >> i want to belabor the point that there are players who have used performance-enhancing drugs in some instances involving cold medicine without documenting forum a longer sentence than mr. rice. the nfl nature i am more familiar that we been utterly sorry to take away from today's hearing to be clear i think is going to be talked about in the days to come and mr. vincent it's something the league will have to deal with the fact that your statement here today that the commissioner didn't need to see the video because he knew what had happened. i think that's going to be problematic moving forward and many of my colleagues are going to be concerned about that statement as well. some of the perception early on was that i was at this perception that mr. rice had not

been accurate and honest about what he had done but in fact the testimony has been the league fully understood what he had done because there is nothing that we see in that video that he hadn't already told people about and despite that the sentence and punishment that was handed down was so limited. i know that the league admits that the punishment was not strong enough that i do think it's going to be problematic. >> senator let me make sure that i am firm in correct and accurate in what i said. no one needed to see again the commissioner had stated he had not seen the second video. he acknowledged his mistakes and not handing out the proper discipline on the initial round. >> i understand and my point on that is your statement is he didn't need to see the video because he already knew what had happened. >> that's my opinion and that's the general public's opinion i

think. >> appreciate you all being here today. i know it's been a long hearing. the record will be open for two weeks and without the hearing is adjourned. [inaudible conversations] [inaudible conversations]

in a visit to the national institutes of health president obama congratulated the agency on the completion of phase one trials of an ebola vaccine. the white house announced that 35 u.s. hospitals designated ebola treatment centers. the president's remarks are about 25 minutes.

>> ladies and gentlemen the president of the united states. ♪ [applause] >> thank you. thank you so much. [applause] thank you everybody. it is good to be back. thank you. thank you so much. everybody please have a seat. thank you. well to secretary burwell, to francis collins, tony fauci, your teams, to all of you thanks so much for welcoming me here today. it is wonderful to be back to

america's laboratory, even if i don't always understand what you are doing. [laughter] last year i welcomed francis and some of you to the white house to launch our brain initiative to unlock the mysteries of the mind and to pursue new cures for disease. francis promoted me at the time to scientist in chief which made me very proud although i sort of felt guilty that i hadn't studied more chemistry. [laughter] that the work you do here is remarkable and i just got a fascinating tour of your vaccine research center. i have to say i was very impressed with how you can clone a virus gene into a vaccine vector and then subjected to gel electrophoresis. [laughter]

and then type at the samples into a 96 well microplate. [laughter] run it through the world's most advanced multiparameter flow cytometer. [applause] i mean, it was impressive. i've been tinkering around the white house is setting up a similar system. [laughter] we use it for brewing beer. [laughter] but it works well for your work also. now the last time i was here at nih early in my presidency i came to announce a historic boost in funding for biomedical research because part of american leadership, one of the things that has always marked us

as exceptional is their leadership in science and their leadership in research. and here at nih you have always been at the forefront of groundbreaking innovations. you have helped pioneer new treatments for everything from cancer to heart disease disease to hiv/aids and as a consequence you have helped not just americans but people around the world live longer, fuller lives. ..

>> they have volunteered and deployed to west africa and some have nerve for testing for ebola. some members of the u.s. public health service have deployed the care for health care workers who got infected in the line of duty. when nina pham needed treatment, tony and his team stepped up and we're ready. demand shifts around the clock and you displayed great skill

and professionalism and reminded the world that it is possible to treat ebola patients effectively and safely without endangering yourselves or others. and all of that has made an enormous difference. like a lot of americans, i know you fell in love with her comment nina pham, she was so sweet and had a big smile and optimism, a wonderful sense of service. she reminded us of incredible sacrifices that the nurses make everyday. we can never thank them enough. i know that tony thinks her for teaching him how to face time. [laughter] and after she was released ebola free, i was proud to welcome her to the oval office and give her a big hug. she is now in texas recovering and getting stronger. we remember what she told the world when she was released. throughout this ordeal i put my trust in god and my medical team. and we thank everyone on her team at the nih clinical center

who delivered such a workable care to nina. but the point is that the what you have done has continued even as the cameras have gone elsewhere. and the urgency remains because if we are going to actually solve the problem for ourselves, we have to solve it in west africa as well. and one of the great virtues of what you got here at nih is reminding people that science matters and that science works. it's not always going to be immediate. sometimes it's going to be iterative and sometimes they are going to be trials and errors and also all starts and blind alleys. but the basic concept of subjecting hypothesis to test and seeing if they work and being able to document them and replicate them -- the basic concept of science -- and making

judgments on the basis of evidence. that's what's most needed during difficult and challenging moments like the ones that we had this summer and that we continue to have in west africa area last week just in time for thanksgiving the nih and partners give us something new to be thankful for. that was news of the first successful step. the completion of the phase one clinical trials of a potential ebola vaccine. and on my tour just now, doctors nancy sullivan and mario roederer showed me how their teams did it. and i have to say that both nancy and mario really good teachers and very patient with my rudimentary questions, and

the lasers were really cool. [laughter] [applause] no potential ebola vaccine has ever made it this far. so this is exciting news. but it is also a reminder of the importance of government funded research and to keep investing in basic research. [cheers] [applause] [cheers] [applause] because nancy, as she was talking about the steps that have been taken, showed me -- this is the kind of mementos scientist keep -- is there were some numbers on a little chart. [laughter] from back in 1999? in which he had first done some

experiments in trials on the ebola virus. so this is the product not just the blasters work, it is the product of over a decade of inquiry and work. and at the time when nancy was explaining when she first had some breakthroughs in understanding the ebola virus, nobody really gave a hoot. and until you do, that is part of how science works, you make investments and you pursue knowledge for knowledge sake. in part because it turns out that knowledge may turn out useful later and you don't always know when. last weeks news is still just a first step. there are no guarantees. but doctor cliff lane, who is

here with us today, is working with liberian officials to begin large-scale test in that country. and other potential ebola vaccines are also in the works. and over here you are also working on potential treatment for ebola. and as you move ahead on all of these fronts i want you to know that you have your presidents will support and the administration's full support. you are a vital part of our fight against ebola across our government. and today we release an update here in the united states and abroad. because we have stepped this up, we are more prepared for protecting americans and we have a quick more hospitals with protocols and we have conducted outreach and training of hundreds of thousands of health care workers. a few months ago only 13 states could test for ebola, today 36

states contest. previously there were only three facilities capable of treating a ebola patient, including nih. today we are announcing that we now have 35 treatments enter his designed to care for a patient with ebola. this is important progress and we are going to keep at it. throughout we are going to be guided by science. not by speculation and not by fear, not by rumor and not by panic, but by science. now part of what the science of epidemiology and experience has taught us -- and i've said this all along -- is the best way to fight this disease, to protect americans, is to stop it at its source. that is why the united states continues to lead the global response in west africa. some 3000 of our service members and civilians are now on the ground manning that their bridge moving and supplies, building treatment units.

i called some of our troops in west africa on thanksgiving to express gratitude and they were inspiring, the can-do spirit that they displayed. the new medical unit that we built in liberia to treat health workers opened last month and begin discharging patients ebola free, we've ramped up the capacity to train hundreds of new health workers per week. we have improved aerial practices across liberia and we have seen some encouraging news. a decline in infection rates in liberia. meanwhile over the last few months the united states has helped to rally the international community. we have mobilized more than $2 billion in commitments to this fight because this has truly be a global effort. but that money would not be there had it not been for the u.s. leadership. so our strategy is beginning to show results. we are seeing some progress. but the fight is not even close to being over.

as long as this disease continues to rage in west africa, we could continue to see isolated cases here in america. in west africa, this remains the worst ebola epidemic in history by a long shot. and although we've made some progress in liberia, we still have work to do. we are seeing that we have still have a lot of work to do in guinea and it's actually been getting worse in sierra leone despite some good efforts from our british partners. this can still spread to other countries as we have seen in the country of mali. every hotspot is an ember that, if not contained, could become a new fire. so we cannot let our guard down even for a minute. we cannot just fight this epidemic. we have to extinguish it. and so much of the progress that we have made -- and the progress

we still need to make -- depends on funding that is running out. this is an expensive enterprise. that money is running out. we cannot be ebola without more funding. if we want other countries to keep stepping up, we will have to continue to lead the way. that is why i'm calling on congress to approve our emergency funding request to fight this disease before they leave for the holidays. it is a good christmas present to the american people and the world. [applause] [applause] the funding we are asking for is needed to keep strengthening our capacity here at home so that we can respond to any future are ebola cases. the funding allows us to keep making progress in west africa. remember, we have to extinguish the disease.

this is not something that we can just manage with a few cases here and there. we have to stomp it out. the funding is needed to speed up testing and approval of any promising ebola vaccines and treatments, including those here at ebola. and it is needed to help us partner with other countries and to prevent and deal with future outbreaks and threats before they become epidemics. this is something that i want to focus on for just a second. tony and i were fondly reminiscing about sars and h1n1. that is what these guys do for fun. [laughter] and we were lucky with h1n1, that it did not prove to be more

deadly. we cannot say that we are so lucky with ebola because obviously it is having a devastating effect in west africa but it is not airborne in its transmission. and there may and likely will come a time in which we have both an airborne disease that is deadly. and in order for us to deal with that effectively we have to put into place an infrastructure, not just here at home but globally, that allows us to see it quickly, isolated quickly, respond to it quickly. and it also requires us to continue the same path of recent research that is being done here at nih that nancy is a great example of.

so that if and when a new strain of a flu or the spanish flu crops up five years from now, or a decade from now, we have made the investment. and we are further along to be able to catch it. it is a smart investment for us to make. it's not just insurance, it is knowing that down the road were going to continue to have problems like this, particularly in a globalized world. would you move from one side of the world to the other in a day. so this is important now, but it's also important for our future and our children's future and our grandchildren's future. the last few elections the american people have sent washington a pretty clear message to find areas where you agree, don't let the areas where

you disagree shut things down, work together and get the job done. i cannot think of a better example of an area in which we should all agree then passing this emergency funding to fight ebola and to set up some of the public health infrastructure that we need to deal with potential outbreaks in the future. how do you argue with that? that is not a partisan issue. that is a basic, commonsense issue that all americans can agree upon. now i have to say that i have been very encouraged so far by the bipartisan support in our various visits with members of congress. for the most part, people have recognized that this is not a democratic issue or a republican issue. it is about the safety and security of the american people. so let's get it done. this can get caught up in normal

politics and we need to protect the american people and we need to show the world how america leads. i have to tell you that i traveled to asia and we had the g20 summit. if america had not led and if i had not been able to go to cbc and make a major announcement about the commitments we were going to make, to be able to go to the united nations and basically call on other countries to step up and know that we were following through with our own commitment, had we not done that, the world would not have responded in the same way. american leadership matters every time. we set the tone and we set the agenda. now enclosing, i want to leave you with a story that speaks to what we have to do. nancy writebol is from charlotte, north carolina. she's a mother and grandmother,

wife and also a christian missionary. along with her husband she went to liberia. she was doing god's work, caring for ebola patients. it's hard to imagine a greater expression of the christian ethic. and she was then infected herself. so she was brought back to emory in atlanta and she received excellent care. she was released in august and she is ebola-free and continues to recover. she said this about how people treat her even today. you have some people that just totally wrap their arms around you and shake her hand. and then you have other people that stand 10 feet away. some people wrap their arms around you. some people stand 10 feet away. this disease is not just a test of our health systems, but it is a test of our character as a

nation. it asks us who we are as americans. when we see a problem in the world -- like thousands of people dying from disease that we know how to fight -- we stand 10 feet away or 100,000 miles away? were do we lead and deploy and go get help? and i know what kind of character i want to see in america. and i know the kind of character that's displayed by the people here at the nih and some of the colleagues that are deployed right now in liberia. that's who we are. we don't give into tears. we are guided by our hopes and we are guided by reason. and we are guided by our faith, and we are guided by our confidence that we can ease suffering and make a difference.

and we imagine new treatments and cures and we discover and we invent and we innovate. we test and we unlock new possibilities. when we save a life, and we help a person heal, we go up to them and we open our arms and we wrap our arms around him with understanding and love and compassion and reason. and that is what you do here at nih. that is who we are as americans and who we will always be. thank you very much, and god bless the united states of america. ♪ ♪ ♪ ♪

♪ ♪ ♪ ♪ ♪ ♪ ♪ ♪ ♪ ♪ >> on the next "washington journal", kevin brady of texas,

on the government funding deadline and efforts to pass tax expansion before the end of the year. then we have senator ben cardin discussing the president's immigration plan and efforts to stop racial profiling following ferguson. and your calls and comments are live every morning on "washington journal" at 7:00 a.m. eastern on c-span. you can also join the conversation on facebook and twitter. >> c-span cities to travel to cities around the country in our cities tour. we visit with waco, texas this week herriot. >> as you can see, it's vital to be digitized. and we begin with what we have received. gospel music was not widely

heard in the communities. but the flipside would be when they discovered quickly was how little of the b-side records were related to the civil rights movement. we didn't know the sheer number of songs like there aren't no segregation in heaven type songs. and there are dangerous things. singing that kind of song out loud as a risk. >> it honors 30 rangers that are major contributions that gave their lives under a road circumstances and we have painted individual portraits

with all of these individuals. austin was very successful and they fought not only to manage to make the area reasonably safe from indian raids but the texas war for independence also broke out in the rangers played a major role in texas getting the independence with him long enough to allow the colonists to build their own army and develop a strategy. as a result, texas became an independent nation for about 10 years. >> watch all of our events from waco, texas, saturday at noon on booktv and sunday afternoon at 2:00 p.m. on american history tv on c-span3. >> health care analyst discuss how information from medicare and medicaid can have a use in further research and how to

address the privacy concerns of patients. from the brookings institution, this is two hours 15 minutes. [inaudible conversations] >> okay, we are going to get started. i know that folks will probably be trickling in. my name is kavita patel, one of the managing directors here in the engelbert center for health care reform and we are glad all of you to join us today. we have a packed agenda, so i'm going to keep things short and simple. we have folks in the room as well as those that are a number of people watching the webcast. because we are recording this event i want to make sure that we have a couple of items, just so you know, that we will have a full recording on our website on the event page on the website in the coming days. and if you do have any questions or comments in the room or on the website, go ahead and actually wait until we have an

open floor for questions and answers and hold it until we have a session and since we are using the web and tv monitoring, we will ask everyone to use a microphone and we will have this available during the q&a. we also have the ability to submit questions via twitter map. the hash tag is #health data. and if you are online, you can immediately download a couple of resources that i wanted to point you to. once i have finished this housekeeping, we will get to why we are to all all here today. but the two items that we have that are also available in the room are first issue briefs that are also on the commonwealth website as well and also

something that i want to thank kaitlyn for who helps with this effort. as we talk to so many of you, we learned that there were many tools around their with transparency that even to us to that daily basis and we get these nonexhaustive resource lists. we would love to be back on this and we would encourage you to go back through the website or through the twitter feed so that we can get the real world take on how valuable some of the resources are. but those are also available through the website. and i will be moderating the first panel and we will do a little intro and stage setting at that time. i wanted to one of the vice presidents of the commonwealth to give us information.

this wouldn't have been possible without the support and the delivery system has been instrumental as we get this passed today into what i hope is health care of the future. we will have questions and comments and then we will start. a few. >> thank you. on behalf of the fun, i would like to thank everybody for showing up here and everyone was watching online. it is have a couple of thoughts to kind of set the stage about this. we have talked about transparency and lately i find myself asking the question as to what that really means. and back when we first started talking about transparency it really caught on in washington and among policymakers and i got this issue that we were really talking about putting the proverbial black inside this box

and calling it transparency and nobody could really figure out what was going on and we could just see the outside of this working. so what do we mean by real transparency? i think the folks here today will help address that and it's great to have a lot of data. below we really want is information. so that means that we need to have data at the right time and we need to have in the right context and it needs to be provided to the folks who can use it the way that they need to use it effectively. we are talking about consumers and also about researchers and of course payers and policymakers. i am hopeful that the topics that we are addressing in the panels today will begin to give us insight as to how we can use

all of this data available and put it to good use to make her policy and make better decisions post boasting what we produce in the health care system and what we consume and how we consume it. and so i won't hold of the show any longer. but thank you again and i look forward to a discussion. >> let's go ahead and get to our first panel, if i could have chuck and charlie come up so that we can put a microphone on you. and we can kind of go in order to rid okay, that way you guys can work this out. [inaudible conversations]

[inaudible conversations] >> for the sake of getting this started, let's get the introductions going, for me all the way to next to me. all the way to your left. so we have charlie, and last but not latest, doctor charles cutler from the american college of physicians. we have all the individuals and

biographies online. so i don't want to do anything except to say that the goal of the panel was to offer perspectives from exactly what started a lot of this with the beta release. it came out earlier this year in 2014 and that was actually the motivation of what myself as a physician who is actually part of this really wanted to explore and understand what does this mean for a patient. i will just tell you that we are going to get into some deeper discussion on this topic and it hit home not only from when i looked myself up online, but also more importantly patient care i had a 61-year-old woman who came in after she got was a cracked rib, and she had a small problem and she said i cracked a rib, it's unusual, long story

short, over $40 and it turned out that she had lung cancer and it's not clear how it started or if it was part of this, but she said were the best opportunity to see. and i pointed her to some of charlie's resources and how much of american medicine is not transparent and i said that i would tell her about this and i said i'd talk to friends of a doctor. so when important decisions get made, we put together a lot of the resources and you a lot of us would tell you that we can do better. some going to leave it at that and hopefully through each of our expert panelists as well as your own discussion we can get into this a little bit more and probe how what we started, and i think that we can speak a little bit more as to what the

administration did, what we started was really just the beginning. so ask you first kind of give us a little bit of a background on what has been done and then also what you hope the future can hold two good today to transparency. >> that is right, it's great to be here. especially since i am an alum here. [laughter] >> you've come a long way. [laughter] >> i think how you have to view the various data releases and exercises is that it's been an ever evolving journey going back to 2010 and 2011 and one of the first things that the president did entering office was to sign an executive order of open government and that includes the cto of hhs who includes the

excess enthusiastically acceptance of this and worked with us to identify a range of available data that was already already been released and maybe not having the attention for the publicity that it deserved, or that could easily be released in a machine-readable or mad. and i think those first couple of years were an interesting process because the commitment to transparency was definitely there. but some of the resulting things were good it was the lot of these data dossiers, variation data, on the city and county level. that's not all to diminish these data releases.

and we have that kind of ways the book open. same when you decompose this at the county levels, this is what it looks like from this actually helped people with readmission rates and i think that and where it started to get interesting and we were trying to figure out where we could move next and the decision was made to release the data and some folks may remember the release of that data than it was for 3000 hospitals and other

dod's, it highlighted massive charges for the same procedure and oftentimes in the same geographic area and certainly nationally. so i think that it really resonated with people and i think frankly more than what we thought that it would and i know that we had certain economists talk about this when it happened. and they say that nobody pays charges anymore, but to a certain extent this is often what people are initially exposed to, particularly if you're not insured or well insured. so to a certain extent it was a was a pillar at step. but the reactions were surprising and it took a lot of people who have been looking at health data and talking about this took a little bit of a surprise as well. and obviously with the release

of the hospital data there was a desire to keep building on this hole after. but the issue is releasing physician data is that we were legally prohibited from releasing any data that would allow anybody to identify the total amount of the physicians medicare reimbursement and that was something that stems back to the 1970s and it is known as the junction. until about a little over a year ago a florida judge ruled were overturned that injunction or the aspects of that injunction that allowed us from a policy perspective to begin considering the release of that data. so we tried to do it in as

transparent a way as possible. we asked for public comment, we took all the comment on board and then finally in april i think bad the open data entered the big database with the release of details of information on almost 900,000 providers over 9 million records. and so that is the story how we got from there to here and it's been a very interesting journey. we have shown a commitment over the past two years. and obviously as a bureaucrat i can get into the specifics of what is coming next. but i would say look at the track record and i think it's unlikely that we would and continue. >> before we move over to charlie just to be clear, this

is not just an injunction but there has been discussions prior to time an administration about whether this data should be released at all. so this is not just a couple of years in the making, it sounds like it has been decades. >> that's right. >> a real accomplishment in your new title is chief data officer is a little bit of a nod to the nation saying that more work needs to be done. and it is part of that -- are you increasing capacity within the cms to kind of explored the use of not just these data sets but the transparent who thinks as well and that includes the data for internal and external users.

and this includes innovative ways to access or control. >> all the comments and feedback we received and this includes catalyzing on what you have been doing and that includes the public and private sector opportunities and i wanted to first say that before we even talk about this, all of us in the room would agree that one of the best in at least trying to offer a way forward but it's

easy to have contacts and we have your website and i know you're going to go through some of this, but as an investigator and journalist, i would put you in the category is a as a researcher as well because some of the analysis is part of the public data set. it would be great to hear your perspective and some of the limitations what we have seen to date is also part of this. and i know that you are working hard to lead the effort on future transparency releases. so thank you. >> thank you. yes, i think that one of the unfortunate things is the more that comes out of there, the more data that you want out there, so they open up this and it's one of the challenges here.

but i would argue that it's more than just patients that want access to this information because i have talked to physicians on the country and one of the things i have been surprised about is how they prescribe jobs and it compares to others. they are benchmarking by word-of-mouth. but it actually comes to how there have been no tools that have been really available. and then they get one report card that does this and another thing they are doing poorly and another that says they are in the middle. and they believe what they believe about it. so i thought it would be helpful to show sort of the real importance of putting a caviar comparison to things. i think putting this out can be very misleading and confusing that's one of the pushback on the data releases that a lot of organizations sort of regurgitate what they put out, which i think is unfortunate.

so even what before they put out their data on the fee-for-service, they thought what it comes to prescribing drugs doctors are catalysts than and they are not paid for what they prescribe. until after a lengthy negotiation and it includes how doctors prescribed in medicare part b, which is the prescription drug program and it looks something like this. and so why if you are a patient

would you want access to information about what you are to prescribe? first of all and that includes and so too, with the doctor's relationships with patients, having access to whether they are prescribing more of a particular drug, buy the companies or he or she and who they are getting it from, that could be helpful as well. we created a tool that a lot of folks were allowed to access this and they think it is important. we don't assume that you know how someone wants to access this data. give them the tools to do it. and that includes the top prescriber's estate and specialty and you can look at it

through any of these portals to get through the results that show you the top prescriber's within a state or just your doctor to prescribe it. but instead of just releasing when you click on this to see all the darker your doctor prescribes, we also have the dashboard which shows how similar or dissimilar your doctor into other doctors and why do we choose this and that includes my folks that here go through it, we show you of the percentage of those that get our products. whether it is a family physician that is a lower percentage base than we also have the mathematical formula that takes into account the doctor's selection of drugs and the

volume of drugs that they prescribe, putting them on a line where you can see that if the doctors on the far right, sometimes they have in a very different way that other doctors are practicing. finally you can see a list of what ranks for that doctor, their number one drug, how the ranks for other doctors in the same specialty and state. so you are able to compare the doctors. one of the things we did with the medicare part b data that came out this year and the fee-for-service, is a long list of each of the procedures in what doctors made an id. the media took this and wrote about millionaires and how much people got from medicare. that was pretty unfair because some are spending a lot on purchasing the drugs when they are using them again, is it fair to say that they are millionaires? welcome well, not necessarily. if they took a lot of patience, is a peer to put them head to head? so we did was create a treatment tracker, we compared this with

people and their same specialty and state. so you can see the number of services per patient and how it compares. consider the doctors in the top 10% are part of this. so we are able to see a real ally or and we not only gave raw numbers but justice number is the amount paid for service and patience. so you are able to get this leveled out based on volume of services. and then finally you are able to see the number of times the doctors do things for patient, how that ranked per doctor and there are definitely a liar is. what we have from this is right now with the information that they are finding those that have questionable practices and to

find those whose practices we want to emulate because there's too many variables that we don't know for now and that is sort of the next age with what we want. right now we have what doctors perform in their office and if they give a referral down the hall, they may be incurring a lot of medical costs and the patient may incur a lot of services, but you might not see that on the profile. we think the next level of information is information that of things that they are a referral for. whether it's lab worker others and they are able to look at the totality in terms of health care services in this includes comparing it to others like him and we're taking advantages of those things that have been part of the system for the last couple of years. ultimately we want to engage people with health care decisions and also the doctors are able to benchmark themselves even before a patient asked them how they compare.

>> do you have a sense given all the work that you have done today and the conversations you have had, you started by saying that they are not the only audience. who are some of the other people who are really interested in what you have done and kind of your database right now? >> i think hospitals are, insurers are, i think we have heard from folks who think that our interface is a lot easier to use. so i think that it defined a lot of folks. and we build products that are more than just things as was to be dry byproducts that you get the first 48 hours of the date of release. we want people to go from our page about prescribing this, it's sort of like very easy to

navigate around and is more information comes out, that's going to be key so that people can and it's exciting to be a part of that because so many audiences are interested. >> since we started this work on the data, they kind of have the open payment database that has been released. and you already saw the technical problems of trying to do the analyses that you have done already on other databases with that particular one, raising a common logistical problem for regular folks to access the data. >> that is right because just because released doesn't necessarily mean that it has to be accurate. in the case of this, they are relying upon the drug and device

company to get it right in terms of what they are cementing with the government, but what we found is that there are situations that are spelling the name of their drug strong and they were listing them in multiple columns, they would list them as devices and devices that drugs. so we spent months trying to sort this out. and this includes spending the time to get it right. >> okay, next we have charles cuter who is a practicing internist that has leadership experience from the physicians. this had come in before you go, we actually looked with dozens of letters that were sent to the finance committee chairman and

this includes any kind of data transparency and he was looking at this for a number of reasons and i think they are detailed thoughtful letters and transparency is good, we know that. there's a huge caveat around in regards to how this is interpreted by the public and it's something that many talk about, and it's been something that we have been threatened by. i'm going to speak to that because i have a number of conversations with the newspaper and radio and other media headlines that went live around the outliers is a kind of reported this and trying to understand these individual

people are and they made a lot of physicians really nervous about how people could use their own kind of charge within these publicly available data sets. and i think it raised an important conversation among the community where everybody was quietly curious as well as cautiously optimistic that this was the right direction. and this is someone that is leading the international level as well. >> for the audience, the american college of physicians and this includes internist and medical specialists and students. and that includes speaking with the chair of the board since last year. in a position i was able to

travel around the country and talk to hundreds if not thousands of doctors. might the job is a general internist and in the morning i go to the hospital and see patients. i can share with you if you took some of my colleagues and put them in a room and said talk about the data released for 10 minutes. you might have nine minutes of silent. and there are a number of medical issues from electronic health records in the affordable care act and data reporting from cns on all of the printers. budgetary concerns than whether or not they will pay the bills with the doctors, i think that it has a much higher priority. having said that, the data is really important in this conversation is really important. the example that you use is

perfect. with every patient that i see as a physician, i have to make recommendations on how to help the patient who to the next step in mib antibiotics and it might be in x-rated or it a procedure. for my entire career i have not been able to help people in the area of cost. but if their art to antibiotics which is the most cost to antibiotics to use and you can use that example across every recommendation that position makes. so we have begun to change that conversation that doctors might have been a 10 minute time frame and there could be 15 minutes of conversation and a 10 minute

time frame because it's so important for doctors to know what things cost. the other part of that, and you have begun to touch on is that you the outcomes because we can't simply make recommendations as a physician simply based upon cost because the costs could be high but the outcome could be even better than a low-cost procedure. and so the outcome is really important and the comparisons really need to be adjusted. if you are a doctor and you alluded to this, your costs may be very high but your outcomes could be very good. so we are in the infancy here and this is great news for the

profession and i think for the american college of physicians we are encouraged by the date of release and encouraged by making the data more useful to patients and physicians and i think that is part of it. >> there were some people who expressed concern, as i imagine many sides of this issue could be. can you left on what the concerns have been about how what has been released to date reign. >> i think it was touched on earlier that this is really important in there used to be a lot of information and it really has to be accurate information. and in the sense of fairness they should have access to the data and there should be a way

for physicians to address what they perceive as inaccurate. is really important and we have to be able to access it in easy fashion. the doctors have to be able to get to it and the patients have to be able to get to it. and it's complicated to access information and it can be a part of the utility including how this can be really important. one of the other things that we have and we have expect -- expected at her, one of the dvd said that releasing this to be a way to address ways in fraud and abuse. and we can argue about it. simply because costs are high. we have to be careful not to

attribute the data somehow fraudulent or the utilizer that is leasing services. he or she may be, but simply by having high cost we have to be careful that there is not guilt by association and those are some of the things we were concerned about. >> okay, great. if anyone in the room has any questions, raise your hand so we can get a microphone to you and then before we get a microphone to you, we want to ask of anyone on the panel and if niles can kind of response, as you mentioned you can't talk about future data or actions that might take place in the future. but when you give us a little bit about it. >> sure. personal i think that we were

both excellent and it added a a lot of important context and in the sense of, you know, we are entering this and this includes if people choose to prevent it. we have many chains and hospital systems undertaking to be more than this includes the

availability and we can believe that we have a health care costs instituted, which is a conglomeration of her large health plans and announce the large transparency initiatives that are going to kick off next year or they are going to look at the data that they have assembled from multiple different health plans and i don't know what the output would be exactly like what we did, but certainly someone along those lines based on everything else that i have talked about. i do think that our actions have trickled down. >> it bears repeating that commercial payers by and large are looking at the quality parameters in the process of

reporting is not taking into consideration the cost. and it's really not high-value care. and i think that the next generation of reports and so this includes good outcomes at a high value. >> a lot of the health plans are looking at the metrics. but if you are a patient you care about your metric. >> so tight, i'm not a smoker, so it doesn't matter to me. do what you want to know, i know somebody who's about to have

heart valve surgery and they want to know which doctor inner-city performs the most heart valve surgery and how many patients are alive the year after that. the fact that we cannot answer that for that patient today or tomorrow or next year, that is the question that we want to answer. and it is the other diabetic and it is under control. we have to make sure that the data releases can be customizable so that person interested in their situation can be part of this. >> at the same time patients are complaining about deductibles and we spend billions of dollars per year in unnecessary care for marginally useful care. this conversation in this beta release is closer but away from

spending all of those extra dollars that we don't need to spend. and so i think that it does come back to haunt the individual patient. if your co-pay goes up, your deductible and cost of insurance is going up, the reason is for spending too much money and how can you provide high-quality care. >> we have a question here and tell us your name where you are from [inaudible] >> with our system, it is great. we have to talk about how we deal with this. [inaudible]

[inaudible] and and that includes the individuals -- [inaudible] [inaudible] [inaudible] [inaudible] [inaudible] [inaudible]

[inaudible] for you to come get a patient's conditions [inaudible] [inaudible] so they can perform the procedure [inaudible] >> i may try to wrap this up. [inaudible] [talking over each other] >> misdiagnoses and all the various reporting [inaudible] >> i understand -- [inaudible]

>> this touches on a couple of things that i think that some of our other panelists might talk about. and i think that over starts with the physicians and charlie touched about wanting to know about the next wave of data that can be important to triangulate. what we are talking about is getting a better picture picture on the complexity of health care services. do any of you have comments, we talked about hospitals and physicians and we talked about drugs and devices and other pieces of this puzzle that are much more complicated. >> some of the endpoints that involve payments can be measured. so when you're talking about physician services and medicare, we are talking about these or at a pharmacy and maybe it's not

just them, they are being paid for when you talk about a referral and are two different claims that are being made. but if you're talking about quality, ensure that the quality of electronic medical records we've so much to be desired that when you're trying to adjust for things like that we are a long way away. you can it's also rather upsetting, obviously hospitals and physicians officers and thinking about your settings and the complexity of all of this can be so overwhelming that we say why bother releasing anything because we can't do all of it. but it seems like the hospital data which you talked about and then thinking about this because of the florida case. and i know other we also have some of these other services. are there other transitional

care settings that we would really like to have better transparency around it would be important reign. >> well, let me talk about the commonwealth publication on this. and now would be the time to look at it. [laughter] >> but i think it really addresses this there are a couple of things that need to be stressed. the physician data has to be integrated with the hospital data and pharmacy data to look at any of this data in an isolated way, in a way that it addresses some of what they are bringing up. and it just doesn't give you the right signature. you have to put it all together. comparisons are really difficult. but as of commonwealth publication pointed out, until

we get into the real detail about the outcomes and status and demographics, we will never be able to make good comparisons are you so hopefully one day we can get there and we are moving in that direction right now okay, passing very quickly 10 seconds, 15 seconds, what have you learned from it, something to give our audience in the room as well as something that can surprise you and i will just go ahead and kick it off and the thing that did surprise me is what charlie touched upon is that this is more important not to my patients but that we had more colleagues and health insurance plan colleagues saying that this is exciting and interesting we would like to get into that.

and so something that surprised you from this process. >> i am a geek, i like to look at patterns generally. i think that in this is looking at how different services were concentrated or not concentrated, i think that includes how few cpt codes that many physicians build. so i talked about how that worked and it's light, easy, 50 or 60 per year or maybe more. and there is a significant chunk they are billing sometimes even less. and so they are specialists.

so that was the biggest surprise to me. >> okay. >> i have grown up as a health order learning about differences between different regions and i think what i learned is just how much variation we have and how you can go one street over and the quality of doctors and services they use are so vastly different in that it really makes a difference to look up an individual doctor. >> i looked up my data and i see that they are getting paid more. [laughter] >> exactly. [laughter] sumac i think you have it right. the it was really hard for me

despite all that experience to make any sense of it. and i began to imagine how did they figure out what is going on here. >> is a perfect segue to some of our future conversation. please join me in thanking our panel. and we will have you all and the second panel coming to the stage. [inaudible conversations] >> i'm going to have doctor paul ginsburg from health policy and economics, who also has an extensive background come as well as the number of of publications related to research in this area.

[inaudible conversations] and we can up all right here. and paul is going to be leaving the discussion on perspectives from researchers and policymakers and payers and we keyed up a number of these issues in our first session. so i think we will have a robust one as we continue. [inaudible conversations]

>> thank you. i think we can start now. and i'm really pleased to be moderating with the panel. and it's setting the tone that this is about transparency and it's been a long term interest of mine and i've always believed that some of the confusion of the transparency comes from the fact that we talk about transparency because we believe other institutions have operations that ought to be more transparent. we also talk about the transparency in terms of it being useful to different types of entities. we first think of patients as consumerism and we've been further about physicians and hospitals and health plans and researchers and policymakers.

this panel is about what the three different audiences can do with this type of information. so we will begin with jason, who is a very distinguished researcher talking about what this means for researcher and then we will hear from paul ginsburg is, talking about this release and what other data can mean for health plans and employees and their clients, and then we will hear from bruce with a policy background and what they can learn from this information that will help them in their work of making policies down the road. there are two continents to think about. one is that we are going to talk

concretely about the april data release described to us. but we will not dwell so much on what was the release but to talk about what could be in future releases whereas these panelists can talk about what they would like to see in the next few weeks to make it more useful. the other context is that these releases are not the only thing. we can go through the process of paying a lot of money and taking a lot of time to negotiate an agreement and get some of the data behind the release. we can either work with a qualified entity and also

another channel and i'm going to stop my talking. >> thank you. that would be speaking with you all today. in the first question i want to get into is whether this is a big deal. so dan, i'm coming up from the perspective of researcher and when this data came out we had a couple of conversations and we are kind of talking about what we can use this for, what we can look at, gradually be figured out that there isn't really much new that we can do with researchers with the data. any research questions we don't want to get into, we really want to have a detailed microlevel than what we do all the time. so that means that this release is not a good deal, not at all, i think that this is really a

step forward and i think that the release of this data has laid it out. the cms has a bed physicians right to privacy does not outweigh the right is the public to know what medicare is running in what medicare is buying. there was an injunction for decades that prevented them from reporting what individuals were being paid by medicare and by releasing this data, they have said that that's a balance between the rights of privacy in the right to know what is going on in the medicare program and it's now officially tipped in the direction of what is the public right to know in the medicare programs. as is the other thing that is important about this would be they lay down a marker and said

that we can release data in the cpt codes without running afoul of hip. and if we do research, that is a barrier reef that you have to learn how to navigate and others can follow it now. so that is the first important thing in the second is that these data by themselves is that they are useful as cms releases more of this over time and we will start to see trends that we have this data we can combine it with the hospital level data for specific regions and get a fuller picture of what is going on. so as other data sources become available i do i'm physicians and other providers, we can

combine this with the other level data. so conceivably at some point private sector health plans will begin to release data if those are released in the data format that the cms is leasing and then you have a fuller picture what is going on in the health care sector. the other last point i would make is that this data release is a small step in the direct of building the data infrastructure to understand where we are and what is going on in the world to help us make better policy choices as a society. so i think that one thing that we forget is that the data infrastructure has been built through conscious and sustained efforts and concepts like gross domestic product that we take for granted and we track how it's going up and down over

time. the concept was defined and the tools have been honed over a decade and we devote significant resources to tracking that inadequacies of businesses, government, and so on, it's a collective data resource that has been built through after it and i think the cms data lays as part of that valuable effort. in terms of where we're going next and what we would be interested to see if the private sector is kind of the blackbox and medicare is trying to weigh all of the cards on the table. but in terms of prices in the private sector, it's more challenging to get a handle on that and to the extent that we can get the private sector data releases that are structured in

the same format, then we can start to compare prices and practice patterns in identifying both of those sectors. to me, that would be the most fruitful and also probably the most difficult. and i will leave it at that. >> thank you. one question for you is many researchers have talked about this. can you talk about how that process can be streamlined and made more efficient and aspect of the transparency initiative? >> the data can be made cheaper and we pay taxes for a reason, so the federal government can provide services that shouldn't have a higher marginal price attached. this is one of the things i

think should be made freely available even though it takes a lot of resources to produce that data. once you make one copy of the medicare claims data file, it is possible that they could generate a thousand copies of that digitally. and so the turnaround time could also be produced in this way. that is a significant problem. so you have to set aside all the privacy constraints and i think that it is a barrier as well. >> thank you to everyone for posting this. we appreciate you for sponsoring this. ..

useful in understanding some of the factors in that variation. frankly, it is so obvious. just useful in bringing transparency around what things cost, the basic information there.

i think claims data provide what i call a coarse, gray in view of clinical phenomenon. useful for some things, not so useful for other things. but it has some useful dimensions around volume. i am not in practice anymore, but i looked up some of my friends to see what there practice patterns look like, particularly interesting from those you would expect a great deal of information. so i think that it is important. it will evolve over time and can provide some useful insights in its current somewhat limited form. the issues and limitations? probably the most fundamental one is that health plans have learned over the years that looking at rock claims data is more an exercise in hypothesis generation that it is in making a determination about much of anything.

you can just look at our raw data table and say, a half. there is an outlier. let's do something. it is really more a hypothesis that you have to triangulate around, look at multiple data sources, trends over time and then have a further exploration, particularly involving a conversation with that physician. you might find an outlier that statistically is an outlier but are actually a referral practice and have unique services. so i think that hypothesis generation is the way we should think about the use of rock claims data. the second thing, a a lot can be done with claims data , but it requires analysis. it is it is not just putting

the raw data out there. starting with some simple analysis, simple descriptive statistics can be useful. a percentile rankings, standard deviations. and then there then there are even more sophisticated uses of claims data through the use of technologies and the ability to do case mix and risk adjustments. there is quite a bit that can be done with claims data even though some of its limitations command i think it is an interesting policy question about how much the sponsor does, in this case having a raw data file, and and having third parties do that kind of analysis. and i think in terms of physicians are any stakeholder, probably the most important attribute is the ability to make comparisons. to do that, you have to have

credible data. physicians want to compare themselves naturally against other physicians. that would be logical and is something that health plans of land. land. that relates to my third suggestion or limitation. what what we have learned over the years is particularly when releasing data around physicians who is a good idea to run what i would call a service bureau function, the ability to serve the stakeholders and in the physician, in the case of physicians to answer questions about the data, to look at it and corrected. physicians are physicians are very data hungry, interested in data. but they want the ability to do what is called drill downs, to drill into the data. all of this is what i would call a service bureau function.

the kinds of things that united healthcare has done, a physician portal. okay got physicians in our network. an important suggestion of how to enhance things going forward. lastly, let me make a few suggestions for i think this could go from here. i have said some of these already. first is to clean up the data and offer some simple descriptive tips for all the stakeholders. i think that is a reasonable thing for a sponsor to do. second, i agree with your. the ability to combine data and data sources and data sets to get an important view