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, in this particular

case is quite a limitation that you can't get the full picture of what the physician is doing. in doing. in the commercial, private sector we might find a physician expending a great deal of resources in the office, but if you look at total cost of care they are actually quite efficient. the reason is, you reason is, you won't see that without the ability to integrate a combined data source. the healthcare cost, that is why we thought it was so important to contribute data as a multiplayer effort to bring transparency to the private sector market. and that is an interesting example and a couple of levels. levels. it originally started as an effort to be a tracker and private sector cost trend data and utilization data. as was mentioned, once they got together in pairs started putting the data and they said, we could actually use this for transparency

purposes, start to look at quality data. as some of you may know, that is an effort that has been announced and will be deployed. to sum up to five and the other thing, a medicare qualified entity. that's a good example. so to so to sum up, i think, a lot of opportunity. this is the beginning of a knew era's. transparency is the coin of the realm. the current release has been useful in some respects and limited in others, but others, but i think it we will evolve and strengthen overtime. >> just one point you made that got me thinking. thinking. you were talking about one of the steps forward is to go from raw unanalyzed data to various levels of

analyzed data. data. at the same time this is evolving we are on track to have physician value modifiers which we will be presumably fairly analyze data. i don't know what the transparency plans are, but any thoughts about these two different tracks? >> again, whenever there are multiple initiatives going on it is always an interesting challenge for any organization to sink them up. and i think that is why it is a great opportunity to have a broader view of all of the data resources. but in general the idea of moving probably the most most important thing, moving fairly rapidly beyond just our rock claims release into analyze data that is

consistent in its direction. the metrics might be slightly different, but as long as they are sort of this is the domain, most people view of best practice has not just a release cost data without quality data, to combine those. any user can look at a picture that integrates both quality information with cost data. >> my job, thank you, is to take a broader policy perspective and with some particular attention to the us congress and now they might benefit from this data release and subsequent data release command i i would like to start as well by keying off of steve's analogy of the black box, it is easy for policy analysts to value transparency because we are the lookers.

we want to see more,, but it is the wookies, the residents of that black box who, i think, need to accept and even embrace the concept of transparency if we're ever going to really achieve it. physicians and other providers need to get used to the idea of having their performance evaluated. as was suggested, their willingness to do that is partially dependent upon how accurate and useful the data are that are being released and how they we will be utilized overtime. you asked for some suggestions of what we would like to see. i actually have have some predictions about what we will see. not been able to say that they we will release more data. i will predict that they we will. in fact, i am going to predict that cms and its contractors will correct a number of the errors it's that other organizations are

pointed out, missing data, core specialty designations. i think providers may well contribute. i think they have an incentive knowing that information will be individually available to a wide range of lookers, they have an incentive not to make sure that there specialty is accurately recorded, an incentive to match up the national physician identifiers with the billing codes. and i hope we we will have more kinds of providers available for analysis in the future. most importantly, as soon as soon as we get that second data release we have the beginning's. every economist. i will give you an example of how that could be useful. the government accountability office took 2,005 and 2,006 data,

attempted to identify beneficiaries who are high utilizes of services given their health. it's not perfect, but we were able to identify a group of beneficiaries. and and then we examined those same beneficiaries in a subsequent year. did did they remain being high utilizes? had a tendency. it's we then raise the same beneficiaries and identify the doctors as high utilizes given their mix of patients, health patients, health status. and then we looked at the doctors the following year. they were twice as likely to remain high utilizes. i would be glad to give you a reference.

i can't go into the details. only certain specialties, but, but it is the kind of thing that one can do with timeseries data that you can do with the cross-section. supervising the preparation of roughly 50 test buddies. anyone care to guess? by the way, if you ask the same question you get the same answer. so i look i look at these news organizations, reports and analyses of the data that cms released as another potentially important source

of information. maybe there were mistakes being made, but it is especially useful when you consider that congress obtains much of its information from companies and organizations, organizations, many of them are constituents that have a vested interest. i remind you, of the five top lobbyists and spending, four of them are healthcare. to have another information source with a different incentive for producing information is useful. does news organizations are complements to, not substitutes to the kind of research at congressional support agencies do. other organizations, these are complements, not substitutes.

because these news organizations will produce information to the congress and give them ideas on what could be investigated a greater depth than might be of some benefit to the congressional support agencies, to be asked questions that were raised by these news organizations to be investigated in greater depth. so my bottom line, not only a good thing but a a necessary thing that we will produce more meaningful information. we all believe that transparency is an interval part of reform, and i look forward to the day were in database is not just cms production on medicare. but medicare the entire story is utilization.

a huge amount of variation. so not only would you have the advantage of being able to combine across different payers to get a fuller picture to get the private sector data into that makes, , a lot more opportunity to investigate meaningful differences. >> very interesting about how some of the media think it was based on this release that made its way through members of congress and staff and likely shaped what they were asking congressional support agencies to look at or % congressional support agencies to look at or even talking about policy wise, legislative wise. do you have some sense of that interesting direction that this release has spawned? >> was that the only interesting thing i said? i don't really know.

this comes under the heading of hope. the publication from members of congress picked up a a number of these stories and reproduce them in their own media. i can't cite a specific instance of where an issue was suggested to a member who then requested some work >> maybe in the clinch of conversation. probably a good time to turn to the audience. >> way for a microphone. >> i don't think.

i was wondering what you he would think of that. one of the few services. his ability. do you think we should change? >> presumably not a medicare issue. very limited constrained by what they can charge. of course of course those prices are coming. it's more of a question. >> that question reflects the desire to have greater and greater transparency. two things. there is is no national requirement, at

least in massachusetts there is new law that requires exactly what you suggest, the posting of crisis. that will be an interesting experiment. there may be other states. i think the the other thing is from the consumer.of view,, and we will here from the consumer panel after us and what consumers want to know is, what consumers want to know is not what the provider charges so much as what i have to pay which then relates to what is the charge in relationship to the benefit package that i have, the network that i have, what does it mean to me. >> and care. >> exactly. if i am choosing option a versus b. the care pathway we will have multiple services in it that information is increasingly becoming available.

>> gentleman. >> thank you. >> the data that is being released, primarily a question of consolidation? is it primarily hipper, some combination? >> if you go through the process of entering into a data use agreement and guarantee that you satisfy all of the data security safeguards they will send you claims data that has beneficiary id, all of the age six, as it could, the beneficiary of the micro level services. the public

release only reports combinations of physicians and cpt codes with 11 or more services provided. obviously you can see all the services. a major hurdle to set up data security systems that are impenetrable and hipper compliant. >> and also provide the opportunity to pull together various services from different providers that beneficiaries had. >> and you have to promise not to release anything. >> a question back their. >> with the genie is not out of the bottle from your perspective what would be best next? >> paul ginsberg actually mentioned the physician value -based payment modifier. how many people no what i'm

talking about? so if i had a wish list it would be that the raw data and the final output modifier calculations be made available at the physician level. i i don't know if that's realistic. that would be taking this raw data dump and doing the analysis that a lot of the other presenters have been talking about, the idea behind the physician value -based payment modifier, measuring quality and efficiency, including all of the services that the physicians order, not just the ones they provide themselves. that would be a significant step forward.

>> a second cross-section would be very useful. especially if cms could correct their errors in the first release so that when they issue the second release the first release is more accurate and therefore you can make better comparisons over time. >> the number of us have talked about comprehensiveness and linkages of the data. a more comprehensive view, either of an attributed population more of a more a more of a 360 view of what a physician is doing. but this was the division is our physician handles the well-defined episode of care >> yes.

>> my question deals with the health exchanges. policymakers, researchers and payers. even though this data is only medicare, what might be some interesting future developments? >> it's a tough one. i think that only in a general way, if you can learn things on drug prescribing patterns than the exchanges might be able to use information of that nature. since they since they are not generally treating medicare patients,. >> i would echo that. we have services to medicare beneficiaries as well as part d, we actually have

data ourselves. we have found we originally thought we could actually combine all that data from the commercial marketplace. but we actually actually have found that these are different populations. the working age population is different than the senior population. when we do quality measurement and recording we use different benchmark levels of performance between the medicare and commercial populations. my guess is the same phenomenon would happen in the exchange but the question is. >> sunday the policy.

the quick question about the office of management and budget. one of the concerns, the mosaic effect. you release you release different data sets there is the possibility of reducing personally identifiable information. can you please touch on that >> this brings up the dr. problem. report physician level data and don't have a minimum number of procedures or patients treated and if you report on the patterns and everyone knows who that doctor is in you can find out everything else. that is the motivation. and you no, there is

obviously a risk that really sophisticated data we will be able to take this data release and combine it with other data sources and figure out things about individuals. my guess is that there is probably a bigger risk. i don't know. i think that we are definitely in an area of risks and trade-offs. there is benefit to data being made available, increased risk. the more data more data sources are made available and greater granularity, the more risk there is for people being able to combine things in novel ways. i would just say, let's keep in mind the benefit of data

being made available, not to just go with the safest approach. >> the principal does apply. even apply. even on the data releases there will always be some errors in misinterpretations and a a physician who is unfairly singled out has behaving poorly. but you have to look. those other costs. you have to weigh the benefits against those costs. we are of we are of the mind of the benefits far exceed them. >> all the time. through underworld hacker websites. our financial system is

constantly balancing the benefits of electronic data exchanges against the risk of malicious hacker activity gradually groping our way toward that balance. >> is time to thank our panel for the really great job they did. [applauding] i guess we we will execute the same thing. transfer this. senior fellow senior fellow at the brookings institution who we will be moderating the final. [inaudible conversations]

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>> how we live? i think we are. now we are going to shift the focus. we have talked about this. from the.of view of researchers. but patients and consumers. now were going to shift the focus to the patient, the consumer and talk about what they need to no. i hope we can be a bit more visionary and expansive because we are where we are. i hope that these three representatives worked very hard on behalf of consumers over quite a long time can help us think about what do consumers really need to back what do they needed for how can that data be

generated? help us with this question, the president of the center for the study of services services/consumer checkbook. and robert rest issue, the executive director of community catalysts, a consumer advocacy organization, and we have doris peter, director of consumer reports health rating center, part of the organization consumer reports. not just health care. that's where you go if you want to no about cars or toasters were plumbers or whatever.

now we are talking about healthcare. a really a really important aspect of so many people's lives. we will start. tell us tell us a bit about what you think consumers need and what they might need in the future. >> first of all, i appreciate being here. our priorities should be to have good raw data readily accessible. if the government can do that, that is an amazing, wonderful achievement. i think the government has recognized this is important and has made significant progress. i am happy about the recent appointment and love the press release announcing his appointment setting the government's commitment to

frameworks promoting appropriate external access to use of data weather in aggregate or granular form. that is what i think should be the government's role. unfortunately there is still a lot to be done. i give you examples of the good and the band that i have have seen the government making data available over the years. it always gives me some anxiety that things might not go so well the next step around. in 2,006 hhs denial of consumer checkbook's requests that we get physician identify claims identified claims so we could get consumers some information on the amount of experience each physician has with various high-risk procedures. the governments siding with the ama and an appeal.

that was disappointing. cms cms interpretation of the actor provision on release of claims data that was much more restrictive. job performance measures nationally to have matching non- medicare data in every region. that is an enormous practical obstacle. on the other hand, there was the great news this past april, the government released this trying destroying the physician privacy argument against release. that was an enormous accomplishment. that was followed by cms action to get physician identifiers in the large data files that we and others have been using for years to evaluate hospital

rates and complication rates , getting those identifiers right in there quickly. the virtual data center program to make use of those by allowing them to be used remotely. straight up which would be a hundred thousand more this virtual research data center system could not be used to produce quality measures. cannot quite figure that one out. the door sometimes swings open, sometimes closes, but we all need to support often in the face of strong

provider opposition. as i say, i believe the focus should be on making raw data available. i i am not optimistic that the government should be itself the producer and reporter of performance measures. it should be a supplier -- a supporter of diverse independent researchers to develop performance measurement methods. i put those put those methods in the public domain where they can be critiqued. we want the data, the method the government wants to do its own reports, even in the face of provider resistance. such reporting would be too cautious.

a lack of development information and physician compare websites. quite a bit of reason for pessimism on the government doing the reporting. contrast that to that creativity which finds a way to put this data in a form that consumers can actually use and be responsive, all that stuff, private entities probably can do a better job we wash watch the use of our consumer checkbook website. the ratings consumers look at most often the ratings of doctors. people don't look at quality ratings.

well, maybe they don't, but they look at them twice as much as they looked at ratings of plumbers and auto repair shops and about 13 times as much as they look at ratings of hospitals. we have also done tests of consumer interest in different measures of doctor quality. by far the greatest interest was in consumer survey ratings and the results of surveys of doctors asking for their recommendations for other doctors for care of a loved one. both of of these type of measures were chosen at least three times as many website users as ratings based on board certification and training or as ratings based on whether a a dr. follows and actually defined evidence -based medical guideline. so where consumers are starting from might be different than what is expected. so now possible measures for

future expansion. i'm not going to limit myself. i'm not going to limit myself into talking about these large data sets. so i think one measure is to expand on whether doctors effectively use electronic medical records. such information can be collected, and it is important to be explained to consumers. it's another opportunity might be to explore the specialty boards, whether they can let doctors voluntarily identify themselves as performing in the top quarter of other doctors on certain

dimensions of the certification process, something i've never seen done that seems to me would be interesting, particularly because it might actually reveal something about doctors diagnostic skills, and one of the problems is that almost all of our measures out there don't really get to the question of diagnostic skills which are so critical. another opportunity would be more measures of clinical bad outcomes, analysis we have done we have seen at the physician level statistically significant differences in surgical death rates, complication rates. this kind of information needs to be public. if we had better data measures might be possible to assess whether doctors are prescribing too many of some kind of procedures identified in the choosing wisely initiative. an important challenge, to

report on patient reported health and outcomes from a similar types of measures. some of these types of measures require assembling better data bits of course. there is a continuing need to push for all payer databases where it we will be understood that the data can be used for provider quality measurement. talking about large national databases like that is great thing. the all payer database, i should say. participation registries is important if the registry rules allow the data to be used for public reporting on provider performance. collect information collect information that goes well beyond what you will find in claims data. it makes sense to find out which physicians participate

that could put pressure on doctors to choose to participate. but the big opportunity is in health information exchange. for performance measurement and various other reasons. it can be the heart of a lot of stuff. that means that means we need to push for continuing expansion of information in the electronic health record and push providers to share this information in large regional and national databases. a public measure telling which providers are participating might actually create exchanges. certainly such information could be a critical component. the government needs to invest heavily. think heavily. think of it as the interstate highway system

for healthcare. a major investment. finally i will focus on are relatively easy and quick but strangely neglected task, getting our nationwide database on individual doctors which would also be able to be aggregated at the group level. why why the government has not pushed forward is baffling. we have a good instrument. give good information on how well doctors listen, explain things, keep, keep track of the patient's history, coordinate care. this is important stuff. if the dr. does not listen the dr. can do a good diagnosis or come up with treatment

plans that fit the patient. the patient won't know or be motivated. one one article in the journal of american medical association put it, a diverse set of studies has been linked with better adherence to treatment plans, more important medical decisions and better outcomes. the journal for internal medicine showed that the individual decision not to practice accounting for the majority of the variance in the communication aspect on patient experience. why don't we have survey results? the explanation we hear is that it is too expensive. the consumer checkbook did a demonstration in collaboration with united. we did a rigorous survey, published results of the

individual physician level showing a large number of significant differences. the demonstration showed that this could all be done for the cost of about $120 per physician and still show these really meaningful results. this is much less than has been demonstrated. that hundred $20 can be be cut to about $60 or $40. it is not necessary to do the survey more than once every two or three years. so this is a big immediate opportunity that the federal government could easily make and. thanks very much. thanks very much that is a wish list of interesting things.

>> and national consumer organization focused on giving voice to consumers, particularly low-income consumers. it it has historically been fighting to open up a black box and supportive of the consumers union. i think it is important to look at consumers from two perspectives. one is the role of user and other in terms of the public policy rule. it is a trend toward cost-sharing and has become more important for consumers to be good purchasers. millions of people are looking at the exchanges, marketplaces to choose of plants. i think we had a lot of experience with that.

frankly they are still not looking at the black box or they are looking at it through a lucite lends. consumers find the most basic information. the urban institute recently came out with a report that is difficult to get information from many marketplaces about websites, websites, the marketplace website about whether a health.is tiered, what providers are in the network than the cost-sharing differences associated. >> most of the people are low-income consumers. very difficult to understand. information eligibility is different.

so in terms of what we're talking about today, we need to start with getting the basics. we need better information about who and what is in the network. charlie mentioned the importance. big nato needs to be made more understandable. the wide range of differences could be broken down into component parts focusing on the particular needs of consumers. we agree, patient reported information. the quality measure and a focus on outcome. finally,. finally, in terms of consumers they need help doing this.

the average person is not going to be able to make the kind of cost quality equations that we need in terms of coming up with a value without support. they get this sort of assistance through the assistance program. we had the consumer assistance program, part of people focusing on enrollment. we need to think about expanding the program. in terms of public policy, there are important pieces to think about. push for transparency around the conflicts of interests of pharmaceutical companies. opening that data up. they took the database, made it into a very effective tool for looking at what is

the relationship of the pharmaceutical industry. that perhaps is not helped in terms of allowing the individual consumers to make choices. but it had a significant impact on medical school and hospitals the other area we have been working on is around hospitals and community benefits. hospitals want to keep. the community benefits are often a mystery. community organizations want and need to have that information. we have been working hard to get a database of information around schedule

h which provides some of that benefit data. looking to move forward, improving that kind of data. they need to understand on the basics of healthcare, the idea of some of the broader trends in health care and the government and community organizations need to push harder. >> consumer reports health rating center. our role is really into trying to translate that data. bring to life. that is what we focus on. it is about having people use the data.

so at the rating center, a a group of scientists and doctors and consumers and writers, much of it is the government and translated to consumers. drug preventive services and the health plan quality. we have been doing this for about ten years. twenty consumers per month. not just through our own media products. probably more familiar with their work in the area of cars and electronics. we often compete with those areas. we can't bring hospitals into the labs and all that.

i was excited to see that in our own measurement of how our readers use data and how we understand these stories. healthcare cost and quality, whether it's about physicians are hospitals are drugs. supersede our rank higher than stories about cars. these areas of cost and quality. so that's another common question i get asked. consumers can really use it. we hear from them about it. more importantly, the discussions they have with our providers. the editorial content drives people to have discussions about the drugs are the hospital.

the thing is, we really appreciate what cms is done. we advocate to continue the use of data. the important thing, the issue of safety and errors. one area that is hard to measure. but skip the difficult task of measuring patient safety. we have asked consumers. about 30 percent of people self-reported they experienced one or more errors. that is probably a huge underestimate. that's what they notice themselves. i really feel like not only in the area of collection but how we measure safety

and errors, this is an important thing to focus on. another way to get at this issue is through registry data, probably the most powerful data out there. i think that's an area where we would like to push more to get the data available to the public. we have been able to be successful in a small area of heart surgery. heart surgeons who have voluntarily released data to the public. doctors that are really high performing and even ones that are low performing that have agreed to release there data. this is the most powerful decision tool. they they can look at a procedure they may be undergoing is they look at outcomes and complications in a reliable way. that is what we ask, make more public.

they make that more of a requirement in terms of being reimbursed by cmf. and then some more tangential requests, to not try to reinvent the wheel. cms has been required to do public reporting. it makes a lot of confusion. those websites that are out there now, hospital compare and things like that is difficult for consumers to understand. i would suggest they focus more on the data in the quality of the data and requirements for reporting the data rather than the consumer side of things. the final thing,, i would ask cms not to forget about infrastructure. we have to deal with the structure of the data, the missing elements of the data that make it hard to release

accurate and timely reports to the public. thank you. >> we have heard a lot about choosing doctors, some about choosing health plans. i would like to ask each of you to say a word about how you would hope the providers themselves would improve the situation over time? isn't that ultimately what we hope consumers having better information will accomplish? >> well, we have watched this most carefully and try to work with some of the societies to tell doctors how they can improve our they can find resources to improve. i don't think we have been particularly successful. but that is probably because

we have not been very good at it. you know, there are potentials. however, yes, that is one of the objections. objections. i also think one of the objectives is helping consumers find the good ones. that also gives you good care. >> i think that when you look for example at the pharmaceutical data that you have the professional societies stepping up and understanding that their are implications to the conflicts of interest in trying to address those within the societies, medical schools and academic medical centers. i think it is necessary to have a partnership. i don't think the market we will move us away from our providers who are poor quality of care.

we are we are going to need to rely on partnership between hospitals, doctors, consumers to really get it right. >> i have to say, we really do see the real big response by hospitals. first they get angry because they don't like to be rated. then they tell us they're they are focusing on the things we are reporting on. that came in the form of a complaint. my physicians are focusing on what you are reporting on. successful. thank you. so that is one area we see changes. we also see areas where hospitals will call us and say, thank you. we did not no xyz. now we we will look more into it. as of the cause i really like to get.

and we also here from hospitals about patients canceling procedures and surgeries and then losing revenue. so there is some market change going on. there is something happening >> talking about getting the raw data out there. the risk in putting out raw data, the risk of misinterpretation, as we saw in the data release that triggered this for them. >> well, well, i think there is some risk and will always be. misinterpreted. you know, i am troubled by that response. the health plan comparison tool. we asked the federal

government if we could have the benefits, the copayments, coinsurance. an actual estimate of out-of-pocket cost for each plant. the best estimate for something like you. make this comparison in a coherent a coherent way that most people don't have a chance to. we're talking here when the government said were not going to give use data. many weeks and complicated calculations. so the reason 252 reasons. one is, the plans would not like it. the it.

the other is that we might put out something that is confusing or wrong. i believe in the marketplace of ideas. no one listens. i like that way. and we take some chances. >> lest we get too focused. big companies don't like it. time for audience questions. we have microphones. the question back here. >> i was actually a guest scholar. so high. i follow medicine a little more closely.

i don't know how to define it. this medicine. that is healthcare delivery. my delivery. my curiosity is to ask each of you three panelists, how do you evaluate what is happening? how do you measure it? how do you describe it? been around for two years or six years or nine years, i don't want to establish or connected to some personalities on tv. i want to connect it to the university of michigan where i read about it. yale university. the question is data. how do you measure that?

>> i think i understand what you're trying to say. that movement has been around for a long time. you have that aspect. we take it in the form of the prevention services. that's one of the areas we focus on. i'm not sure if that is along the lines of what you're thinking of, but that is our focus, the end that we take. >> i guess i guess i see that there is a trend toward payment reform that would move you in the direction,, move hospitals and payers in the direction of treating a person more realistically. it certainly has been around for a long time. i think it's getting much more traction. >> some of it is not medical. >> exactly. are there involving systems for evaluating that from the.of view of the consumer?

>> if you think about the dual demonstration projects i think their are evaluations going on now. that is really working to take medicare and medicaid payment, combining it and keeping people out of hospitals and nursing homes and theoretically healthier. that is that is something that i think the research triangle is doing right now. >> i think the visibility of patient self-help and non- allopathic medicine has increased over time with tv and every place else. a lot of newsletters. i do think that many of the health plans are looking for alternative ways to help their members, hoping that these will self-help and reduce the health plans cost

and some of these providers, for instance, checkbook, checkbook evaluations of acupuncturist. the more straight up sort of thing. we don't really know. some are much harder than others. some of those things can get meaningful feedback on the quality of providers or the ability to explain things are good miracle cures. i cures. i had a miracle cure by an acupuncturist. you have to listen. and then he put a lamp on my leg and put on music and let me sleep for a half-hour. he said, well, how did that work? it was terrific. when he wasn't talking to me i was just thinking, asleep. i don't know. people have

have different views on how this stuff works. it's -- >> i think in general it's a a bigger and bigger part of the system and the economy. i don't see it as having the same level of visibility and measurability that we're trying to see's. >> other questions. >> a question from twitter. is there information about increasing consumer engagement through transparency cost and quality data? >> anecdotally, we definitely see an increase in engagement from consumers in both the data that we are

providing out there in the stories and consumers. what can make it more useful , all the things that we heard today and making it more about their day-to-day decisions such as maternity, childbirth, knee replacements, things like that. >> why consumers get involved or not involved. for low income consumers it somewhat different. you need to think about how to engage folks who have historically maybe been uninsured. consumer assistance is important. the medicare program, people choosing plants, something that would really help. >> thank you. >> providers and

organizations that are in the business specifically to help people and others that are in the business to make money. from from your analyses can you differentiate one from the other? >> we can look at performance. overprescribing. choosing wisely. the assessment. an important thing. we all no how to do that. better data. identifying providers as

opposed to just getting a lot of referral. >> before we wind up let me ask each of you very quickly , if you look ahead ten years, what would you like to see in this world of consumer information about healthcare and consumer choice? the most important thing that you think the world ought to look like ten years from now in this dimension? >> i go back to where i was before. we have we have been trying to crack that not for at least ten years. we are able to have a way for consumers to understand the risk of medical errors in any particular hospital. that would be where i want to be. >> fewer whiskey providers.

>> we need to consolidate information. we need to focus more on outcomes. >> i i would agree that we have to push toward measuring outcomes. no acute condition, not much interest in how it comes except they want to avoid having something go wrong. really looking and measures that are very clinically oriented. >> thank you very much. much. this has been a good panel.

let me turn it back. [applauding] panel remarks. >> thank you. this won't take very long. i just wanted to thank all of our panelists and the excellent staff at brookings a number of people who help make sure that everybody was as comfortable as possible. also for the folks watching on the web i want to highlight a couple of things i mentioned the work we're doing with this data set and data release. several more that talk about topics covered today. i wanted to be a little provocative in what might be coming after today's conversation. we have talked about uses

that are not just consumer centric but what happens if this data could be used to create the high high-value networks we're seeing in the private marketplace as well as on these health exchanges what if we could get researchers together and almost to a crowdsourcing, valuable research cases or findings, things that we all find interesting that we don't necessarily have one entity taking lead responsibility for but the could work with nonprofits, research organizations as well as consumers on what they find interesting and try to put that together in a way a way that is not contingent on what the government would do. finally doris talked about the conversation. it was not that long ago. some of the work of colleagues who highlighted these problems unless we'd be remiss to think that we

solved all of them. how can we be pointing to her places to improve and think about concentrating effort from transparency and data to show people not just what is bad but what we can do to improve the infrastructure of healthcare in our country. i did want to.out the conversation won't end today we will be extending this. thank you for your time and attention and have a great a great rest of your afternoon. take care. [applauding] [inaudible conversations] [inaudible conversations]

>> on the next washington journal congressman kevin brady of taxes and the government funding deadline and efforts to pass tax extenders before the end of the year. the president's immigration plan,, efforts to stop racial profiling following ferguson, and the work left for congress before the christmas break. cause and comments live every morning on washington journal. you you can also join the conversation on facebook and twitter. >> and compton who recently retired as abc news white house correspondent on her over 40 years covering the white house and the administrations of gerald ford. >> watched him listen to a group of second graders. she came and interrupted the president. my reporter's notebook, nobody interrupts the

president. the president stood and said that he had to go. and then we heard that it was two planes down. came out to the pool and said stay right here. the the president will come. i said, no. he did not want to scare the children. he went into that cafeteria and said it is an apparent terrorist attack and i must return to washington. we washington. we raced to the plane. then the pentagon was hit. >> sunday night at 8:00 o'clock eastern and pacific. >> representatives of the nfl, major league baseball, the nba talk today about the

issue of domestic violence. witnesses violence. witnesses from professional athletes and unions also testified. this hearing is to two and a half hours. it begins with committee chair senator jay rockefeller. >> the hearing will come to order. sports has sports has played a huge role culturally and otherwise in the united states. just last week millions of americans are probably paying more attention to their tv sets than to their turkeys. it is part of our cultural deal. i hope it is a good one.

athletes have become icons in america. i remember my 25 at that time my ten -year-old son had this gigantic poster that took up half of his room. that is the way it was then end the way it is now. whether we like it or not major league athletes serve as role models for our youth generations of children have grown up watching sporting events with their parents. game day traditions have been handed down from generation to the next. it is an amazing american phenomenon. kids where the jerseys of their favorite players, have there posters, collect there cards, most of most of which are not charged for, i guess it is an amazing figure.

it is one that we want to talk about. given this reality i hope we can skip protestations about how domestic violence is a larger societal problem and not unique to sports. we often get that. ..

>> this includes how we are handling cases of domestic violence. we want to talk about the players associations and what they are doing to address this problem. we really do want to find out.

and i want to know if you are developing reform policies that will effectively and appropriately punish those against women and children. and i want to learn what they can already do in the nfl comes to mind on that. and what must be the move of collective bargaining. and i also want to be clear that this is not a problem unique to the nfl. the nfl has made most of the headlines in recent months with high-profile incidents and the league's controversial response, all of the professional sports leagues represented here today have those that have committed violent criminal acts. and i can give them to you if

you try to deny it. until very recently the records have not been good. there's a long list of players in the nfl and the nba and nhl and major league baseball who have been charged with domestic violence and they have done little or nothing in response. and in fact the press has reported the culture of silence often prevents victims from reporting their abuse to law enforcement. and this has to change. there are reasons for that because in most cases the athlete is mail and the wife doesn't want to give up salary and it has to stop and that is what we are here for.

and we have a cochair here as well. >> i met the 10-year-old kid that we are talking about and the i grew up in a small town in south dakota with 800 people were we didn't get a newspaper until the following day. and so you didn't get it these baseball players and we have one television and we have the cbs affiliate in some places that is true. and so i got to watch the green bay packers twice a year and that was the two-time slave played the minnesota vikings and that was my team and that is all we had. and we didn't have a lot of the peril that we now have and the

l.a. dodgers and others, i was a big fan just to indicate all of us here in this country have tremendous admiration for people who succeed at that level and it is incredible influence of power that people are successful in professional sports and what they have in this country and some people are watching whether they like it or not it is the people that have those conditions who are role models and certainly we hope good ones. but i just wanted to tell you that i think this is a domestic violence issue that has been brought to our attention here and entered into a national discussion is so important. from the father of two daughters and i found this graphic footage running back to be sickening

like so many others across this country and i think the nfl had a part of his two-game suspension and we have to best understand the scope and severity and this sends a mixed message to millions of fans in the general public. as you mentioned, this is not unique to professional football, we will hear this with similar acts of violence over the years. and you'd see the extent of the problem with his sport rather than minimizing the issue i believe the correct approach is for them to engage with players unions and others to ensure player conduct policy is sufficient when such acts of violence are carried out and that could mean renegotiating

certain contract provisions where appropriate. and that includes how and when a player should be disciplined is an important part of the conversation. this is the one that needs to take place because sadly this issue isn't going away anytime soon. and this includes acts of violence. and that is simply unacceptable. and that includes those who are addressing these issues of the national sports leagues are insufficient to address these concerns in an equitable manner and i'm hoping that the hearing will take pressure and the players unions to make whatever changes are necessary to ensure that such acts of violence are just swiftly appropriately. and this includes steroids in

sports are protecting children from concussions. questions are raised about the best situations. i wasn't on the committee at that time, but i'm aware of some of the headlines are we had hearings generated and this includes the so-called storied era and sweeping reforms are still a part of us. our committee's ability to shine a light on problems is often all it takes to induce change and we have been able to do so without changes in federal law. i believe it is important and this includes scrutiny by this

committee. professional athletes are for better or worse role models and opinion makers. and we want to ensure that the commissioners speak. it's also part of the heads of the other associations that are not here today. these are issues that are not partisan. and may very well be appropriate as we assess the progress in dealing with domestic violence. mr. chairman, thank you. >> thank you very much. and now we have the chair of the relevant subcommittee and we would like you to invite to speak for two minutes.

>> we are returning a high wattage on a problem that is part of this, with great power and influence comes great responsibility. and this includes believe he represented here today have more power and influence in our country with other institutions that i can think of. professional sports musto better job of setting an example and those who face very different difficult decisions to hold people accountable. professional sports have done little to hold those that commit this crime accountable. and perpetrators know that they

can only get their victims if they refuse to cooperate and threaten their financial future and threaten the future of their families financial status or put them on an airplane to venezuela if they can accomplish those things, then nothing will happen. there has been little or no effort to independently get the facts whether they use the predictable outcome of very few that our viewers will have an adequate support system within the families of the professional sports teams where they exist to get the support to come forward and hold their abuser accountable. and by and large professional sports teams have relied on the failure of the criminal justice

system to get convictions as an excuse as to why very few players have been held accountable. i'm anxious to hear how you view your responsibilities to independently gather the facts and hold the professional athletes that commit these crimes accountable with sanctions. thank you, mr. chairman. >> thank you, mr. chairman. i appreciate the attention to this important issue. i didn't realize that this was so advanced. we have three television channels that are able to watch the seven cisco 49ers and the giants play. anyway, i know that there are some in this room that could question why congress is involved in this issue and i would like to going live. twenty people every minute experience domestic violence in the united states. one in three women will

experience physical violence from a partner sometime in their lifetime. children exposed to violence are more likely to commit domestic violence later in life. as a husband and a father of two wonderful daughters, this is unacceptable and something that must be changed. these numbers are not just people. but his wives, mothers, daughters and friends and this includes the most successful sport leagues in the world and united states. the star players are household names are role models for fans and aspiring young athletes. the faster years we have looked up some truly shocking figures. this is concerning is how the league handles the situation and how we do we protect these players. it's very clear to me that getting these players back on the field is more important than addressing them with sexual assault or even child abuse.

many brush these problems aside and leave it to the courts. only when the video service did the collective conscious of america demand these unions change their approach. and i can only imagine what survivors are like today. as i wrote a letter earlier this year to the nfl commissioner roger caddell, by waiting until the video until one of the players became public, they effectively condone the action of this player. the same holds true for the players association and in fact i don't think you understand the full scope of the problem. when the reruns decision was overturned, is that this is a decision that is a victory for a disciplinary process that is fair and transparent. we need to stand up and fight for the due process of our players. this is not about due process. this is not about collective bargaining agreements that you

do not like any more want to change. this is not about any type of any type of labor issues that you may have with the league, this is to help a terrible problem in society. wives and mothers and sisters and daughters and friends are being beaten. so when you worry about getting that more, priorities are out of order. this includes aggressors that have not been dealt with appropriately and the survivors have been left behind. there's a place in any society for domestic violence and sexual assault. our nation's export leagues have the ability to make a difference. the american people need you to step up and this committee wants to know what you're going to do to take a stand. thank you. >> thank you, senator. we go now to the witness list and we expressed our appreciation for you being here.

we will start with troy vincent. welcome. >> thank you. mr. chairman, members of the committee, my name is troy vincent and i'm the executive vice president at the national football league and i'm pleased to discuss the work that we have under way to address conduct standards including domestic violence and sexual assault. we want to set high standards for personal behavior in order to meet the expectation of the fans, players, and those of the general public. in 2007 the policy was issued for all players and owners and league employees. but recent events made clear that we have not kept our standards current with our own values. we have made mistakes and we have been humble, we expect criticism and we are committed to being part of the solution. we will get this right.

mr. chairman and committee, when i consider these issues we bring this is a way of life for some people. domestic violence was a way of life for my brother and i as my mother was beaten and knocked unconscious and we dial 911. we saw how she struggled to seek help them find the courage to say no more. that includes the complexities that remain violent in our lives today. i have committed my life's work for the last 20 years as an advocate against domestic violence keep others from experiencing this as well. i relate to the 20 million victims. the survivors of domestic violence in every community across a great nation and in addition i have the honor and the privilege of playing in an

international football league for 12 years. twelve of those years i served as a union official and 12 of those years i served as an association president. and i support the interest of all players in the fair process. and i leave these efforts and i know the majority of our current and former players are terrific fathers and men who have made incredible contributions to their communities. they are not labor and choose the entrance issues come at their issues to everyone. we need to work to collaborate and i was part of those efforts. today just as in the past, the league has invited us along with other experts to assist us in setting the highest possible standards. the nfl is taking steps to improve how we respond to incidents of domestic violence

and child abuse and sexual assault. with efforts personally led by the commissioner, we have undertaken a thorough review of the conduct policy consulting with 100 experts across a broad range of subjects to government accountability permit conduct to establish a fair process for the players and employee disciplines. we will create a conduct committee responsible for review and recommend changes going forward area and experts will continue to advise us that we will always have the right voices at the table on educational and disciplinary work. second, we are having a mandatory education program of more than 5000 men and women of the nfl family and the goal is to ensure that everyone understands and has the full scope of this behavior and is familiar with the warning signs

associated with these crimes. education promotes prevention and how we can help those at risk which is another key focus area of our education. we are also training critical response teams to help prevent and respond ugly to family violence and sexual assault, including safety, medical, legal, and financial support. including leading domestic violence intervention groups, including the national domestic violence at the resource center. we are finally raising awareness of this critical issue. in collaboration with the foundation and the public service announcement, finally we

are promoting programs for those who coach and manage the game at all levels, including age-appropriate character development and healthy education as well as domestic violence, child abuse and sexual assault education. we have learned a great deal from our mistakes than by listening to experts, the more that we listen, the more that we learn and become more aware of the complexities. both of the problem and the solution and we are working hard to balance issues of a fair process with the goal of preventing and punishing these behaviors. mr. chairman there is a privilege and it's not a right to play. and every member of the nfl community must embrace this unique leadership role that we

play in our society and we look forward to working with the committee to advance these goals and i know that we all share. thank you for this opportunity and mr. chairman, i think you for your lifetime service in this area. >> thank you, sir. that was excellent testimony and honest. and it's a good beginning. thank you. ms. terry patterson, deputy managing director of the football association. >> the afternoon, mr. chairman, and members of the committee, as stated, my name is terry patterson and i'm the deputy managing director of the nfl players association whom i represent on the panel today.

we greatly appreciate the committee's interest in the critical issue of domestic violence. we always welcome the opportunity to meet with those to discuss issues concerning support. the leadership of elected officials brought meaningful change in the area of concussions. we have worked with unsupported members of the committee as they continue to push for better standards for those on all levels. we are here today to address your concerns surrounding domestic violence. just to be clear, neither are players or others condone domestic violence in any form and we understand the significance of our position for society and the families and individuals involved. in any incident of domestic violence by any player is one too many, but it does not and should not act on the overwhelming individuals to contribute to the community and countless ways.

you will see players in the community with many constituents and their children as part of this campaign. and we believe that a comprehensive system of education and prevention and intervention counseling will help us to find solutions to lower the incidence of domestic violence that presents itself each year. we believe that those two combined is the best way to achieve this and assisting those involved. unfortunately, we have seen repeated instances where discipline under the nfl is implemented to fail to get closer to the solutions. we have seen on more than one occasion when disciplinary matters were left in the nfl in the process is mismanaged and often the end result has not been able to withstand the outside review. for example the unilaterally impose discipline not only by an arbitrator provide a former nfl

commissioner who was tasked with reviewing the nfl's actions. in the more recently it impose discipline, the arbitrary discipline was also returned over further review appointed as the neutral arbitrator. this current system on unilaterally simply does not work. it does not work for members that continue to express distrust and displeasure in the current system and so we have been tasked to find solutions and to bargain with the nfl for a better process. accordingly in early october of this year we established a blue ribbon commission to advise us on matters of domestic violence prevention and processes of discipline. i have included these names of the member of the commission and submitted testimony and also biographies. we are also fortunate to see

that a number of the commission is testifying at the hearing today. and we have started a meaningful dialogue on ways to create this through societal issues. the nfl has declined for moving ahead. but we cannot go ahead without improving the personal product by which it is to be administered. providing them with a fair proposal over a month ago and despite the letter responses past sunday, the nfl refuses to commit collective bargaining. we believe that a jointly broken system is the only way to ensure this approach has the credibility and effectiveness for the fans and the partners and our players have come to

expect such as our comprehensive policies. we remain fully committed to addressing these issues in a meaningful way because that's the only way we can ensure that change has happened and we also remain ready to his this any members of the committee and improving the way that domestic violence is addressed in our country. thank you for your time and we look forward to answering any questions you may have for us. >> was an enormous amount of pressure coming from many directions and not necessarily the folks at the witness table, but the folks that you work with for us not to have this hearing. and we went ahead anyway. not everything -- this openness is not as commonly held of the process as i would like. mr. joe torre, who is executive president of baseball

operations, welcome. >> thank you, mr. chairman. good afternoon. chairman rockefeller, members of the committee, executive vice president of major league is welcome i want to thank you for the opportunity to discuss this issue with domestic violence and sexual assault. this is personally important to me as a person whose childhood was touched by domestic violence i have come to understand that doesn't issue publicly has the potential to help millions of victims who believe they must suffer in silence. my wife and i formed the safe at home foundation at created safe at home programs ending the cycle of domestic violence and i am proud to day that we have reached close to 50,000 youngsters and that time.

that includes children exposed to violence, i have had the opportunity to work with outstanding individual is who have devoted their lives towards working towards solving the issue of domestic violence in this country and this includes the understanding that major league baseball is our national pastime has an obligation to set a positive example. in this includes crimes against women's and family. and we recognize the professional sport to be leaders in addressing this. and the seattle mariners have partnered against a statewide educational initiative called

refuse to abuse. going forward they have developed a standalone policy prior to the upcoming season and although we are in the midst of developing this policy, i would like to explain to the committee will we have done and what we hope to do in the next two months. since september 2014 as part of her education process, representatives of major league baseball have met with local organizations were focused on addressing violence against women were providing services and support the victims. representatives from those groups insistently told us that while they are were obviously unsettled recent incidents of domestic violence, they believe that those incidents have shined a light on an issue often in the

shadows. they believe that and we agree that sports leagues can make a difference and we have begun selecting a variety of organizations to serve on a committee that will develop education and training materials for players and staff and their families and some of these initiatives include hosting informational materials of minor league ballparks and publicizing contact information through confidential hotline since shelters. this includes those specifically designed for the intimate partners of players and we also are developing protocols that we must follow in response to domestic violence or sexual assault that will include appropriate measures to ensure the safety of effective

individuals and counseling and can intervention from perpetrators. this includes futures without violence to help us develop the training and education program for all of our players. it has been partnering with the giants on these important issues for more than a decade and this has included linda chamberlain to speak with a medical staff in san diego this weekend. she founded the alaska a violence prevention project and will be speaking to our medical staff on it, informed approach to the addressing domestic violence. in january of 2015, the top prospects in baseball will be educated on domestic violence and sexual assault during the annual rookie kurt development

program. beginning with a spring training this february and every major and minor league there will be educated on issues related to domestic violence and sexual assault and other organizations including violence prevention and others as well. in this also be part of the educated. the commission understands that a component when assault is part of it, as appropriate for those who have collective agreement with the players that have conduct that is materially detrimental or prejudicial to the best interest of baseball,

including but not limited to this in violation of federal or state or local law. under the just cause standard, the office has a wire to talk about violation by a player at a hearing before a neutral arbitrator. which can be difficult in the absence of a conviction or a plea or without cooperating witnesses or evidence regarding this conduct. in addition the arbitrators in the past have been less inclined to uphold severe discipline. under a just cause standard for all conduct that does not impact the player's ability to perform. and that includes making it easier for them to commit acts

of domestic violence and the nlb does not have the right to insist upon any changes until the current collective bargaining agreement with the players association expires in december 2016. however we are hopeful that we will come to an agreement with the players association prior to the start of next season on disciplinary policies and sexual assault. as we told our owners two weeks ago, major league ace paul is committed to developing a culture in which the athletes implicitly understand their moral obligation as both men and role models to speak out and act against crimes against women and families. we fully understand that educating over 4000 players from diverse backgrounds on an issue that many of them have not

previously considered is not an easy undertaking. however we intend to devote the time and the resources necessary to accomplish just that. thank you, mr. chairman. >> thank you, sir. it is my mistake that i did not say the beginning of the current that we face two challenges. that includes a rule that witnesses can speak for five minutes or less but not more. and secondly we have votes starting at 4:00 o'clock. so that puts pressure on all of us here. on all of us to get on with it. so are you a a part of them or do you advise him? >> i'd buy some, i have been doing it for the past 25 years. i have been outside the special counsel for most of the last 25 years to major league baseball players. >> but they couldn't make it.

>> on behalf of the executive director, he couldn't attend the day because he is right now churning the annual executive board meeting. and it will not be surprising to hear that one of the major topics that is under discussion is domestic violence and what we have been doing to address it. >> please proceed with your testimony. >> i will attempt to be brief. >> you don't need to be, the time is mine. you can have your full five minutes. >> is all a players association has been working with major league ace all to examine the current program addressing domestic violence in light of recent events. we have been considering how needs to be modified and perhaps pulled into a program for the entire baseball family based on accountability and fairness. back in 2011 the players association negotiated and implemented a policy that addresses violent conduct including domestic violence in

two ways. it provides for therapeutic intervention and cases of inappropriate and unlawful conduct. with respect to the first under the joint treatment program, we utilize medical professionals all around the country to design treatments for players who are charged with domestic violence related crimes. based on our understanding of domestic violence, we have moved away from a one-size-fits-all approach in favor of individualized valuation and case-by-case treatment for the player and the family involved. with respect to discipline, as the gentleman described, the program wherein player club where an act of domestic violence has been alleged, under the agreement the player may be disciplined for just cause for any conduct that is prejudicial, including any conduct that violates state or local law. it is greatly important from the

association's point of view this be imposed and that it be subject to review before a neutral arbitrator. in addition to the program, the association maintains that a local psychiatrist on staff. he is well-known and meets with players on a confidential basis to address mental health issues as they arise. this part of the association's program reflected that the most effective treatment is what happens before violence can occur. for current program includes the player may be disciplined or undergo treatment developed by licensed professionals and may he tells her own clinical psychiatrist. we recognize that more can be done and so it we have begun a dialogue about modifications and improvements to the program and that includes an enhanced publication program to promote the understanding and eradication of domestic violence in our society and that includes

the program for the major league players and their families so issues can be addressed before violence occurs until all are aware for those that can provide assistance and prevent harm and then possible changes to the existing disciplinary structures toward disciplinary tactics. we have devoted a lot of time and energy consulting with a wide range of expert organizations and the domestic violence area. we have learned that there is no one simple solution or easy answer, but we hope that by working with the experts and gathering their recommendations that we can develop a more effective program for all of baseball and become a credible voice about how to end the domestic violence. mr. chairman, thank you for the opportunity and i'm happy to answer any questions you might have. >> thank you, ma'am.

executive vice president, their programs of the national basketball association, please proceed. >> thank you, mr. chairman and members of the committee. we appreciate your inviting us to the hearing today. i written testimony has been cemented to the committee. so i will certainly try to be brief in the interest of time and we share your view that a hearing like this is certainly helpful and we expect it will generate not only thoughts but actions and that can certainly help all of us. it can help all this of us at the table. i am the executive vice president for social responsibility and as such i oversee all the community programs and partnerships as well as all of our education efforts with our players. the commissioner regret that he is not able to be here today, but he had a long-standing commitment to lead a group of executives on a trip to india this week. like the committee unlike others

have spoken, we are taking a fresh look at the programs and policies and educational efforts in this area over the course of last few months and we have determined that there is more that we can and should be doing to educate our players and to help prevent domestic violence from occurring. we work closely with the players association on all of our educational programs for players and have determined that this year we need to do even more. we will be doing new awareness educational sessions with our players and family members and with team staff and helping to raise awareness and inspire leadership and hopefully prevent domestic violence from happening within the family. at the same time we know that discipline is part of the process as well and the collective bargaining allows for the commissioner and also neutral arbitration for our players. two processes we believe our fair.

in the end we want to stress to this committee and others that we take this issue seriously and we are committed to doing all we can to prevent it and we are committed during the weekend to provide firm but fair discipline when necessary and we will continue to learn and improve in all of these areas and i am happy to answer any questions that the committee has. >> thank you very much for that. ms. roberts is the executive director of the nba players association. welcome. >> good afternoon. but odd. >> my name is michelle roberts robertson i am the executive director of the national best players association and the labor union that represents all nba players in collective bargaining. i appreciate the committees at desire to explore this in sports

and as a lawyer for most rewarding project involves representation of victims of domestic violence and civil protection orders right here in washington dc. and i was encouraged to learn that the domestic violence is a topic that our players recognize it to be addressed long before the events of recent months when the public attention has turned so intently on the subject. recent events have given us an opportunity to re-examine and strengthen the already comprehensive scheme at the nba had in place and add even more safeguards with a focus on prevention and counseling. we want to make sure that every player and wife and significant other and family member has a safe and i are meant to be held without fear of retaliation or additional harm. and in doing so recent efforts

have brought together the representatives of all members of the nba family in unprecedented fashion. we also want to lead by example and help to create the kind of awareness and attention that this society deserves. ..