today is one of several congressional briefings, and so i welcome you today. thank you for coming. thank you:mc(tq(rp&lyzd7g c-span for being with us and those of you watching on tv i think you'll find this interesting state of play sunshine act. to introduce our going to turn to my friend and colleague debra whitman. she's the director of policy at aarp. and she's been heavily involved in this issue. debra, it's all yours.xcq>ñ1e6a >> good morning. i think this is a really important issue that a lot of people don't know section u&7l6002 of the affordable care act was previously knownz-

the physician payment sunshine act. it was a bipartisan piece of legislationó senate by senatorrófz- grassley. republican from iowa. and senator herb kohl a democrat from wisconsin. and the bill sought to lift the veil on the relationship between industry and it was a true piece of bipartisan legislation that was founded on a lot of the research that you're going to hear from some of our great speakers today. it was written in conjunction z>/ with the information that we gotrcd from the research community, and the consumer community, represented by pew and allen here today and aarp and amsa and m'e concerned that these r(b2bk@; relationships, the financial relationships, were impacting both the quality of health care,

and the cost of health care.j2.sñ and i have to say that the process was long and tireless. at the time i worked for senator herb cole and we had, with my colleague chris armstrong from (óa senator grassley's office, about 300 meetings with consumer a#d)z%tr(t&háhp &hc% groups, and ivj understand comprehensively what these relationships were, á

there were different reporting requirements in each state, there was a lot of chaos for the industry to actually make sure wz1wu they could report to those individual states. and so there was kind of a pressure to have a federal law where things were more cohesive and reporting requirements were more standardized.[am: now, this law, as i said, came from state legislation, went to a federal legislation, and actually has spurned laws across the globe.o]r0lg although they are not all implemented the same. the french decided that it's great to report the financial relationships, but we shouldn't qepñ make the money about public. so the actual usefulness of some of the global laws are probably even going to be less than the united states laws. we also saw in the fall that there were a lot of bumpy implementation issues. implementation had been delayed

by delays in regulations gettingz out.[v f1 o websites had issues. we've heard that before. there were issues in actually downloading the data, and using it in a usable form. and there were concerns about ccñ whether data was both accurate, and also given the proper context. so these are the issues that we'll be talking about today. and i'm really delighted because we have an amazing panel of speakers.ci first we have rodney whitlock.zbl÷ who is just a real expert here on the hill. he has 21 years of experience and he's currently working for 6.byk senator chuck grassley. as the health policy director in5! the senate finance committee and he's previously worked on a variety of staff, including representative charlie norwood.k÷z3 and he also is a part-time #q$x teacher at george washington sú university for health policy. so we welcome rodney.

second we witdy haveml fugh-berman, who iso 7÷ association professor in the department of family medicine inclmñgeorgetown university medical center.:@$ñ she's the director of farmed out which promotes rational prescribing and is the lead author of several articles on physician industry relationship. next, we'll have allen kokal who is a clinical pharmacist and senior)j"dç director for health trust programs. allen was very involved at the state level and the federal level. i had him on speed dial for this legislation and pew continues to be very involved in the c+r implementation of the legislation. finally we'll have dr. william bjgz jordan president-elect of the national physician's alliance and co-director of the medical student education in the department of family and social medicine and director of preventative medicine residency.

so we have a great panel. we'll let them each speak and take questions at the end. rodney?v y-÷; >> so thank you all for having us today.r7 g coalition on health care, and john rother for organizing this thank you c-span for being here as well and giving my wife an excuse to dress me this morning. senator grassle9n;dd a long history in the subject of transparency in the public interest. he's worked in the subject of whistle-blowers, and whistle-blowers' role and their ¤8ç ability to provide information for the judicial process, medicare transparency of data, working with senator widen, and r3v seeing that medicare data could be released publicly for research purposes and some of the work we've done in not for profit hospitals.3ad and providing information as to what they're doing with regard

to providing services for the uninsured, and the things that êm allowed them to derive their not for profit status. the public benefit they provide. senator grassley continues to believe that more information available to the public is in the public interest.>jmgñ and that motivates how we approach -- how we come to this subject. if you look at it there's a disclosure also out there for participants. clearly members of congress. and staffers like me. are subject to financial disclosure. the freedom of óvn)[fñwáqr information act makes information available to individuals about wh [gát)áh @r(t&háhp &hc% government is doing.oqc and tax exempt organizations have to provide certain information for their status.7af so, the idea of providing information into the public forum is something that we have consistently supported. and bring to this conversation. about a decade ago we started looking at this.ief ñ

and it begins with -- it begins with investigations about what are the relationships between manufacturers of drugs and devices, and biologics and providers.da.z and you have an early "new york 2@ ñ times" piece on a pro x+hr is participating in a study on sareroquel and making recommendations for.q8ñ ñ! antisawcotics for teenagers, and what are the financial relationships that that individual provider has?@0÷ turned out the provider was receiving money from five different manufacturers of similar drugs. not disclosed as part of the research. we went and did further research.0czm we did investigations there were media work where places like baylor and stanford and harvard. we have research going on, and financial relationships that are not disclosed with the subject / matter that is under research.

and so, we know that there is a there there. we know there's something going on.@g ÷t+b the magnitude of it is unclear to us. but we know. we have work from groups from pro-publica and pew out there showing there is somethingëx worthy of consideration here. now it's important to note that what we're talking about, when we talk about these financialkjb÷+u transactions, money moving between the covered entities, the manufacturers, and bm providers, physicians, group purchasing, hospitals, these are not illegal. make sure we're clear about that. these are not illegal. kickbacks, those that fall under anti-kickback statutes, are. but that's not what we're talking about here. these are perfectly legal transactions. transactions, and the medical community argues, rightly, that they are legal.m% that we're not talking about zçzxñ things that should -- that are illegal, or types of kickbacks.p8@= these are particularly related oftentimes to education.ó

and that for doctors to take 6(dñ their time to be engaged in the educational process for wér$emselves and for their peertbñíñ you know, is in the patient interest. and so these transactions are occurring around those types of things. and so, if you look at how you approach this as a matter of cwirz legislation, now, some people could come to this with a very purist approach. an absolutist approach.d!@ that we should make these types é l of transactions illegal. that's not the way we approachedvb6 ñty it, working with senator cole's office of wisconsin. we looked at it from more of a transparency perspective.r that if these transactions vjq remain legal, and we believe that they should, then they f@0t should be reported, and made available to the public. since they are legal transactions after all that there should be no qualms about nz([÷ making them publicly available. making them so that they can beoad seen by the public a.ñxák9 r discussed.hzv"w

so that was the genesis of the physician payment sunshine act. introduced i believe first in '07, and ultimately becoming statute through the affordable care act.ú÷1(r now once in statute it went through the implementation process.w5,jñ i!+.táháurned ovmdç+ cms to figure out how to make it work and bring it to the public.wañ and cms, i'll drop in my &>÷j southern colloquialism, bless their little hearts, they have trouble websites.÷f wad so, you know, the rollout didn't go as expected. and you know, in their defense, that they -- the data available to them to be able to confirm identities of the providers out there, to make sure the data was.ñ right, was horribly flawed.çg and so that led to a rollout that was bumpier than anticipated. and certainly than we would have preferred. but they did get out the door. it is live. you can go in and start searching."7a=÷ and to cms' credit, dr. agrawal 21bg

made consistent improvements on wtd%3já$u$ere.a jys[m7÷ their tu deidentified to identified, and and so, from my office's pe#o u up)e very pleased with what cms has done. and this is important. because, moving forward in the future this really needs to be commonplace.@my this needs to be something that is just part of the health care relationships out there. that we come to expect it. it's available, it's searchable, and it just is. that everyone is comfortable looking at that. because that's ultimately what we believe from our perspective is in the public interest. this transparency of the relationship so that we all know. and so that it can be simply part of a conversation. %tc"af1 o a conversation between a patientf;r0ç and a provider.tñ a patient should be perfectly adt comfortable as an educated consumer looking at this data and seeing what their provider

is doing and then asking their provider.f)ñ and a provider should be absolutely comfortable saying, +]9÷ why the data is in there. what it says. now we know as we look forward, n fg0l ÷ again, that there are things that will need to be approved on the site. and that's going to be a collaborative proce#sbszgknñ and that involves cms. it involves the reporting entities. the manufacturers, and it involves the providers. and everyone has to take the vested interest they have in looking at the data. and making sure it's always accurate. and making sure it is -- it provides proper context. so that the consumer then really gets to know what's occurring to= make these conversations that occur between the provider, and the patient more beneficial. but we continue to stand that l this is a good thing, a positive thing, and it is in the public interest, and it is in the cj patient interest.yd ÷ now, to the sort of elephant in the room, the data is now out there and we went from having @íh= suspicion to having actual data.

and the actual data, and this is is going on out there, these lf1- financial transactions, that the total value that cms published as of december 19th in these transactions was $3.7 billion.nq÷ the number of records, those 7p)ñññ individual transactions that areb;b÷ occurring, or over 4.4 million transactions reported.úc[- and it involved individual records for 366,000 physicians. and so there's a lot going on out there.rjn+ñ now what that means, what ck2úrñ done with the data. the research you can go into and find out about what's going on is turned over to the research community.k and how that then informs public poí3gi]%11"uu$u(on the research done.m that, then is again a subject for the folks doing research, k"da

whi(ef2p is my segue to my fellow panelists here. again, ready to answer questions and appreciate you all being here today.f5buç@" >> good morning.cúcti rp(py to be here today.. u physicians find it very difficult to speak without slides, and you'll notice both physicians on the panel have brought slides today. expert witness at the request of plaintiffs in matters regarding educational projects and&qç practices in the departments of pharmacologist and physiology at georgetown university.1"ñz>2zñt the physician payment sunshine act has been a success. it's been wonderful to have this information out here. reporters, for researchers, and

also for consumers. hpñ and just the f4ñ of@sé its existence is really important. physicians don't like its existence or at least physiciansn6.y who are paid by pharmaceutical companies don't like its existence. apparently it's quite popular zsy among divorce lawyers, though. pro-publica had put together publicly available information gz cms. and they've continued to refine that database which has been really great. and they've also created several tools. not only dollars for docs but and they have a wonderful series of 32 articles, analyzing the data from the new database. it's really great. so if you haven't seen 4÷lgvé÷ please take a look at it. i want to make a plea to keep our state disclosure laws, as well. d.c. of course isn't a state. but dr. susan wood at george -.;qtgc washington university is leading$g6 an effort that i'm involved with

as well. we have disclosure laws in d.c. p and we do an analysis of the u of the disclosures from pharmaceutical companies of payments to all health care practitioners every year. and we also do a special report.xñ9 and i can tell you that the ppsa only picks up about 20% of to d.c. y so some states, or nonstates have reporting laws that are /@jx even more stringent than the ppsa, and i would make a plea for keeping them.r! w our latest report,0tw 5uu(s&y looked at organizations in d.c.,5lpox÷!4u we're required by law not -- we o-k÷ can't actually name those organizations, but they may be u@1ñe=z represented in this room, and we found that of the almost $20 million that was -- that was écib spent on d.c. based organizations, about a third of these organizations failed to

disclose their corporate donors nm+ ph on either their website or an +t available annual reports. for the year 2012. anyway our report is available on the d.c. department of health website. disclosure should not just be limited to physicians, and to other health care providers. but should also extend to organizations. also of seven physicians on our list who served in leadership bdç.d°çpabdlh]f>u5

leaders which i'll talk about later, and direct to consumer promotion. which includes direct to consumer advertising and even targeting of individual patients. if you have an expensive disease pharmaceutical companies may é send a visiting nurse to your >x you fill out insurance forms to convince your insurance company to pay for an expensive medication."!s 9 one of the things that has gone ímáub]ñ?s( away sincehv-fq 2009 is promotional items, but we collect them at pharmed out, so i had to showh 4 @r(t&háhp &hc% you our collection.!4;vf9ñé some marketing tactics have changed, however, some have become more subtle and some of the targets have changed. that to some extent physicians .;jdñ a medications than other people.z than other entities.n more and more formularies. pharmacy benefit managers,ùcf1 o payers are deciding what gets

paid for or how much is spent on various medications. and pharmaceutical companies :w will always try to effect whoever is affecting market share. if that's the physician, it will be physicians. if it's the patient, it will be the patient. if it's the payer, it will be the payer. and payers, there's a lot of shift towards targeting payers, especially with cost hxpz÷9!z(z effectiveness studies, for example.6 because if you're a company with[9ç a really expensive drug, you're going to need to try and though this drug is terribly expensive, it will save hospitalizations, or it will save you money down the line somehow. there's a lot of cost meant to persuade payers to cover a drug. disease awareness programs are very important, and pharmacists getting very involved in a very scary way in disease management.+dh the pharmaceutical companies would like to help health care $av$p provideri'.nd systems manage dfmhñ

their patient. you should be very afraid of this.íz1oqkfil&vñ and there's a lot of partnering with government agencies, with medical groups, with ra0uc&ñ specialty groups, et cetera,.çf and groups. some of which have been invented, or have been created by pharmaceutical companies. and others that have been co-opted by them.k #+âáq re very few -- there are very few consumer advocacy groups that don't take money from pharma.tq there are fewer than ten national groups in the united states that do not take money from pharmaceutical companies.r9ñ#hctqgaezuhp &hc% for individual physicians, the réx f shift has been away from cash, and towards more services.u we'll do a website for you.we we'll provide web pads that your jjents can fill out their information, their medical history on so that somebody doesn't have to transcribe that.uqf]ñ that information actually gets sent back to pharmaceutical companies. it's deconfidentialized first.r but it's a way for them to

collect all this information, in medical records are also sold to pharmaceutical companies.lbzi those records,?a so it's anonmized patient ym+el data, but pharmaceutical companies know everything about your health history. your you went to a doctor, your zip code you live in your body mass index. as long as they don't know your name, they are allowed to have longitudinal information on every other aspect of your health history. pharmaceutical companies also ú+ç$ fund tvs in waiting rooms that have fake news stories on them.hoac÷ possibly pharm ads but often the messages are incorporated into the fake news stories. and you can imagine what a great audience this is. people stuck in a waiting room, with old magazines, are really the room.

there are new targets for pharma marketing and one that i think is really important to mention ryñ are nonphysician practitioners. so, advanced practice nurses, which includes nurse practitioners, nurse midwives and nurse anesthetists, and physician assistants. so these are practitioners who h have prescribing authority in all 50 states. and one out of four prescriptions in the unite$z practice nurse or a p.a. one quarter of all [n(g÷ prescriptions. and there is no requirement in the ppsa to report any payments to these practitioners. the d.c. law does require payments to these practitioners, the ppsa does not. a quarter of all prescriptions is a lot of prescriptions.÷é&fxpmçzte and p.a.s are being targeted, and advanced practice nurses are being targeted. and another target that really flies under the radar is social workers. in many jurisdictions, especially busy city mental

health clinics, it's the social 0 workers who are making make the high targets, the nps /tre) r pads. gatekeepers are really important.ç ñl the receptionist, the nurses whoécq1÷ work in a doctor's office.be#ç so even a nurse who is not a social worker who is not a prescriber, they can influence %d;q prescribing of a particular health care provider.; and that's really important. so this is also from a industry magazine. t] this is also from a industry magazine. kol, again, is a key opinion leader.bta this shows the matrix of

everyone who has to be affected. all the peopmpdgat t hg& can affect. there's very -- this marketing is extremely elaborate. it is extremely subtle. so let's say a physician doesn't see drug reps.ykbp which about 4 out of 10 physicians in the u.s. now do not see drug reps. so pharmaceutical companies will actually figure out who their social contacts are in their professional networks. who do they refer to? who refers to them? who do their kids play baseball with. who is their spouse's best friend and they will try to target those people in order to try to get a marketing message to the targeted physician. marketing for a drug actually starts seven to ten years before a drug comes on the market. now it's illegal for a company to market a drug before it's on the market. so what they do is a market the disease. and that's done through key opinion leaders. and here's a company that specializes in building your ÷nb[y brand before it's birth.

or what's called prelaunch marketing. so prelaunch marketing might highlight the severity of the disease that the new drug is meant to treat. or it might highlight the problems with existing drugs.x or it might emphasize a & particular mechanism of action and there's a drug on the market i think what we should really berf/t watching for is the establishment or t redefinition of specific conditions. so pharmaceutical companies have actually invented some conditions wholesale.o dñscá including hyperactive sexual desire disorder, daughter of the invented female sexual dysfunction. gerd, gastroesophageal reflux disorder. this is what used to be called heartburn. we used to tell people drink vqsñ less coffee, drink less alcohol, smoke less, don't eat a full meal and go to bed right away. now you have to be on potent ?5t life. pediatri tolar disorder.

what we used to call the terrible 2s.fv[h excessive sleepiness. anyway there's been many other conditions that actually do exist but have been redefined. so restless leg syndrome iyiki actually a rare neurologic condition but it's now been redefined to anybody who fidgets at night. i won't go over these other ones. i'm happy to discuss them. here's an award winning ad campaign for a tragic medical condition, severe underarm sweating. so apparently injecting botox in the underarm area could help with this. so now it's a serious condit'%e low "t." there are quizzes online as to whether you have low "t." we gave the quiz to everyone in my office and everyone failed, including the 23-year-old women. excessive sleepiness can be a real burden. anyone suffer from that?

these are all conditions that q, have been invented by industry. anyway pharmed out works with a lot of industry insiders and we have information that is unusual. and these are some of our publications available on our website. we have promotional items available on the table outside.uáfñ# and we are planning our fifth conference. we've done four conferences on these topics. ç this will be june 11th and 12th. and i hope you all can come. it will be at georgetown.@g thank you very much.zqwjyu >> good morning i'm very happ[#qtñ to be here today. i'd like to thank the national coalition on health care for 0$ñ÷ hosting and deborah whitman for the kind introduction.u as a couple of people have

already said, the first version of the physician payment sunshine act was introduced in j!nx 2007 by senator grassley and senator cole.5k i think if you called your o@qíñqcñ bookie in september of 2007 or your washington lobbyist, and said what are the odds that this3 thing will become law they would have said it was pretty unlikelydfby at that stage.x ño zbbd÷ a few things happened. some of them have been mentioned. we had investigations by senator grassley and by the senate agent committee of senator cole. we had high profile media coverage of the issue of conflict of interest and payments to physicians.xysrç we had state laws that required this kind of reporting at the 'eó¡ state level and created a kind of compliance nightmare for companies that made÷óh willing to entertain a federal law. but we also had leadership within the medical profession that i think was also important. the institute of medicine issued a very influential report on conflict of interest.46f8r

the american association -- the association of american medical colleges issued a report calling for much stronger conflict of interest standards. we had leaders within individual(hb schools saying we just can't keep going. our profession can't keep going the way it has.shppjzìáhp &hc% so all those things came together and the law passed in 2010. but the other piece of context ?yñ8dlfb x5.pá i think isn't approximal to the law's maspassage but is really important to understanding how it fits now is this sort of much wider recognition that wi really,[z need to understand in this country the drivers of health care costs and where the dollars go.ffñ and if you went back to 2007, i think it would also be close to unimaginable that cms would be publishing individual physicia.? uv f1 o payment records. but that's happening now, too. as rodney mentioned this morning, we now have the first report from the sunshine act ydññ)

$3.7 billion in payments to p=n hospitals in fiveú&r months of the first year of reporting. that's a÷n1szw+eájjr(hvqp). those are funds that are either going to research and product development, and that's important and important for the public to understand. or going to drive uptake of particular products. that's also important and important to understand.éb÷ so where are we now? pew has been involved in this áçs issue in a long time, as have the other folks on the pafj0o% today, and many other organizations. and since passage we have s continued tkgf$%-:)hp orking group of consumer organizations, and also individual companies to build shared understanding about how the data should be presented. and about some of the technical challenges in getting that data d,s7÷? úujeu)q ublic domain.

data for the first full year of reporting has been collected. 2014 data has been collected. it will be submitted to cms in march. and in june we will have publication of the first full ÷ $bko year ofút9 data along with some delayed publication of data that for various reasons wawant released from the first five so the law is moving forward and the question is what happens now.o$ let me give you three thoughts. one thing that i think will happen, one that i think ñ probably will happen, and one ç/qp÷ that's important, but will take some concerted effort on the 39,÷ part of stakeholders if it's going0fhxaa9ñ so what will happen is that the tdjá process of]%qq%9 (hu)s& continue and be refined and we

will have this year the first full year of data.á0!ñ what i think and probably will happen is center forf. medicare continue to refine thep presents that data and as rodney said in his remarks this morning, the firstnc website wasz8ç not very user friendly. it was pretty difficult to go on there and find your own but cms to its credit within a couple of weeks of launching that first website put up a much;:ei÷49 more user friendly tool to let consumers search, find their own doc, and the agency tells me that they continue to work on refining t improving the search tool, but tz(h also thinking about how to provide the data in context by medical specialty, by geographical location with time trends. so those are all things that they're thinking about as a way to make the data more useful.

so they're working on that. and i credit them for their dqmh9 .t willing to continuously improve that. the third thing and this is the thing that i'm not sure will happen but is really important rlyç is the law creates a lot of descripters for payments, so is it a consulting payment, or is wsájñ it for marketing, or is it a meal. áxt and those aren't defined in the law, and some of them are overlapping. and what we suspect right now and don't know is that probably companies are using the terms in.e x fairly different ways. so if the data is going to be useful and comparable across compana(fzájjtjuu(áq here will have to be a concerted effort by stakeholders outside to sort of sit down and say what do we mean when we use this descriptor category? and that will have to happen.p ñ there's also an ongoing discussion about how to provide fñq+q

context on this data.l=3wñ the law allows for individual essentially a comment field associated with each payment most companies haven't used that and from what i hear they sd probably won't because from a p0hóñ compliance point of view the compliance officer at a company doesn't want somebody on the 3g front lines to be just free texting into an individual payment field and we're talking about millions upon millions of payments here. so, we're left with how does cms, how does the public, interpret the payments we've got. and there is some context language on the website saying what's meant by a consulting payment, what's meant by these other kinds of payments. but there needs to be an ongoing process of developing that. but there's also inevitably ir going to be a need for an bha ongoing societal process of understanding which payments are+7a&ñ we concerned about, which ones / ÷ are we okay with, and what do they mean?

so that culture change in medicine that i talked about that help to drive the move towards more transparency. v awt will have to continue, andn$j. so the data in the)q4r public do7 really an "i"çgm step and the result of a lot of hard work by thegc÷ people here and people across thebb÷ country in the industry. and believe me there are a lot of committed people in companies who are spending a lot of time and money to collect this data 3'ñ and ad@%qzue)ju)q ublic. and by the way, learning some interesting things, too. i've had people from companies say once we started collecting this, we realized we were payingj>ña$m the same guy from five different budget lines. that was really interesting.l9tw there's a lot of work yet to go in terms of collecting this data, understandokgt, and thend6té deciding as a society what to make of it. thank you. ñ

>> we're just going to pull up my slides.íz.yvxra9(t&háhp &hc% so i'm bill jord!?@i %9qñ elect of national physicians alliance. i want to thank the hot having us as well and also the i'm going to talk about the f 6÷ influence of pharmaceutical companies on doctors, and ny+g personally as a doctor, but aluv as leader of an organization that has taken on this issue as d9ú one of our core issues around professionalism. i don't have any disclosures in terms of receiving payments. áuájsju )ju and einstein but the opinions are my own. background on national z@b physician's alliance we were founded in 2005 to strengthen yzñ movement on behalf of patients and build a community that dvlk and really restore integrity and

trust in medicine.& we don't receive any funding from pharmaceuticals companies or device manufacturers. ÷ so let's talk about some of the ñ

on clinical care, our research, l19pq=sb and our education of up and coming physicians. and it really erodes public pfzd trust in health care.nq it's also clear as everybody mentions companies target physicians.yb 9iz[éñ drug reps -- oh, there's an error.i!e there were 38,000 in 1995 and 100,000 in 2005.vaj÷c!eá so this is old data but there was a drug rep for every eight doctors. and with a cost of about $12,000 to $13,000 per docto d country, which is enormous.ñ you can see on the chart on the )fp, right that detailing doctors made up about a quarter of the j promotional spending budget.1gm%m this is also old data but the per same. and actually more than half of the promotional budget was connected to free samples. so )u nd talk lj about that for a few slides.qxbyí just because i was asked in partyfd3 to talk about what are the gaps m

xñ that the -- that the movement forward in transparency are not addressing.íú-ubeym i would say that it's mainly q2lcq!%m ejt$u$at's going to free samples.1@ so 94% of doctors have a relationship with pharma. that's all the red frowny faces. doctors self-report that 83% took food or gifts.

pressure who you tried lifestyle changes with and then you move on to prescribing medication.gd:ytíry tñ and 27% said they would dispense a free sample to this patient.n and about a quarter of them said they would give the free sample ñ6 w even though it was a different medicatioák)ln what they 'r),ñ thought would be best for the patient.=ñ and even more troubling is if this patient went on to get insurance, 17% of the doctors would continue the free sample 1sñ insured.zjú!v there's good data as well from clinics that bann ia1 ññc-cz increases prescribing of first $m. line drugs like the most appropriate drug for that @=z patient.l

brought forward by the aamc report and they're more often vvcjz subject to black box warnings 4;@b=5 ue)u released to market.p obviously it's a major marketing tool that's very expensive to health care./fnb it increased patients' out-of-pocket expenses. 5dr5 accounts for a large portion of pharmaceuticals' promotional rw&v fvé$!xu expenditures and really is a main driver of#c 2cy the increase in spending.ó6ch out of the huge number of medications that are on the market, the ones that are most promoted are driving most of the spending.$q this is a report from ims healt vñ talking about avoidable costs in the health care system. data from 2012.1y÷ you can see $213 billion they tallied up.# you can see that major chunks of this are nonadherence which i often due to patients not being able to afford the medications that were prescribed for them u which is directly linked to advertising.]

which is also often linked to promotional activities.fy'ñ and underutilization of genericsj'bew which is also directly tied to ix that.f;aô4 obviously there are a lot of alternatives to free sampl% some of them are politically challenging such as universal =p health insurance and government pc negotiation with prices, things áe5> that are good enouó háhe department of defense should be -hjtdtb

but doctors are still doing hñm them. that's out of the good stewardship project and became the choosing@7 sñ@'ds is one example y.p )jjunñ(ñ that came out of that choosing z8; wisely campaign in terms of really need this medication or procedure. so definitely patient engagement is needed to engage in this issueèfv@ obviously a lot of the speakers ys"áñzz have spoken about the open áú:bhó&pñ payment sy t length which has been getting better as time goes on.é1nkaiváww this is just a review of the pi statistics that are already offered. as the data has been clean the number of individual physician &háhp &hc% records has come down.\ but, you know, hundreds of ay÷áo÷ thousands of physicians, and over $3d&#t&ion.>& and that's just over five months.&1m also i wanted to highlight 1300 teaching hospitals.czac)e and that speaks to the point of the formulary of particular

hospitals being influenced by pharmaceutical 3j

partners like amsa and community2q catalyst to get information out )>fnn to academic institutions around the counhand practicing physicians to really change the culture, andr u of the seriousness of this efl< @r(t&háhp &hc% issue.yafdq so we can use transparency for good, and i'm hopeful this will ye"t(ju)áu b as the improves, it works as a shaming tool for better or worse. that's a speed bump for getting involved in these entanglements in the first place. and also allows for the /$ ñ possibility of loss of peer respect when people become aware of these relationships. also affects patient opiih patients are often very concerned when they find out e ÷ that the doctor that prescribed a particular medication has received payments from the manufasv nd can have career implications as academic institutions increasingly have $';añ strong policies around conflict of interest.a5y÷páb7rbp@r(t&háhp &hc% obviously we need to follow the6r8á money to know where most of the money is going and how to v6+ @r(t&háhp / g% improve the situation. ñ.g

this is a quote taken from a x n- ,bú (áá$u$e iom report, and i hope that this will be a springboard for action as we úif have better access to information on this issue.zpx 4ñúi0#1pçd yl4ñ thank you.áó÷ >> i think we had a wonderful ìáhp &hc% panel that has raised lots and >g lots of issues. i just wanted to highlight a couple key points. one is that there were a lot of í8jñm different industry players both pharmaceutical and mepjp+ey device manufacturers that emb gq dea of transparency.n%w some did it because of consent but i think moved forward being hgkh very open to the issues around &hp:÷ transparency. and some were real voluntary

leaders, and so i really want tozqpr÷ cite the fact that there wasn't =uáum@qz1%f÷pç massive industry opposition, at " gé÷3e!ú-o cf1 o least at the federal level to this legislation.: q as allen said, it has changed their business practices from what we've heard.oyíx but that there really was a coming together across lots of groupsu0n saying that this information can be valuable to the public.; + i also wanted to point ou$ú í rodney's point on clinical research. and the value =)klowing when researchers have conflict of 7 ;e interest. senator grassley's office did an amazing series of investigations]of that highlighted some of these conflicts that weren't being reported to medical journals.hfzx and several of the medical ffcúñ journals have, as a consequence pgk9 over the last several years, really changed their practices on disclosure.x÷ and you could hear that from thezx@r(t&háhp &hc% doctors as they got up today and announced whatever disclosures

that is a lot more common and we/of legislation itself. xy a good thing for all people to know who's funding what information. a couple other points we heard /zuz about the legislation that there the physician payment sunshine act was targeted towards physicians, and as we heard wcfc different states have expanded pr#no that coverage to other v

others who have been, you know, really tirelessly trying to look at correlations.(ajp and then i want to finish with a question and then i'll open it up to the floor.qà# which is to rodney, because i 8l?ñ think his boss really has set : the standard for transparency on a variety of different ways. yj and in particular, the efi legislation or the push to cms directly to doctors, along with t/#[y the physician payment sunshine act transparency.[égxxwm,[a

at almost simultaneously having rñ7/d7 cms ra5urá )(p)e payment g g data to " cr"ers and the physician payment sunshine act, r/í>c5gz the open payments website comingrõj7c0.fp online within months of each other that it does provide payments and the patterns of practice.zaid÷ information particularly as research has done to see what is going on there that will inform zilka us in the policymaking realm as to whaãol!q _t(qááp)y, what might be things of interest or 8x n/ and again, consistent with the 9 theme from senator grassley that we're better off with more information than less. allen and the doctors on the ÷ panel, if i'm sitting at home cky@fg@r(t&háhp

&hc% and as a consumer and want to know what are these íx relationships for my own doctor. how do i go about getting that informationù9yñi.v$pïc what's the best resource that rcl0÷ you think is out there for consumers to understand this new allen, do you want to take that one? >> i think right now there is some context information on the open payments website lhl 5y very general descriptions of $pñqaúy cf1 o what's meant by the different payment types in there. beyond that, i think you need tohx ñ /ñ4sf look to a variety of resources. and i think different people ylvrá$rju$ey interpret and value those payments.™÷ but you 3 organizations like npa, consumer) reports, consumers union as wellvdjb

as to industry websites and continued medical education companies and so on. so i think right nn2 uá to read broadly so they can make up their own minds. >> do you want to add to that?b÷ >> patiñ 4jáj$áqq physicians who see drug reps.c01xr it's easy to tell whether d[$u"uo see drug reps or not.3qeq> theyadvld be looking up their cix7a@vñúf÷ doctors on dollars for docks to see what money they are taking it's l5ncuáq#ul to figure out :dút#b",ç'$7 what the effect is on individual?$-÷swmhñ drugs. like i [°ñ marketing starts0sbíl seven to ten years before a drug comes on the market.6h-, a patient isn't going to know but they s#rp+e a conversation with their doctor. if there's payments on that websiter48 to their doctor about it. but i think patients shouldn't -6!r see doctors who see drug reps. gznuátjáp!out the 40%.c.+n 40% of physicians limit or d

forbid drug reps to see them about 1 out of 4 doesn't see yh÷ drug reps at all. doctors out there.+r=ñx$ ñ >> bill, a similar question. you talked a lot about samples.f7a my own physician. what are the questions i should j5 doctor's office when that is offered to me?6fé >> say no.:ózop >> yes, just say no.>s work.n xrç i think that all patients should ask their doctor do i have other alternatives to what you're this and any alternatives cjbb including the cost.f y>5÷tqaas and that that often leads to a ] better decision both for the patient and the doctor.ziy &úñ i uy/)háhat it's great for patients to become more aware : and to think twice about seeing 1hijñl doctors that have clear reé cy coming into their office.

it's not always possibth%kxf(ñ0u9 but i think having more of an ezv activated patient makes a huge í:ojt&háhp &hc% difference in terms of thinking about these issues. >> samples are the most clf$a= effective marketing tool that pharmaceutical companies have. to see the look on the doctor's face when you say can i have a an sñ:ñolder time-tested medication, please? and really it would be the best thing for your health. >> you also mention consumer tz[y look, who do studyçi the drug costs anda jw effectiveness and they're good rux]awqáá they have. i'd like to open it up to the audience to ask questions. wait until the microphone is n÷2op handed to you by mr. mcneily and your questions for this 0xv9)j @r(t&háhp &hc% pane,]2÷d m right here in the front.8ó&w4/çifh"ñ

>> joyce freeden fmi1h> t today.@@ç i was interested in what you jo:ñ said about how pharma companies have different marketing targets now and that they are getting into who does the doctor's son play baseball with and all that. is that a relatively new thing k and can you give examples of vd .kfe what they're doing?/o,ykte/nhñ9gé >> targeting people around a physician is not new. so the tarb@r-d doctor is the atom and everybody around them 7tsñ is the molecule. so that's not actually new.i)ñ while physicians know that a drug rep who comes intg $ office is there to sell them !ñh something, they are not really bf÷ being suspicious of their ]vt receptionist or golf partner or their friend. 0s9sç[%iátázwy if a marketings"omqf3÷ message gets conveyed through another person

whov3vs isn't their sales rep, it's much more effective.;dvjneásp)keting messages are not necessarily about using a specific drug. it might be that the marketing s message might be that excessive sleepiness is not a joke.2f$@ it's a real condition.7e% ç low "t" is a tragic epidemic. or that a particular competing drug is so problematic no one should prescribe it.j so every drug on the market is j/s q8] 15 to 20 mg associated with it.rmñ have nothing to do with the drug itself. it's a very difficult to figure out.m:"m >> other questions from the aud yes.9j)ó( 6déuwéñ you raised an interesting point drkj during your discussion about 0828 marketing practices and one [cjf thing you mentioned is one place practice you see around vya÷

and as you on the panel likely know, there are many fire walls '.d÷÷2q in place to ensç&t ád accredited providers are prevented from allowing @vvñq pharmaceutical companies or commercial supporters to have • undue influence over the content$@ of those cme events, the attendees.rzlñ0 ?r but as you also may know, this 80n is an issue that's kind of come q%s under a little consternation during the rule-making process. the "wall street journal" recently reported that cms has essentially changed their position or interpretation as h ÷ many as five times on whether cme payments should be reported..py6y so my question for rodney and % for the panel, you may be able to provide some consy#on the ú! congressional intent aø reporting for accredited cme k.s payments, but especially ep]]fñ considering the unique reporting>kvzúugi challenges considering that thatjie

firewall is in place to make $ [h sure that the manufacturers or the pharmaceutical companies don't 5÷]çx #rz don't know, for example, who the speakers are that are being recruited for those events. how could we overcome some of /b.sula8y2y ÷ these reporting challenges?r[r was there any conversation on éñ ñ the political side about whether those payments should be ê reported.h14hñ are there any other thoughts on the panel about reporting for #z continuing medical education? >> we'll start with rodney and líñ then allen.çtf >> cme, the conversation there is ongoing. that we spoke to cms, we talked to folks who were from the cme x+ñx sidui3"áuj$u$roughout )fh last summer.gt+ cms, they issued their cúw regulation as it relates to

reporting right. have that to become more l1.a;w8f subsl8 páed, expected that the questions about how the report ing there worked prior to aggressivelv jurt$r'to the world because the cme world usi% zq is much more complex b7 npçi &háhp &hc% the nature of the blinded transactions that occur there.

good morning welcome to the woodrow wilson center. we become the ambassador of italy. good to have you. good to see you frank islam from our national cabinet. and i should be pointing out

others but welcome. it's good to have you here in the wilson center. this is a signature event we're doing on energy. it is let from january kalicki. you will hear from him in a moment. this short book you can all read it by tomorrow -- no it is truly an expert take. they have done two editions of this, an expert take on energy security -- energy and security, as they say. looking at global trends in energy and putting it together and looking at where we're going globally. today today's event we have looked regionally at eurasia and east asia and north america. we'll continue on africa, the 34i8d east and other parts of the world as well. the idea today is to take stock globally where are things goingich. and we're at the time where oil price is dropping and a number of conflicts around the world in which energy is in one way or another part of the equation.

and there are other opportunities in places like north america where energy is also a huge opportunity in people coming together. so you are going to hear really a broad overview today on what the trends are. this is an issue that matters a great deal to the administration, it matters a great deal to congress that was [inaudible] yesterday. and hope flyfully we'll have great ideas for the future. we invite you to be part of the discussions moved forward and today you will have a fabulous overview of the entire world and you will hear later from the secretary of energy as well later today. let me turn you over to january. take it away. >> thank you very much andrew. great pleasure and thank you for your kind and welcome introduction. and as andrew mentioned this turns out the on that

particularly important time four regional event here at the center. and also we'll be joined by secretary ernie moniz about 11:30. so we can look very forward to that. we're fortunate in the meantime to have a canal of the ed morse andrew slay and david goldwyn. ed morse heads global commodities research as citi group. ana depalacio is the former foreign minister of spain and will speak to the 2015 european energy outlook and key issues in the e.u. and the e.u.'s neighborhood, including ukraine. and david goldwyn is the former special envoy and international

energy coordinator under former secretary of state hillary clinton and david will focus on the u.s. domestic and foreign action agenda based on ed and ana's remarks and as a segue to ernie moniz. in fact moniz joined me and our authors of the book. and there is a sample of the book and even order forms -- that is the oechbtdend of the advertisement -- outside of the auditorium. and it was published by the wilson center press and johns hopkins university press. energy and security. and the sub title of our second edition is "strategies for a world in transition." and little did we know what this transition would be when we were putting this together. second edition already in its second printing and it is a book that offers both regional and

global perspectives on energy, the environment and technology. and service as a framework for our bimonthly energy series here at the center. in the book we acknowledge the progress made, especially in the domestic front. although a lot more has to be done. and we point out that that has to be done not just here domestically but in developing regional and global policies. and we propose a global energy security system, or what we call gess with five main components. first to propagate the unconventional energy revolution abroad. second to create a global natural gas market. third to forge greater coordination of emergency response measures. fourth, to lead a multilateral effort to end energy poverty. over 1.4 billion people still do not have access to electricity in the world.

and fifth, to commit to global engagement and protection of sea lanes. so that is a framework that you see edwards thetowards theened end of the book it is full of regional ideas. with the shift of the global energy balance from east to west and advent of lower oil prices, we have opportunity to make real progress on this agenda, and more broadly environment, energy and technology. and i look forward very much to our panels' views on these items and more on our policy agenda. and without further ado, i will segue over to ed chief of global commodities research at citi group to get us going on the overall situation in 2015. >> thank you very much. good to be here with people i've been friends with for a very long time.

the chapter that amywe were responsible for in that big book came to the question of the opec. and answered the question if it was likely to be as important in the next 45 years as in the previous 45 years. and the answer was almost certainly not due to structural changes happening within the world. happening within oil-producing countries, if not slightly less than the consequences of high prices and bringing to bear new technologies to exploit. including u.s. resources shale resources that reeves ss previously had been beyond the complex of the international exploitation. a lot of that chapter is unfolding and in sets the stage for 2015 which opens with

significantly lower pricer than the year before and opens with significantly additional disruptive changes that are likely to be occurring in the oil market over the course of the next few months the next year. as oil prices test the cost of producing oil around the world including in the united states. and has as one of its consequences kind of unknown disrupted, unintended consequences that result from a world of ultimately lower oil prices. so what are the three trends that the market is starting with now? trends that are continuities from what had transpired in the latter part of last year? first a weak economy. last year we reckon global gdp growth was 2.7% that. compares to expectations of 2014 gdp growth as of the middle of

2013 for 240u014 to see 3.4 5 or 6% for the world as a whole. a lot of that decline, some .9% was situated in emerging markets. china which performed less well than people had thought. the other large merging market countries as well india, brazil russia for obvious reasons related in part to sanctions and turkey. so there was a radical deceleration of growth in emerging markets. we think this will be a weak year too although not as excpected and that is because low oil prices tend to have repercussions around the world in terms of spurring on economic activity. the imf blog had has some very interesting calculations on this. our own calculations are similar to those of the imf.

we expect that if prices stay more or less where they are, the gdp impact of that globally by the first or second quarter of 2016 could be as much of .8 of 1% of gdp growth. and that will bring more oil demand although probably less demand than what's associated with the global gdp growth because global demand has become less energy intensive, less oil intense. and china is kind of leading the charge in losing the energy growth and --. a second feature has been the shale revolution in the u.s. we expect that the continue. we expect there be no way in the first six months of the year to show a decline in the rate of growth of u.s. production. so u.s. production is likely to

grow by a rate of over a million barrels a day per year for the first six months and then the consequences of lower cap ex on the upstream will come in probably an accelerating way over the rest of 2015 so that by the end of the year we expect u.s. production growth will have slowed down from 1 to 1.1 million barrel a day increment on analyzed basis to something on the order of 2 to 300,000 barrels a day analyzed. the third feature of the year has been saudi marketing problems. and yes, the saudis are selling less crude oil. they are consuming more production at home. they have more refining capacity than they used so. so rather than being an exporter of 7.3 million barrels a day of crude they are around 8 or 900,000 barrels a day lower.

still the largest exporter of crude in the world. as they discovered over the course of 2014, they were losing market share considerably. in the u.s. market they were exporting around 1.6 million barrels a day just under that in the last four months of 2013. in the last three months of 2014 it looks as though they were exporting less than 850,000 barrels a day to the u.s. a drop of more than 45% overt the course of a year. they found it very difficult to market that crude elsewhere. europe because of difficulties in the european refining system and competition against other crudes. china though in particular where their exports have been falling and where their market share has been falling even more and where due in part to u.s. sanctions and chinese buying habits, by

buying oil on a pre export basis, the market available to those competing in a market are shrinking. and particularly in a country where we reckon incremental oil product demand last year was less than 2% and we think it will be less than 3% in 2015. so we've had this well publicized clash between saudi arabia and the shale revolution in the u.s. as the market unfolds. briefly we think the market will be more disruptive in the coming weeks and coming months. we have a new pipeline structure open to bring canadian sour crude to the u.s. gulf coast market. the flow is going through the seaway system at the moment. look as though it is an incremental 400,000 barrels a day coming from canada into a market where competition by the saudis venezuela and mexico,

among others is particularly acute. and this will probably have significant -- pose significant challenges to sour crude producers on the u.s. gulf coast. to say the least we have iraq ramping up and russia increasing exports, actually, into europe. all coming in the first quarter. leading to lower prices and in all likelihood if we separate the financial flows from market fundamentals. but weaker market fundamentals going into the second water when oil demand tends to plunge compared to the middle of the winter. so we think there will be much more difficulty ahead before the market begins to settle. markets balance. they always balance. it takes a long time to balance. there are many ways that the market can balance. i suggested one in terms of lower increments of u.s. production growth by the end of the year and another, increments

of higher demand by the end of the year. but i think the year will be challenging because of the inintended consequences. -- unintended consequences of very low oil prices on things we don't really know about. we have opec countries. other than iraq by the calculations of adam sminski's e.i.a. calculated that opec revenues other than iran were around $825 billion in 2013. and it looks as though their recent calculations are going on the on the high side. and it may be that 2015 will bring less than 400 billion of opec revenue to countries that are challenged by fragmentation problems by general governance problems, by problems delivering to their publics. the concentration of paying from lower prices is a sovereigns that depend on oil and gas revenue, whether they are opec

countries or non opec countries like oman or russia. and we don't really know the unintended consequences of this. i was in g.c.c. countries in the middle of december talking to -- more to locals and to ex-pats who reminded me about the unintended consequences of saudi arabia and kuwait raising production by about a million barrels a day a right at the end of the iran/iraq war when the world expected more oil coming out of those countries. oil prices went down and one of the unintended consequences was the iraqi taking of kuwait. so we don't really know what the unintended consequences are. but they can be chilling. and they could give rise to more disruption. so with that i'll pass the baton. >> thank you very much. and yes over to ana. >> thank you. first of all if i say it is a great pleasure and a great honor

for me to be here. it is not rhetoric. this is the transatlantic relationship with content. and if there is an area where today because of geoeconomic reasons that you have hinted at, but mostly because of strategic reasons there is is precisely in energy. so now a disclaimer. i will be with paint with big brush strokes, and when you do that you exaggerate. my disclaimer is that the energy policy of the european union is a policy in the making but it couldn't be otherwise. and it has a lot of contradiction. it is not easy, but honestly this is a working progress. why, if you take the prospective

of the construction energies and there was an ambition of having a common energy policy but ambitions that have not yet been fulfilled. we have just kept pushing the common market in electricity and gas. this was the last deadline. we are far from there, but this business today. it is what we do, in common. the best way and more descriptive way. and in the last -- the one that just what we do there is an important novelty and you will say it's worse, but we are a

construction of law, and it means a lot. for the first time we have solidarity. as for the rest a lot of contradictions. the community has to -- is in charge of security of security of supply but at the same time every member state has an absolute freedom to have it's mix, energy mix, so on and so forth. the second, the second issue is that in this evolution, we have gone from a policy of the '90s, the policies that we're now in. in the '90s, it was market oriented and short-term oriented. this was before 2000 and in the run up to 2008 the other

marking moment energy policy had nothing yet hijacked by climate change policy. 2008 could not mention competition because you would be -- immediately. there was no security of supply. there was no concern about the competing. everything was geared towards this issue of climate change. second characteristic is it security of supply, which is really our biggest problem. why? first because of our resilience of our system. i will speak about it later. because of our external dependence it goes to almost

90% -- almost 70% in gas, and 40% something in solid. with this, how come that woee don't -- in the situation but we could do -- never with the ambition that this would be a changer as it has been in this country. the ambition should be there. it isn't. this is really simplistic. there are also reasons of how our property is structured. you don't own -- you have no rights on what is under the -- but the last thing is when they say you have a reason -- okay

but this is not realistic. the european union makes it reasonable, but it is not realistic. the defense is 98% on oil. with this, i think that i would highlight four challenges. the first is to keep abundance between realism and ideology. okay. do it, realistically. today, the industrial electricity in germany is 13 cents. it is 5.5 cents if my figures are good. or another residential electricity price it more than double in europe than in the u.s. in spain my country, because of our betting on renewables we

generate 30 billion euros which is a lot of deficit that we, we change that by changing the frak framework of the responsibility. the first thing that we have to understand is that 60% of our infrastructure has to be renewed in the next 40 years. this means 2.2 trillion euros. at the same time what we have is that -- it is getting out of generation. in spain and germany we're closing plants because it is -- companies, many companies have existing models on the brink of just bankruptcy.

the third important challenge is to balance public and private. 2.2 trillion. it must be an imbalance. you know that president of the european commission launched this idea of 313 billion euros in the next 30 years. it's for infrastructure and i don't know how much is marked for energy, but it is not sufficient. we need to find a better balance between private and public. but we need to have a short vision, and the united kingdom is a good example. they have bet on nuclear, and because nuclear means such a big investment, they have proposed a fixed price to warranty the price.

and today, in europe many times the wholesale price of electricity is zero. which by the way doesn't benefit the consumers. . the last challenge for me is the national nalal association. as i have hinted, we think we have the market. policies are made in the member states. for instance germany goes out on nuclear from one day to the next. not at all. but this means a lot for the system. and this is something that there, we have to really put our words and our deeds in order. because we speak about this internal market. now, if security of supply is important, because of our

dependence this has a name today, it could happen any time but not to the same extent. we import around 14%. but for the moment, the name is russia. and the concentrate today in ukraine. and this is where this transatlantic community of interest and purpose makes sense. we need to stand together in the sanctions, but as you know the sanctions for us and are important for you. many americans told me that they will never accept the sanctions we did and we are there. there are some that are unfortunate. and a disclaimer. what he is said to have said.

he said that if conditions improve, we should scale down, which is different from what we have been reading in the news. so our policy towards russia is a point where we really need to -- with this space. sanctions first, and the support of ukraine. ukraine, we cannot expect a success to start tomorrow. we have to be persistent and consistent. and they have to get their act together. in order for ukraine to have their act together we have to support them and to support them in an effective way. there have been criticisms and with this i will finish and we can touch up on, there have been criticisms on the world bank, the imf have been doing. i think that these are not

really that founding but let's not forget in the world bank and the imf between you and us, we have 37 or 38 of us, and you 16 point something, so we have a majority. so let's just put here together our -- where our mouth is, and just understand that this is a challenge in the long term. >> thank you very much. >> thank you for your leadership in this series and in the book. i want to acknowledge robin west, one of our contributing authors in the house today. all of what we heard this morning about economic volatility and policy confusion in other places questions what we in the united states should do at this moment. i offer three framing comments.

now when we talk about energy security, it's really not just oil security any more. in the u.s. we're talking about comprehensive energy security, the security of the grid the stability of the grid the resilience of the system, oil is still part of that, but it's more of a comprehensive picture. the second reality and political reality is that we can't talk about ways to increase domestic production without talking about the environment and the consequences that come with it. it's two sides of the same count and we will not have a reasonable political conversation about any of these issues unless we deal with both of those. that may mean as we try to grow the productive bait that we have to deal with issues like methane. right now the polarization of the debate leads to paralysis. also avoiding complacency. being self sufficient, not caring about the middle