to put last-minute amendments is because they cannot be challenged. fined for $700 million they got a refund from bill by congressman -- who was it? the speaker pro tempore: the house will be in order. the chair lays before the house a commoon case -- communication from the speaker. the chair: the speaker's rooms -- the clerk: the speaker's rooms, washington, d.c., december 1, 2014. i hereby appoint the honorable mark meadows to act as speaker pro tempore on this day. signed, john a. boehner, speaker of the house of representatives. the speaker pro tempore: the chair will be offered by our

chaplain, father conroy. chaplain conroy: let us pray. gracious god, we give you thanks for giving us another day. you have blessed us with all good gifts and this past week with thankful hearts we gathered with family and loved ones throughout this great land to celebrate our lettings together. bless the members of the people's house who have been entrusted with the privilege to serve our nation and all americans in their need. grant them to work together in respect an affection and to be faithful in the responsibilities they have been given. as the end of the first session approaches and important work can is yet to be done, bestow upon them the gifts of wisdom and discernment that in their words and actions they will do justice, love with mercy, and

walk humbly with you. may all that is done this day be for your greater honor and glory, amen. the speaker pro tempore: the chair has examined the journal of the last day's proceedings and announces to the house his approval thereof. pursuant to clause 1 of rule 1, the journal stands approved. the pledge of allegiance will be led by the gentleman from south carolina, mr. wilson. mr. wilson: everyone, including our guests in the gale are, -- gallery, please join in. i pledge allegiance to the flag of the united states of america and to the republic for which it stands, one nation under god, indivisible, with liberty and justice for all. the speaker pro tempore: the chair lays before the house a communication. the clerk: the honorable the speaker, house of representatives. sir, pursuant to the permission granted in clause 2-h of rule 2 of the rules of the u.s. house

of representatives, the clerk received the following message from the secretary of the senate on november 21, 2014, at 9:28 a.m., that the senate agreed to without amendment house concurrent resolution 119. that the senate agreed to without amendment house joint resolution 129. that the senate passed without amendment h.r. 5728. that the senate passed without amendment h.r. 5441. that the senate passed without amendment h.r. 4067. that the senate passed with amendments h.r. 669. with best wishes i am, signed sincerely, karen l. haas. the speaker pro tempore: pursuant to clause 4 of rule 1, the following enrolled joint resolution and bills were signed by speaker pro tempore thornberry on friday, november 21, 2014. the clerk: house joint esolution 129, h.r. 4067, h.r.

5441, h.r. 5728. the speaker pro tempore: the chair will entertain requests for one-minute speeches. for what purpose does the gentleman from south carolina seek recognition. mr. wilson: i ask unanimous consent to address the house for one minute, revise and extend my remarks. the the speaker pro tempore: without objection, the gentleman is recognized. mr. wilson: mr. speaker, the president's illegal alien amnesty plan is unconstitutional and destroys american jobs. according to a recent article in the "washington times," quote, prom's temporary amnesty which lasts three years declares up to five million illegal immigrants to be lawfully in the country and eligible for work permits, but still deems them ineligible for public benefits such as buying insurance on health exchanges. under the affordable care act, that means businesses who hire them won't have to pay a penalty for not providing them health coverage. making them $3,000 more attractive than a similar

native-born worker who the business by law would have to cover, end of quote. this gives the disadvantage to legal americans and citizens and also legal immigrants who deserve a job. sadly we are seeing yet another example of how the president has pushed failed policies instead of working with house republicans to help american families find jobs. in conclusion, god bless our troops anti-president should take actions, never forgetting september 11 and the global war on terrorism. the speaker pro tempore: pursuant to clause 12-a of rule 1, the chair declares the house in recess until approximately

payers, and consumer advocates this afternoon. this is just getting underway.

and in him >> we are going to go ahead and get started. them managing directors here at the institution. we are glad that all of you can join us today. we have a packed agenda, i will

keep things short and simple. we have folks in the room and i wanted to acknowledge a number of people watching via webcast. because we are recording the event i want to make sure we have a couple of items, just so you know, we will have a full recording on our website, the brookings website, in the coming days. if you do have any questions or comments in the room or on the website, go ahead and actually wait until we have an open floor for questions and answers. hold time until we have a questions and answers session. we are using web and tv monitoring and we will be using the microphone mics available during q&a. we also have the ability to submit questions by twitter. you will see the #for this event is held data. just in case any of you would rather use different media.

online,re viewing us you can immediately download a couple of resources that i wanted to point you to. once i finish this housekeeping we will get to why we are all here today. the two items that we have that are available in the room, if you are here in person, are one, a first issue brief on the commonwealth website as well as ours regarding cms medicare physician payment data and the topic that we are discussing in part today. and then also something that i caitlin brandt, who helped with this effort, for, once we spoke to so many of you we learned that there were so many tools out there around transparency that even to us to talk about this on a daily basis it became overwhelming, so we decided to for the sake of today's conversation put together our own online nonexhaustive resource list. we would love feedback on this and we would encourage you to send us the act to the website

or through the twitter feed so that we can get your real world take on how valuable these resources are, but those are also available through the website in the link below. with that, i wanted to just start things off. i will be moderating the first panel, doing some intro, but i wanted to actually ask one of the vice president of the commonwealth fund to give us some of his thoughts. this would not have been possible without support from the commonwealth fund. the work that they have been doing on transparency and delivery system reform has been instrumental in helping us get to today and hopefully passed today and into the health care future. stu, then we will start. thank you. >> thank you. on behalf of the commonwealth fund, i would like to thank everyone for showing up here and

everyone who is watching online. i just have a couple thoughts to set the stage. we talk about transparency. lately i find myself asking the west and -- what does that really mean? back when we first started talking about transparency and especially in, washington amongst policymakers i got this image that we were really talking about putting a proverbial black box inside of a lucite box and calling that transparency, but nobody could really figure out what was going on, you could just the outside of the black ox better. what do we mean by real transparency. i think the folks here today will help to address that. what we really want is information. that means we need to have data in usable forms. we need to have data at the right times and in the right contexts, provided to the folks

that can use it the way that they need to use it. effectively. we are talking about consumers, researchers, payers, and of course policymakers. i am hopeful that the topics that we will be addressing today will begin tos give us some insight into how we can use all the data available for good use, to make better policy and make better decisions both in what we produce in the health care system and what you consume and how we consume it. i will not hold up to show any longer. thank you again. i look forward to the discussions. that let's gowith ahead and get to our first panel. if i could have chuck, charlie, and miles,, so that we can my

queue. if you don't mind? you will kind of go in order. and then charlie, and then me. yes, that way you guys can get the mike's up. -- microphones up. good? all right, good. we've just got to wait for the slide. ok, good, perfect. so, we have -- for the sake of getting us started let me make

sure that i get introductions kind of from me going all the way to next to me and to your left. centers forthe medicare and medicaid chief data services. --t but not least, sect charles cutler. we have extensive bios for these individuals in the packet available in person, as well as online biographies. i don't want to spend time reading their bios, but the goal of this first panel was really to offer perspective on exactly what started a lot of this, a data release that came out earlier this year in 2014. that was actually the motivation of what myself as a physician who was a part of the data set really wanted to explore and understand, what does this really mean for patients? i will just tell you that we will be

getting into deeper discussion around these topics. this hit home that only from one i looked myself up, which you can all do online, niles can tell you more about accessing that information, but more importantly with real patient care -- i have a 61-year-old woman who came in with what she thought was a cracked rib after picking up her grandchildren, who were fairly heavy at the time and she was a small, diminutive woman. i said that that was unusual, cracking a rib, we got an x-ray and over 48 hours become that she had lung cancer. it's not fear how it started or if it was metastatic, but she said -- who are the best doctors for me to see? i pointed her to go public to resources that i will share with you and then i went through the difficult conversation of how so much of american medicine is not transparent and she said she would talk to a friend who was a doctor.

alternately when really important decisions get made, we cobble together a lot of these resources, but i think that all of us in this panel and future panels today will tell you that we can do better. andi will leave it at that hopefully through our expert panelists and your own discussions we can get into this a bit more, probing how what we started, and i think that we can speak more about what the administration did -- what we started is really just the beginning. first tog to ask you give us a bit of background on what has been done and a little bit about what you're hoping the future can hold with regards to transparency. >> sounds great. thank you. great to be here. especially seeing as how i am an alum of the center. >> you have come a long way. [laughter] i think that how you have to

view the various data release exercises in transparency is that they have been an ever evolving journey dating back to 2010 and 2011. one of the first things that the president did upon entering office was to find -- signed an executive order for open government. cto of hhsthe then to that charge across the department. he worked with folks to identify a whole range of available data that was already being released -- no, maybe not getting the attention that a publicly deserved, or could easily be released in a machine-readable format. as those first couple of years were an interesting process, the commitment to transparency was

definitely there, but some of the resulting data sets -- they were good but i think that they left people wanting more. so, there was a lot of facility level data machine-readable hospital compare data with geographic variation data, state hospital county levels. not at all to diminish would mean that data releases. the variation data, yes, dartmouth historically released the data out, but that was the first time the cms had laid the book's opening said -- when you decompose spending of the county levels, this is what it looks like. this is what it looks like in very granular ways, helping people with readmission rates for county level friends and er visits, images, etc.. think that where it started to

get interesting, if you will, was about 2.5 years ago when we were trying to figure out where we could move next with our transparency effort. was made to release hospital chart data. again, some folks may remember the release of the data. hospitals, and highlighted massive variation on hospital charges for the same procedure, oftentimes in the same geographic area. certainly nationally. i think that it really resonated with people. frankly, more than i think we thought it would. i know that certain health economists said -- well, no one pays charges anymore.

but to a certain extent charges are often what people are initially exposed to. particularly if you are not well insured or initially insured. it was a deliberate step on our part, but the reaction to you sometime and a lot of people who have been looking at health data , it caught them a bit by surprise as well. obviously with the release of hospital data there was a desire on this wholeng effort. the issue was then releasing physician data, that we were legally prohibited from releasing any data that would thew anybody to identify total amount of a physician with medicare reimbursement. that was a legal prohibition that stemmed back to the 1970 part.

in date a geek speak, it is known as a florida inject -- data geek speak, it is known as a florida injunction. then a little more than a year ago a florida judge overruled or overturned aspects of that us fromon that allowed a policy perspective to begin considering the release of that data. and asto do it deliberate and transparent away as possible. we asked for a comment. we took all the public comment on board. finally in april i think that the open data answered the the data phase with the release of the detailed information on almost 900,000 providers and over 9 million records, i think. that is sort of the story of how we got from there to here. it has been a very interesting

journey. i think we have shown our commitment over the past few years and, obviously, as a cannot comment on specific predictions coming next , but i would say look at the track record over the next four years -- last four years and i would call it unlikely that we would not continue to build it. >> before we moved to charlie, to be clear this is not just in a florida injunction, but internally there have been discussions higher than yours about whether the data should be released at all. >> this is not just a couple of me -- a couple of years and the right -- a couple of years in the making, it has been a couple of decades. a real accomplishment. but your total is -- title of chief data officer is a nod to the idea that more work needs to be done, fair?

are you increasing capacity within cms kind of explore the theof these data sets and transparency movement as well? is that part of what we will be doing in your job? >> our unofficial tagline is maximizing data for internal and external users. whether publicly or through private physician data releases, or innovative ways in which access more control in a secure manner. >> as part of the work we have been doing one of the comments that we have received is trying with,d ways to help work whatever you call it, public or private partnerships to find ways to capitalize on what you have been doing, crowd sourcing these different tools, private

sector and public sector opportunities. will transition. charlie, you have already got the pointer. i know you have some sides, but first i wanted to say that the war we spoke to charles, all of us in the room agreed that from public a had done one of the best jobs and at least trying to offer a way forward for that 61-year-old patient. when i pointed her to a website, i pointed her to yours, to be honest, and said that it was easier to use because it gave context for understanding. we have your website in our resource and i know you will go through some of it in a bit. filling in the category of researcher, one of the first pieces of research on these public data sets, it would be great to hear some of your perspectives. without all of this just seeming like it is rosie, there are

limitations based on what today and i know you are working hard in the effort on future transparency releases, both from medicare and the private sector. thank you, charlie. >> one of the unfortunate things is the more that comes out, the more data you want out there. they open up one door and then we want to run in and slam seven more. that is one of the challenges here. i would argue that it is more than just patients that want access to this information. things i have been really surprised about is how little positions know about their own practice of medicine and prescription of drugs compares, sort of benchmarking by word-of-mouth. when it comes to looking at it objectively there have been no tools really available. says they ared doing well, another says they are doing poorly. often in the middle they throw

all three out and believe what they believe about themselves. of theed to show some real importance of putting caveats and comparisons into things. i think that putting of raw data can be misleading and confusing, which is one of the pushback so the data released, a lot of media organizations sort of just regurgitated what the government put out without putting context around it. put out well before cms his data on medicare fee-for-service, pro-public thought that if cms was limited, catalogued what the doctors are paid. they are not paid for what they prescribe. the pharmacy is paid. by requestingthis what doctors prescribed.

so, after a lengthy negotiation thanks to the advocacy on our behalf, cms released data on what doctors prescribed in medicare part d, the theyription drug program described -- program. they described much information. can you imagine? it doesn't mean much of anything to them, but if you had it why would you want it? one, if your doctor is andmmending a drug for you and if there is one with a lot of experience, that maybe something else worthwhile. with all the data out there on doctors and drug companies, there are doctors prescribing more of certain particular drug.

that could be particularly helpful as well. we think this is really and people want to access data in a lot of different ways. you need to give them the tools to do it. access by state, specialty, or the name, drug, you can look at any of the results.o get to these or you can just situate prescribing doctor. him instead of just releasing all the drugs that the doctor prescribes, we have the dashboard that shows you how similar or dissimilar your doctor is to other doctors. why did you choose the specialty of the state? we did not think it was fair to compare.

each of them had different ways of describing and if you just released the total and swim your way through it, that can be confusing. we showed you the percentage giving narcotics, but if you are a pain medicine doctor, that brings the whole specialty up. compared to doctor that? we also have a mathematical formula that takes into account volumetors selection and , putting it on a line of bars with the doctors on the far right practicing in a very different way. finally, you can see a list of doctors, drugs, and what it ranks for that dr. and others in the same specialty in the state, making you able to again compare the doctors. one of the things we did with medicare part d data was this release, a long list from each doctor.

the media took this and wrote a part that wrote about medicare millionaires. which was not fair, doctors are spending a lot on in all his drugs in when you use them again is it fair to say they are millionaires? if they treat a lot of medicare patients versus someone who does not, that fair? we can marry within their same specialty and state. you can see, for example, the number of services per patient. these marksts -- show the outliers compared to the big numbers. we gave not only raw numbers, but adjusted numbers. you are able to get a sense of the doctor in comparison to their peers, trying to level out

based on the volume of services. finally, you were able to see the number of times the doctors did things per patient. was it ranked? there were definitely outliers. one of the things that we take away from this data is that right now it is a lot easier to find doctors who are off, who seem to have questionable practices, then it is to find doctors who are good. there are too many variables that we do not know for now and that is the next stage, what we want. right now we have doctors performing in their office, but if they give a referral to the doctor down the hall it may incur a lot of medical costs and services that you don't see on the profile. we think the next level of information is about things that the doctor is a referral for. when you are able to look at the totality of what they are

controlling terms of health care services, you can see the complete picture in context, comparing it to others like that. we think that there are huge amount of advances taking place, but there is still a lot of work to be done that will alternately lead to more educated patients who are more engaged in their health care decisions with doctors who can benchmark themselves and take the position before the patient can ask. >> real quick, before we go to chuck, you have assisted in all the work you have done to date, all the conversations you have had, you started by saying that patients are not the only audience. you mentioned physicians. who are others who are really interested in what you have done ? >> i think hospitals, i think insurers. folks with medicare. we have heard from folks in these organizations who think that our interface is easier

than their own. withind a lot of folks, access to a ton of cabinets. we build products that are more than things that are supposed to be drive-by products. we want people to keep coming back. from the pageo go about prescribing directly to dr. services. it is sort of like very easy to navigate around, but that will be the key, people saying -- this is interesting. it is exciting to be part of that. >> and you mentioned the pharmaceutical relationship? , you we started this work already saw the technical problems with trying to do the

analysis you have done already to date on other databases with that particular one, raising a common logistical problem for regular folks to access the data shown in its raw form. christ is right. the assumption that the government has to be 100% accurate? that is not necessarily the case. they were lying on it in device companies so that they could get it right, but that is not with a released. we found institutions where drug companies spelled the name of their drugs wrong, listing them in multiple columns instead of a single column. .hey would duplicate it they would use drugs as devices and devices as rugs. we have been trying to sort this out and it has been very complicated. it is an interest amongst the editors in getting it right

rather than facing the clock. vice a perfect segue to charles cutler, a practicing internist with leadership experience for the american oncologist association. you, weide comment for actually looked on brookings through dozens of letters that financet to the senate committee when ron wyden had asked for public comments from physicians groups and orientations and anyone on this topic of data transparency writ large, looking at this topic for a number of reasons. number of other physician organizations they have very detailed and thoughtful letters that also probably, just to gloss over, similar things. like a huge caveat around how

the data is interpreted by the public, that is something that many physicians, given what charlie have pointed out with headlines, had been threatened by. i am just going to try to speak to that. i had a number of conversations as the media headlines went live in the outliers spent for the charges of millions of dollars trying to understand the medicare charges. it made a lot of physicians very nervous about how people would view their own kinds of charged patterns within this available data set. anhought that it raised important conversation where, in the end, everyone just kind of remained quietly curious and preciously optimistic. chuck, your thoughts as a practicing physician in the data

set? >> if this is the largest specialty medical organization in the country, we have thousands in medical students and services -- i speak for the woman who was chair of the board until last year. in that position i was able to travel the country and meet hundreds, if not thousands, of doctors. but my day job is as an internist. with you, if you took my colleagues and put them in a room and said -- talked about the data release for 10 minutes, we might have nine minutes of silence. are a number of medical issues, like electronic health records, the affordable care

act, data reporting from cms on quality parameters. the bill for doctors has a much higher priority amongst physicians. now, having said that, data is really important. and this conversation is really important for doctors. the example that you used is perfect. with every patient i see as a physician i have to make recommendations to help the patient moved to the next step. or ay be an x-ray procedure, but for my entire career have not been able to help patients in the area of cost. it is clear to me that an antibiotic can get you better, but if there are two of them, which is better?

is the most confit -- cost-effective to use? you can use that example ross every recommendation. what charlie has begun to put together begins to change the conversation that doctors might have from nine minutes of silence over 10 minutes, there may be 16 minutes because it is to knowtant for doctors what things cost, and we never have. now, the other part of it that you have begun to touch on, we also need outcomes. we simply cannot make -- i cannot make recommendations as a physician. the patients, simply based on cost in high, the outcome could be even better than a low-cost

procedure. so, the outcome is important, the comparisons need to be adjusted. your costs may be high, but your outcomes may be good. so, i think this is something that has been encouraged by the data release. they were even more encouraged by honing the data, making it useful to patients and physicians. >> and with a question from the previous? there were some people that expressed concern. i imagine you will hear many sides of this issue.

can you reflect a bit on what some of the concerns have been from the physicians about what was released to date? >> first of all, and i think it was touched on earlier, accuracy is really working. there is a lot of information out there and it has to be accurate information. a sense of and fairness, should have access to the data and if it is inaccurate there should be a way for physicians to address what they perceive as an act writ and make it more accurate. the usability is really important to. we have to be able to access it in an easy fashion. the doctors have to be able to get to it. the patients have to be able to get to it. if it is complicated, it can use that to lose its utility.

so, some easy mechanism to getting the information is really important. one of the other concerns that the physician community has had ist we have expressed to cms one of the deputies alluded to the fact that releasing this data might be a way to address waste, fraud, and abuse. we can argue about it, but simply because costs are high, we have to be careful not to attribute that that is somehow fraudulent. the utilizer would be wasting services. maybe, but simply by having high costs we have to be careful that there is not guilt by association. >> does anyone in the other room have any questions? we will get a microphone to you.

-- ifnyone on the panel you could respond, miles, as you mentioned you cannot talk about future data or actions that might take place in the future, but can you give us a bit about today? what you have seen on the public side so far? things outside medicare or medicaid, for example? >> first of all, charlie and chuck both had excellent comments that added a lot of contexts.rtant my remarks were little thought driven, i guess. we are in our infancy. this is a fluid area. we tried to make it clear what the data was and what it was not. the nature of the fact that it is open data means we have very

little control over how people choose to analyze and prevent -- present it. in terms of the effect on the private sector, you have many hospital chains and systems attempting to be more transparent in how their charges are displayed. there is legislative activity in looking totes address or formalize the publication or the availability of pricing information. most recently the health care cost institute, which is a conglomeration of pretty large national and some retail health plans announced some pretty large transparency initiatives that i think will kick off next year, where they are going to look at the data they have assembled for multiple different health plans.

output isow if the going to be exactly like what we did, but certainly something along those lines. i do think that our actions have had a trickle-down effect. >> i think that charlie referenced this, but it there's repeating. large,ial payers, by and are looking for quality parameters. even if you are in a fee-for-service environment, that there isting quality reporting, but the so-called quality reporting does not take into consideration costs. care really not high-value . these are measures that don't consider costs. i think the next generation of ports that physicians are expected to turn in will be high-value care with good

outcomes at a high value. move it forward. >> one of the challenges is that we are looking at population metrics. but if you are a patient, you care about your metrics. it is wonderful that doctors give quit smoking advice to patients, but i'm not a smoker. think that what you want to know is, like, i know someone who is about to have heart valve surgery and they want to know which dr. inner-city performs the most part l surgeries and how many patients in one year are alive after that. the fact that we cannot answer that today, tomorrow, or even next year, that's the question we want to answer. if i am a diabetic and it is under control for me, i don't care about your other patients, i care about me. yes, but we need to make sure that the data releases can be

customizable. that way the person can get some answers from it. at the same time patients are always complaining about high co-pay, deductibles. we spend billions of dollars every year in unnecessary care or marginally useful care. this conversation and data release gets us away from spending all of those extra dollars that we don't need to spend. i think that it does come back if you'rehe patient, co-pay is going up, your deductible, your cost of insurance goes up in the reason is we are spending too much money. how can we provide high-quality care? we have to factor the cost. rights we have a question here. tell us your name and where you're from.

>> [inaudible] you on thengratulate transparency of the data system, which is great, but how far do you go? maybe you are an assistant? the list that they gave to you, this is the information that you received from patients. it is both critical and important. physician? which hospital, in which area? do you check my checkbook? there is no way to find it. they use a false limb or a puddle blame. something like that.

something like patient's relatives, they complain. not just them. the patient asks for it. those records, they don't give you records. they do they give you the old permanent records. it is essential, and for you to condemn the patient physician who is a professional, think. a lot of the emergency stuff, about the liquid for the patients in the procedure.

if there is approval they say no, we don't have it. >> let me try to wrap this up. misdiagnosis? >> [inaudible] >> and all the different reporting systems. >> [indiscernible] >> i understand. thank you. so, this touches on just a couple of things that i think some of our other panelists might get into. especially our last panel. we started with the physician data set, but as we are hearing -- andre so many streams you touched on this, wanting to know on the referral network in terms of data that is important to triangulate, we are talking about painting a better picture on the complexity of services. do any of you have comments on

-- we mentioned hospitals, drugs, and devices. other pieces of the puzzle that are much more complicated? question, some of the endpoints that involve payments can be measured, right? these are the pharmacies where they log the suspense. when you are talking about a referral, they make two different claims. if you are talking about quality metrics -- chuck, i'm sure you can get into this, but the quality of records leaves so much to be desired that when you are trying to adjust and things like that, we are a long way. thinking about postacute, er

settings, with the complexity of all of this so overwhelming it can be tough to say why bother seeing anything. but it seems like the first was the hospital data that you were talking about. know that we haven't even new to me some information on dialysis and other services, released on other transitional care or care settings where we think we need to have better transparency around it that would be important for patients to have. >> not to -- let me plug the commonwealth publication on this. >> unsolicited, exactly. [laughter] pull it out now. >> it really is interesting. need tothat two things be stressed. first, the physician data has to

be decorated with the pharmacy data. to look at any of it in an isolated way, in a way it addresses some of what we are bringing up. to do it isolated does not give you the right picture. comparisons are really difficult. as the commonwealth publication pointed out, until we get into aboutal detail demographic status, we will never really be able to make the perfectons, the comparisons. so, hopefully one day we can get there. and we are moving in that direction right now. >> i am doing a lightning round to ask some quick questions. what has been released to date? what have you learned from it?

something just to give the audience in the room and on the something that may surprise them about what has been released. i will just kick it off. the thing that surprised me was exactly what charlie touched on, that this was more important to not necessarily my patients, but to my physician colleagues and health insurance friend colleagues, they said that this was exciting and interesting and they wanted to get into it. i think that is a bit of what the next panel might speak to. but something that surprised you from this process? i just likeek, looking at patterns. >> that's good. >> in the data, just looking at how different services were concentrated or not concentrated in certain specialties? and the thing that surprised me the most, actually, was how few codes many physicians build.

before i started the project i said -- how many go up for billing? i would have said -- easy, 50-50 per year, maybe more. for a significant chunk of physicians, they are building 10, 15, sometimes even less. but some of them are really cranking through. that was the biggest surprise to me. >> perfect. >> i had grown up as a health reporter learning about the in regions, but here i learned just how much there was where you could literally go one street over and the quality bydoctors as measured services that they use and the drugs that they prescribed are so different and it really makes a difference.

>> chuck? >> i looked up my data, i thought you were paying you more. [laughter] >> i had to take a cut off the top. >> that's right. >> i thought that i would complement cms, i thought that you got it right in my case. i have been doing this for more than 30 years and it was really thatfor me, despite all of experience, to make any sense of it. -- what aremagine patients thinking? out what isfigure going on here? --that is a perfect subway topics.or our future please join me in thanking the panel. let's do this, we will have you all with microphones and if i could ask or second panel to

come to the stage? and i will ask for dr. paul ginsburg from the schaeffer center for health and economics -- who also has an extensive background i will not be reading , as well as a number of publications related to research in this area, he will be leading the second panel. let me make sure i do not get in everyone's way here. also, take off. good, paul? paul, sit down. let's see if we can swap out the glasses. the is going to read discussions on implications and perspectives from researchers

that policymakers have paired. up some of these issues, but i think it will be robust in the second panel. thank you. >> thank you, i think that we can start now. i am pleased to be moderating this panel. at the beginning of the conference they set the tone that this was about transparency. this has been a longtime interest of mine and i have always believed that some of the confusion about transparency comes from the fact that we talk about transparency because of that aspect of sunshine.

we think about other institutions and operations that should be borne more transparent . although we also talk about it in terms of it being useful to different types of entities. consumers,ink about but when we go further we think about physicians, hospitals, health plans. researchers and policymakers. this panel is really about what different audiences can do with this information. j are going to begin with white, a very distinguished researcher talking about what this means for researchers. then we will hear from lou sandy , the executive of the unitedhealth group, talking about what this could mean for and different

employers. and then we'll hear from bruce, with his long policy background. what will help them in their work for making policies down the road? there are two contexts i would like to ask the speakers about. were going to talk concretely about the april data describing to us, but we are not going to dwell so much on what was in the april release, but also to talk about what could be .n future releases these panels can talk about what they would like to see. to make it more useful. these are not the only game in town.

he's a researcher and he can go through the process of paying a lot of money and making a lot of time. go sheeting a data use agreement and getting some of the data that is really raw behind the release. with united health care, either work with a qualified entity or and also has another channel. i will stop my talking. >> thank you. it is great to speak with you all today. the first question i want to get into his if this data release is a big deal. i am coming at this from the perspective of a researcher, when the data came out, we had a couple of conversations.

we were salivating over this new data source and what we could use it for. we figured out there isn't anything new we can do with the data. any real research questions we could get into, we would really want to use microlevel claims data. does not -- does that mean this is not a deal question mark no. i think it is a step forward. i -- why?on mark the right to privacy does not outweigh our right to the public to know what medicare's buying. for decades, there was an injunction in place for cms to be reporting being paid by

medicare. cms said that balance to the right part -- right privacy in public's writer know, it is now officially tipped in the direction of the public's writer know what is going on in the medicare program. him -- the other thing that is important about the data is they have leaned down a marker and down solutionsy and codes without hip up. a you do research, hepa is vast barrier reef you need to learn to navigate. -- one thing we forget, we

going up it is and down. the tools have been honed for decades. it is a collective data resource. pieceta release is one of that effort.

tot, i would be interested see the private sector is a kind of black box. medicare lays its cards on the table. in the private sector, it is more challenging getting a hand on that. we can start comparing prices and practice patterns, identifying both of those sectors. that to me would be the most fruitful but probably the most avenue to go. i will leave it at that. >> you mentioned in the beginning the agreement and things that cms would access, it probably better serves many

researchers. any thoughts about how the process could be made more efficient as an aspect of the initiative? >> the data could be made cheaper. we pay taxes for a reason, so the federal government can provide services to have a heart -- a high marginal price attached to them. data is one of the things that should be made freely available, even though it takes a lot of resources to produce that data. once you have made one copy of the medicare claims data file, it is trivial to generate 1000 copies of that, digitally. so the price could be made lower. the turnaround time could be produced. that is a significant problem. att is just a fact of nature this point. you have to satisfy all of the privacy constraints. the turnaround time and the

price, i think our barriers to research that could be lowered. >> thanks. i appreciate the chance to be here. i appreciate stu and the commonwealth fund for sponsoring this. do isk what i wanted to talk about what i see as useful in the release, what are some of then some ofns and the suggestions to your point about where we go from here. i want to say is commenced cms for their efforts to promote transparency and the use of these data. it is refreshing. it is incredibly important. idea ofevolve, the development and evolution over time, that is an important theme of this. even in this current release, there is some utility in this information. we heard a little bit about this today already. it is useful in raising

awareness of variation. the pervasiveness that we see out of the data. in understanding some of the factors in that variation. obvious, and so dr. cutler mentioned this, useful in bringing transparency around what things cost. just the basic information there. i think claims data provides what i call a spring view of clinical phenomena. useful for some things and not so useful for other things but am useful dimensions around volume and the service mix. i am not in practice anymore. but i looked up some of my friends to see what their practice patterns looks like very particularly interesting for those where you would expect they were great deal of information, concentrated the senior population. it is important and it will evolve all the dashed over time.

it will provide useful insight even in the current and somewhat limited form. what are issues and limitations? fundamental most one is i think health fans have learned over the years that looking at raw claims data is really more an exercise in hypothesis generation than it is in making a determination about much of anything. you cannot just look at a raw data table and say, there is an outlier, let's do something. hypothesis that you actually have to triangulate around, look at multiple data sources, look at trends over a furtherthen have exploration. particularly may involve health lands to regulate, having a conversation with that physician. you might find an outlier that statistically is an outlier, but

they are actually a referral practice and have a unique of serpents is and they're the only ones who provide that in a region as an example. generation is a way we should think about the use of raw claims data. is, as i said,g a lot can be done with claims data, but it requires analysis. all of us will say it is not just putting the raw data out there. starting with simple analysis and simple descriptive statistics can be very useful. percentile ranking, standard .eviations then there are even more sophisticated uses of claims data through the use of technologies such as episode groupers, and the ability to mix risk adjustment. there is quite a bit of things that can be done with data, even with some of its limitations.

it is an interesting policy question about how much the come in this case cms, versus having a raw data file come out, and have third parties do that analysis. an interesting question. any stakeholder, probably the most important attribute of this kind of data -- youhe ability to make need credible data. dr. cutler mentioned physicians want to pair themselves naturally against other physicians in the same vessel to. that would be logical. that is another thing health plans have learned over the years. that relates to my third suggestion or limitation. what we have learned over the when is particularly releasing data around physicians, it is a good idea to run what i would call a service bureau function, the ability to serve the stakeholders and in

the case of physicians, to answer their questions about the data, to be able for them to look at it and correct it if there are errors in it, and the physicians are very data hungry and are interested in data. they want the ability to do what is called a grill -- a drill down, to drill into the data in ways that make sense to them. all of this is what i would call a service bureau function, and the kinds of things united has done, such as in our premium designation program we have done since 2005, we have a porter that has data on it, it is open to all physicians in our network, the service bureau function is an important suggestion on how to enhance things going forward. lastly, let me make a few suggestions for where i think this could go from here. i have said some of these are ready. first is to just clean up the some simpleer

descriptive statistics for all the stakeholders. for is a reasonable thing the sponsor to do, even as others do some other kinds of analysis. point, i agree with your the ability to combine data and data sources and data sets, to get an important view, in this particular case, it is really quite a limitation that you cannot get the full picture of what the physician is doing in medicare. we found in commercial private sector that we might find a physician expending a great deal of resources in the office, but if you look at a total cost of care or an episode basis, they are actually quite efficient. the reason is that is their practice style. you will not see that without the ability to integrate a combined disparate data sources. it was artie mentioned, the health care cost institute, we thought it was so important to contribute data to health care cost institute as a multi-payer effort to bring transparency to the private sector market, and that is an

interesting example in a couple of levels because it originally started as an effort to really just be a tracker of private sector cost trend data and utilization data. as was mentioned, once the parties got together and we were organized and tears started putting the data in, the hcc i said we could use this for transparency purposes. we can actually start to look at quality data into -- as opposed to just cost data. that effort has been announced and will be deployed in 2015. the other thing, hsc i is a medicaid quality air -- quality care entity. up, there is a lot of opportunity. this is the beginning of a new era. transparency is the coin of the realm.

the current release has been useful in some respects and limited in others. i think it will evolve and strengthen over time, particularly if it moves along some of the directions it suggested already. >> thank you. one point you made got me thinking. you are talking about one of the steps forward is to go from really raw and unanalyzed data to various levels of analyze data. at the same time as this is evolving, we are on track to have physician value modifiers in medicare, which will be presumably fairly analyze data. i do not know what the transparency plans are, but presuming there are transparency plans, any thoughts about the different tracks these are moving on? >> i think again, whenever there on,multiple positions going it is an interesting challenge for any organization to sync them up.

i think that is why it is a toat opportunity for someone have a broader view of all the data resources, as he mentioned, to use them internally and externally. ofhink in general, the idea moving, probably the most important thing is moving beyond just a raw claims release. into analyze data that is consistent in its cnet--maddock direction. long as, this is the domain, most people view a best practice, for example, not just to release cost data, without quality data, to combine those. so that any user can look at a picture that integrates both quality information to the extent one can have it, with cost data to be useful. as a partial answer. >> excellent. >> my job is to take a broader

policy perspective and with particular attention to the u.s. congress and how they might benefit from this data release and subsequent data releases. i would like to start as well by keying off of stu's analogy of the black box. it is easy for us policy analysts to value transparency. we are the lookers. we want to see more. but it is the look ease, the residence of the black rocks, who i think you need to except and even embrace the concept of transparency if we are ever going to really achieve it. physicians and other providers need to get used to the idea of having their performance evaluated. as dr. cutler suggested to us, the willingness to do that is partially dependent on how accurate and useful the data are that are being released and how

they are being utilized over time. for some paul suggestions of what we would like to see. i actually have some is -- some positions on what we will see. not able to say we will release more data. i will predict they will. predict that cms and its contractors will correct thatber of the errors media organizations have pointed out. missing data, specialty designations, other things of that nature. i think providers may well contribute to that effort. i think they have an incentive knowing their information is going to be individually available to a wide range of lookers. surehave incentive to make they are recorded, to match up the national position of identifiers with doing codes. i hope we will actually have

different kinds of providers available for analysis in the future. as soon as wely, get the second data release, we have the beginning of a time series. economist wants a time series. i will give you an example of how that can be useful. the government accountability office where i worked for several years took 2005 and 2006 data, exactly the same database, in essence, that cms released in april, and attempted to identify beneficiaries who were high utilizes of services given their health status. the correction for health status is not perfect, but we were able to identify a group of beneficiaries that were high youth -- high utilizes. we examined those same beneficiaries in a subsequent year. did they remain being high utilizes? did they have a tendency to

remain high utilizes question market tendency. rate the same beneficiaries among the doctors who treated them, and identified the doctors as high utilizes, given their mix of patients and health status and how many resources they consume. then we look at how many doctors the following year. they were twice as lucky to remain as their patients. i would be glad to give you a reference to the work. i cannot go into all the details. only certain specialties in certain geographic locations. the kind of thing one can do with time data that one cannot do with the cross-section. i work for a congressional support agency for about 12 years. i supervisedd -- the preparation of roughly 50 testimonies and reports to the congress, different congressional committees of jurisdiction on health care spending. case you're wondering, what

do members of congress spend more time reading, gao reports or newspapers and summaries? anyone care to guess? the same question about congressional staff, you get the same answer. so i look at these news organizations reports and data that cmse three release, as another potentially important source of information. ande it is not in death maybe there are mistakes made, but i think it is especially useful when you consider that congress obtains much of its information from companies and organizations, many of whom are constituents, that have a vested interest. the five top d.c. lobbies in spending, four of them are health care and the fit is double aarp. to have an information source with a different incentive for

producing information, that is useful. and i would say these news organizations, publications are complements, not substitutes, to the kinds of research congressional support agencies do, like gao and cvo and other underzations like contract with cms. these are contracts and not substitutes. because thesethat news organizations will produce information to the congress and then give them ideas on what can be investigated, there might be some benefit to the congressional support agencies, to ask questions raised by the news organizations to be investigated in greater depth by the organizations that have the resources and capabilities of doing it. my bottom line is that this is not only a good thing. it is a necessary thing. it will produce more meaningful

information as time goes on. we believe transparency is an integral part of health care reform and i look forward to the day, as others have alluded to, where our database is not just cms production of medicare. in medicare, the entire story is utilization. constante fairly except for geographic cost of business. in the private sector, you see a huge amount of variation. not only would you have the advantage to combine across different payers, to get a fuller picture of what individual providers are doing, to get the private sector data into the mix and have a lot more opportunity to investigate very meaningful differences in how these are performed across the country. >> thanks. you said something interesting about how some in the media was based on this release, made its

way to members of congress and shaped whatkely they were asking congressional support agencies to look at, or even talking about policy, legislative lies. do you have some sense about interesting directions this release has spawned? >> was that the only interesting thing i said? i don't really know. this comes under the heading of .ope i did look out and saw the hill, the publication for members of congress, did pick up a number of these stories and reproduce in their own media. but i cannot cite a specific anerest -- instance of where issue was suggested to a member who then requested some work of gao or other agencies. >> may be in the course of conversation, others will have

ideas about that. this'll be a good time to turn to the audience. why don't you wait for a microphone? >> [indiscernible] doctors, today, i required to post someone what they charge. i was wondering what you would think of that as one of the few important, toare not have the market visibility that you have, do you think we should change it? >> this presumably is not a medicare position come a very limited constraint about what they can part -- can

charge in medicare. those are coming. it is more a question of right insurance. i do not know if you want to take that? >> yes. i think the question reflects, again, the desire to have greater and greater transparency in all aspects of health care, including what providers charge. he does things. first, even though there is no national army, i know at least in massachusetts, if there is anyone here in massachusetts, there is a new law that requires exactly what you suggest, which is the posting of prices. that will be an interesting experiment to see what impact it has. in that state, maybe other states and i'm just not aware of it. the other thing is, from a consumer point of view, and we will hear from a panel after us, what consumers want to know, our experience is, what consumers want to know is not what the provider charges so much as what i have to pay, which then inates to what is the charge

relationship to the benefit package that i have, a network i have, and what does it mean to me? >> a care pathway will have multiple services in it. it will be interesting to see, that information is increasingly becoming available again in the same transparency theme we are in. >> the gentleman there had a question. >> i was wondering about the difference between the raw data you have to pay for and the data being released. is it primarily a question of consolidation? you download less data to answer questions, is it some combination? go through the process of entering into a data use and yout with cms,

guarantee that you will satisfy all the data security safeguards they require, which are serious, they will send you claims data that has a beneficiaries id, that has the basic code of residence, the beneficiaries, it has a micro level service, the cms public release, only reports combinations of physicians and codes with 11 or more services provided. data, buy the microlevel you can see all the services. but it is a major hurdle to set up data security systems that are impenetrable and are hipaa compliant. >> and it provides an opportunity to pull together services from different providers. >> and you have to promise not to release anything that violates it.

click back there. -- >> back there. >> if the genie is now out of the bottle, from your perspectives, what would be best next? >> paul ginsburg mentioned a physician value based modifier. i'd be curious how many people know what i'm talking about? list, it would be the raw data and the final output of the modifier calculations be made available at the physician level. i do not know if that is realistic. but that would be taking this made andcms has just doing the analysis that a lot of the other presenters have been

talking about. the idea behind the payment provider is that medicare can be quality and it will be measuring efficiency, including all of the services that physicians order, not just the ones they provide themselves. that would be a significant step forward. i doubt it will happen. i think a second cross-section, as i mentioned, would be useful. it would be useless cms could correct their errors in the first release, so when the issue the second release, the first release is more accurate and you can make better comparisons over time. >> i think a number of us have talked about the theme of war and unlinkveness inching -- of the data. in other data sources, so you can have a more conference of view, given and attributed population, or more of a 360 view of what a division is doing

for the seniors he or she is treating. >> if i can add one thing, more advanced would be grouping data in episodes of care to look at how it physician handles a joint placement or some other well-defined episode of care, to really be able to compare them to others. yes? >> i am frank with the brookings institution. my question were -- it deals with what this might mean for the health exchanges, typically for each of your constituency groups, policymakers, researchers, even though the data is only medicare, what might be some interesting future developments we might see with more cms data releases? >> that is a tough one. only in a general way. if you can learn things about,

let's say, drug patterns, then the ability for exchanges in that, they are not generally treating medicare patients, there is a limitation. >> i wouldn't echo that -- i would echo that. services to medicare beneficiaries, united health care does, the medicare advantage program, and we actually have data ourselves on the medicare population. we originally thought we could actually combine all of that data with the data we had from the commercial marketplace so we had a larger sample size. these aretually found different populations, and that is pretty obvious. the commercial population, the working age population, is different than the senior population. do quality measurement reporting, for example, we use

different benchmark levels of performance between the medicare and commercial populations. guess is the same phenomenon would happen in the exchange population. that would be a different population. and it would be evolving over time. >> questions? oh, there is one back there. >> hi, rachel hornstein. i work with the department of health and human services. a quick question about last year, the open data initiative. one of the concerns was a concern of the mosaic effect, ,ow we release different data there is a possibility of identifying more information on beneficiaries and clients. can we please touch on that?

>> yes, so, the doctor problem, which, if you report level data, and you don't have a minimum number of seizures were patients treated, and if you report on the practice patterns and everybody knows who the doctor is, then you can find out everything else. so that is the motivation for the 11 plus minimum claim requirement. and you know, i mean, there is that reallyrisk sophisticated and analysts will be able to take this data release and combine it with other data sources and figured things out about individuals. my guess is there is probably a bigger risk just from hackers getting into the cms mainframe. but i do not really know.

areas are definitely in of risks and trade-offs. there is a benefit to these data being made available and there are increased risks. the more data services are being made available, the more risk there is of people being able to combine things in novel ways and undo the privacy protections. just as research, i would just say, let's keep in mind the benefit of these data being made just go witht to this approach. >> the principle of the greater good does apply here. in fact, even on the data releases, there will always be some errors and some misinterpretations of the data. there will always be a position that is fairly singled out that behaves accordingly. toess jason says, you have

look at, those are the costs, but you have to weigh the benefits against those costs. we are of the mind that the benefits exceed them. certainly, privacy is a risk as well. >> using our credit card all the time even though our credit card ourers are for sale financial system bouncing electronic data. a similar kind of balance. >> it is time to thank the panel for a really good job. [applause] we will execute the same thing. transfer this to a senior fellow.

\ [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit ncicap.org] [captions copyright national cable satellite corp. 2014]

>> ok, are we live now? i think we are. now we're are going to shift the focus. we have talked about this data release and several other data releases, and talk from the point of view of researchers and health plans and the policy community. what it is all about is patients and consumers. now we are going to shift the focus to the patients and the consumer. and talk about what they need to know.

we can be more revisionary and expensive in this panel. i hope these three representatives who work very hard on behalf of consumers over quite a long time can help us think about what consumers really mean and what do they needed for, and how can that data be generated. with this question, theave robert, who was president for the center of the study of services, and consumer checkbook. we have robert, the executive catalyst,f community a consumer advocacy doris,ation, we have

part of the organization in doris'sports, they rate a lot of things and not just health care. that is where you go if you want to know about toasters were plumbers or whatever. now we were talking about health care. a really important aspect of so many people's lives. we will start with robert. tell us a bit about what you think consumers need and what we might need in the future. >> ok. all, i appreciate you here. i believe our priorities should be to have good, raw data, readily festival.

if the government can do that, it is an amazing, wonderful achievement. fortunately, i think the government has recognized it is important and has made progress. about the recent appointment and i love the statement and the press release announcing his appointment here in citing the government's commitment to frameworks promoting appropriate external data for and use of aggregate -- aggregating reform. i think that is what the government's role should be here. there is still a lot to be done. i give you examples of the good and the bad that i have seen with the government making data available over the years. it gives me some anxiety, that things might not go so well the next step around.

in 2006, there was dhhs's denial of consumer textbooks, a request may get, so we can give consumers some information on for high risk procedures. there was cms's interpretation on the release of claims data anyone who wanted the medicare data in order to do performance measures nationally, to have matching, non-medicare data in every region. that is an enormous practical obstacle and it would have to be interpreted that way. on the other hand, there was

great news this past april. the government's release destroyed the privacy argument against release. schmidt, i enormous, think. that was followed by the click in an to get identifiers large data file that we and others have been using for years to evaluate complication rates, getting the identifiers quickly with exactly what needed to be done. and cms recently created a virtual program to use those files and make them more ,inancially successful remotely still more expensive than i wish that $45,000 annually for a civil person to use, although cheaper than trying to get those files straight up. 100,000 for more range and it is

quite unfortunate to cost that much, but there was bad news when we were told this virtual research data center system could not be used to produce quality measures on doctors. i cannot quite figure that one out. so the door sometimes swings open and sometimes closes, but i think we need to all support those at cms working for openness, often in the face of strong provider opposition. i believe the focus should be on making raw data available. i am not optimistic that the itself at should be producer or reporter of performance measures. but it should be a supplier -- a supporter of diverse, independent researchers to develop performance measurement methods and put those methods in

the public domain, where they can be rude -- critique by researchers and purchasers and consumers. we want to data, but it is fine if the government wants to do his own reports, even in the face of provider resistance, but we were -- we were -- we worry it would be too cautious to give people simple -- simple information for their personal needs and preferences. of development and one reason is a, get for pessimism and you contest that to the creativity, which finds a way to put this data in a forum that can be used and to be able to find the data. all that stuff, private entities probably can do a better job

than cms can do. what is needed to support them, from a disruptive perspective, let me share with you what we from consumers. we watched the use of our consumers website. along with many types of playthingse evaluate of doctors. reports, saying people do not look at quality ratings. more than they get raiders -- raters of plumbers and hospitals. we have also done tests of consumer interests in different measures and by far, the greatest interest was in consumer survey ratings of results of of surveys of doctors asking for their recommendations of other

doctors. both of these types of measures, children were at least three users asmany website ratings based on board certification and training, or as ratings race on evidence lines for quality care and measures. where consumers are starting whatmay be different than some of us expected. possible measures for future expansion, i will not limit general, trys in to think about anything consumers might possibly find useful. one is to use electronic medical records. useful. active andan become

it is important -- its importance need to be -- another opportunity might be to explore specialty boards that let doctors voluntarily identify themselves as performing let's say in the top quarter of other their uncertain dimensions of certification process. that is something i've never seen done. interesting, particularly because it skills that one of the problems, almost all the measures out there, outcome measures, do notthat is someth'r seen done. interesting, particularly because it might actually reveal something about doctors diagnostic really get to the question of diagnostic skills, which is really critical. bether opportunity would more measures of a clinical bad outcome.

in an analysis we have done, we , statistically, death of informationd needs to be public. if we have better data, measures might be possible. prescribing too many of some kinds of procedures of informatn needs to be public. if we have better data, measures might be possible. prescribing too many of some kinds of procedures identified choosing wisely. it is possible using promise and other similarother similar type. they calculated some of these measures in the

database. they continued to push for all database or understood. large national measures in the database. they continued to push for all database or understood. large national databases like that, that is a great thing. participation in registries is important. registry registry rules allow r public reporting on provider performance. think, which physicians registries can collect information that goes well beyond what you will find in claims data. it makes sense to find out, i anticipate it appropriate registries and explaining why precipitation matters that actually put pressure on providers in general to choose to participate. the big opportunity is in health information exchange. for performance measurements and various other regions -- reasons, that can be the heart of a lot of stuff. to push for aneed continuing expansion of information in electronic health records, including patient and pushinformation

providers to share information in large, regional, and national databases. a public measure telling which providers are participating in these exchanges might actually create incentive. certainly, such as a patient could be critical and the government needs to invest heavily in this. it is a major investment and really should be a focus. i will finish on a relatively easy and quick and strangely neglected path. patient is periods survey results. a database which would be able to be aggregated to a group level, starting with the individual level dr.. -- doctor.

why this has not been put forward is baffling to me. cg cats, survey, impossible variants, it gives good information on how well doctors listen, explain things, keep track of the patient's history, coordinate care, engage in shared decision-making, this is important stuff. doctor does not listen, the doctor cannot do a good diagnosis or come up with that fit thens patient. if the doctor does not explain things or be motivated to do their part in care, as one article in the journal of american medical association put it, in a diverse set of studies, it has been linked to better appearance, treatment plans, more appropriate medical decisions, that fit the patient. and better outcomes. measurements should be at the individual physician level. general medicine showed that the individual physician,

not the practice nor the group, nor the plan, counts for the the aspect of the patient experience. why don't we have survey results at the individual level? we hear it is too expensive. to prove this wrong, a consumers checkbook did a demonstration in four metropolitan areas in , andboration with united we did a rigorous survey and published results at the individual physician level showing a large number of significant differences among physicians. demonstration showed this could all be done at the cost of $120 per physician. and still show really meaningful results. that 120 dollars can be cut to about $60 or $40 per year. it is not necessary to do the

survey more than once every two or three years, although physicians can be enabled to do it more often than they choose, this is an immediate opportunity and the federal government can easily make it happen with a little support, financial support and encouragement. thank you very much. >> thank you. -- that was a rich list of the very interesting things. >> the national consumer organization focusing on giving to consumers, particularly low income consumers, where they had historically been fighting to open up the black box and have been supportive of the consumers union and his work. it is important to look for consumers for perspective. one is the role of the user impaired, and others in terms of their public policy role.

towards cost-sharing and become more, it has and foreign for consumers to become good purchasers. recently with a report that it is difficult to get information from many marketplaces about websites. and what are the

cost sharing differences associated. information a six-year-old dewey needsle for information to checkbook. in terms of what we are talking aboutmillions of people are loog at the exchanges of today, i tho start with better information about who and what is in the network and what are the costs to consumers and charlie mentions the support of accuracy taking into account a wide range of differences supporting an effort to develop a single composite quality measure

focusing on the particular needs of consumers. ofagree with robert in terms patient reported information we seek collective patient application as a quality measure, in a focus on outcome. finally, in terms of consumers, they need help doing this. average person will not be able to make the kind of cost quality equations that we need in terms of coming up with values without support. medicare beneficiaries get the through assistance programs. we have consumer assistance need to think about expanding that program. as inch of consumers public policy, there are

important pieces to really think about. were one of the first organizations to push for transparency around the conflicts of interest of pharmaceutical and physicians. it was actually the court that "data. to the crow public at database and made it into a very for looking at the relationship of the pharmaceutical industry to the physicians. that has perhaps held in terms of allowing individual consumers to make choices around their aoviders, but it has had significant impact on medical schools, high schools, and from a public policy standpoint it has been an important change.

area we have been working on is around hospitals and community benefits. hospitals want to keep their community benefits a mystery. and the value of those benefits to consumers. community organizations wanted them to have that information. getave been working hard to a database of information around which provides that benefits data to george washington university. we are looking to move forward in improving that kind of data for consumers. consumers need to understand that on the basics of health care the idea of some of the broader trends in health care are a black box to consumers. government and consumer organizations need to push