i retiree coverage some have complicated formulas that has to do with sick time remain and the number of years worked, variance things that weren't account to the difference we don't account for those this is a guide rather than an exact measure but again given this information in san francisco the benefits esteem to seem to be generous in this department and in terms of 9 counties that were surveyed can we assume no data those counties not one service system that administers or reviews plans like in san francisco how could monotony know what mraung not

know this. >> i mean, we're talking to the right people. >> correct there isn't as i said earlier every county has a way to administer other employee health care benefits in many instances in the access not been able to get the information and not knowing exactly why not and we'll talk about towards the ends some difficulties within the data collection effort you know wouldn't be generous of me to assume the worse case scenario so the short answer not case of san mateo county a system to the premiums it is about bit con equivalent i couldn't get numbers to represent their data. >> commissioner lim. >> or. >> the san mateo cover retirees. >> to an stent to an stent the

extent to of they do is unclear i'm not comfortable or confident giving us more concrete answer and there is sick pay but the last i checked that's been a while. >> it may not amount to much. >> commissioner lim. >> for the retirees and the agency. >> i don't have is fine grain daily. >> it didn't include any thoughts retirees they have definite - and we couldn't get to that level of detail. >> that's small there's a presentation for next time it will change eventually 5 or 10 years after the premium they have retirees depending on the

number of services assume more of the costs. >> overwhelm to ask i know we have a serious or series of charts that is counter to the first pass we're traeg to do this is it your sustainability to receive or refine to come up with a summary of some kind of major themes that run across the graphics your shoukz. >> you'll with to ask director dodd about that. >> director dodd (laughter) by i mean it is useful information yeah, he recognize you can go back if and do our magic with the adjustments given planned and demographics that's all interesting by once we have these data delayed is there a

theme you're trying to get at in doing the project at the out set. >> the goal to look at how we compare to the other counties and included retirees when we do the 10 counties analysis which we set over mandated contributions to active physicals there are represented by retirees those are counties that are not anything like us so to compare to san francisco to la county is like commissioner vice president mar apples and pin apples similarly and i think neil can atte

>> the school teachers have that i think our 10 county analysis is as inaccurate as this is to the intent was to kind of give us a per of were there similarities or not as you can see that there are a couple of places where we are off the charts but for the most part we're similar to the county that explicit sprees us we looked at the utilization data from cape and they ran the counties and allowed us to look at our data we're similar to the bay area county it not surprisingly our

costs are similar do we intend to go back to piece this out this is how many months of work 6? >> we congressmen's this in july it has not been a full team efforts but as well as say more towards the ends the labor that went into getting 24 was not ensignificant that's not just my labor and the labor of katherine and rosemary the communication manager i was extracting and in some cases x tracking this data if benefits representatives and have any things they consider important to do so you know the level of detail i was trying to get required you know lots of nominees e e-mails we contacted

the chairs of the board of supervisors which we should have contacted the h.r. directors but we need that and it is useful to you, too no incentive to give us data and so - >> let me say for the record some of the benefits were trembling on top of and very responsive giving of their time as and could be and some of them there is a tremors generous of them but the up shot viewing this is not a hop skip and a jump if he were to consider that. >> i too want to know the goal that takes that much time we've changing the 10 county survey what's the goal.

>> all are have to ask director dodd. >> see how different from the 10 couldn't to see if we could make a cost to see if they hire in cancel to give you a sense of how much other counties were spending on premiums and how well or not well, we quarry think that it is pretty clear we do well at norwalk premiums given our size when you look at the another counties that was the goals. >> questioning egging questions or comments. >> thank you for you will this data and getting to the counties the cost of the 10 counties is different from the 9 counties the cost of living is similar amongst the different areas of counties so thank you for all

this data it is helpful when will you have the data on the number of members and lives it would be more helpful how many members are dead to san francisco or let me see what my fellow commissioners have to say and contra costa. >> we didn't analysis for those differences in the appendix we have the number of covered employees per plan you'll see inform each county within the appendix. >> thank you. >> sorry. >> just have to add. >> you have to look at that but even within that covered number of employees i mentioned we don't have the excuse me. per county and for lives per plan getting that would have been - >> monumental. >> good word. >> our presentation people go

to our website and get this information we have far more transparency than any of those other 9 counties a contribute tribute to the system h sf was detain we did the demographic reports all along and the county board of supervisors didn't want to see that it is kind of surprising. >> yeah. we want to reiterate while we're on that point i was wade through the counties presentations of the benefits information i can say that our presentation of information is head and shoulder above that of other counties we present more information and in other same place places than other counties do that is something we should all be very proud of. >> your referred seechlts i'll

be saying that later we're at the point of later and unfortunately are fortunate. >> let's talk about page 9 we spoke about. >> this relevant to ann presentation a little while ago it is the plan deduct for employee on this coverage within the plans we had planned designed information the 9 bay area counties currently over 67 plans and out of 67 plans we have plan design information for 53 all detailed within the appendix if you're interested in looking at it. >> but we see the majority of plans were excuse me. planned

deindict were $500 or lower 87 percent of plans had relatively deduct they have a deduct of zero dollars and level of 11 percent have annual employee detublts over $1,000. >> okay moving on to page 10 we start to look at the employee only dental plan maximum and i'll discuss we'll see on the no objection page some counties have dental plans not plan year maximums those maximums are for the plans that

have maximums and the range from 14 hundred excuse me. one thousand 200 plus to $3,000 for dental plan maximum again, this doesn't adjust for plan design and the provider network we collected data on dental plan and i suspect the wide range this the depth if you'll turn to page eleven you see that we had 8 dental plans offend by the 9 plans with not a year maximum this is interesting but we don't know exactly if they have one one half dentists or may be one

hundred we don't know that moving to page 12 math preference, etc. in bay area counties. >> now this dynamic shows of percentage of licensed hospital beds you do understand by sutter if each bay area counties i want to caution that is meant to be a guide and interesting starting point but number one getting the number of licensed hospital beds was not a straightforward endeavor as one might imagine the counts i have could be 100 percent accurate i'll not try to sill that with you know on the honor of my kitty cat and everyone else i spoke with hospital administrators websites and drew on other sources

sometimes two experts of same hospital will give me a different count for the licensed by these those are the kinds of things we don't know this time around and important to keep these in mind licensed by these are the beds for which a hospital has a license to operate it might be i'll have to look at available beds or staffed beds so with a grain of salt this is the math resource of sutter. >> yeah. i have a question within this a little bit for example, for san francisco i'm assuming you excluded the va hospital they don't a license the beds. >> correct. >> it's the federal number one and so certain institutions like laguna honda that has the most licensed beds in the city and sfgh which if not two or three

are they included they're not commercial beds in the search warrant someway that civil right e.r. charity. >> those are include in san francisco is count so the percentage is available for example, to health plan service is contracting maybe higher i mean 19 percent maybe underestimated because a lot of the beds are not assessable to us the laguna honda is not offering health plan options. >> right if we want to get more precise what question count as a bed that is accountable we need to set the criteria more specifically correct. >> okay page 13 is glossary and pages 14 and 15 how the nitty-gritty what

the limitations and we've gone through many of the things here i caution that further analyze should take into account the time and effort that is involved in such an affair and what is not listed it is the matter of timing the other counties have their goals of work throughout the year open enrollment makes everybody busy but prior to open enrollment they don't know what is rates are figuring out what best to conduct that kind of a survey not a simple thing to establish that's not to say it wouldn't be worth trying tee create a work plan that is more systemic that was a pilot effort i'm sure that

would be reif i understand in the future for now it is xfrm to point out the perplexity those numbers should be available to you know the inquiring minds that want to know each community presents their information in a different way some presentation of information are more assessable though the intersect than others and more complete than on the information is available throughout the year, and so forth. >> i for one thank you for your work and effort in doing this we may consider that i know we like to know this every year this might be in every other year or 3 years and refined you know we'll assume this is baseline all of caveats you've outlined thank you for your work. >> i want to point out the

caveats i feel it is important to do but emphasis this is a starting point more than we knew about more of months ago and let me emphasized if you want to know more go online with the appendix and detailed information as we could get and don't print it. >> right. >> thank you very much. >> all right. we're at a decision point unless everyone brought lunches or diners i'm going to take the pro romantic of the chair and we have a series of emerging topics we're going to discuss and when i see.

>> i think this will take discussion. >> i believe beven duffey was going to present he's not here yet so. >> i'm going to suspend on that one all right. i'd like to had had pharmacy and the excise tax okay. then we can get internal like katherine and mitch that are ready to present they're always with us we're not losing them and say oh, my god we got out before dawn to page come forward. >> the person from the xhoiz wisely is here. >> i it out that was you not you katherine defendant's

deposition we'll have that person choosing wisely where are you so any of the guests their speaking on topics make sure we get them done out of courtesy and the team members we'll beg over dloenlz so pharmacy benefits. >> player and members of the commission i'm with hewitt and today i'd like to spend. >> few minutes talking about pharmacy tearing and i think one of the things we talked about in may was the fact that there is a big procuring on pharmacies the trend is increasing as you can see at about 25 percent of the costs

now relate to speciality and that increasing the speciality costs are increasing at 20 percent a year clipping that is sustainability is becoming an issue as we going forward and we have 3 health plans they're struggling how to manage the specialty costs within the parliament and within the rates they substantially offer to you so tiering i i he giving different types of drugs and costs structures is one of the attempts that people are using to balance the pharmacy program so if you look at page 3 let me see - you will see your current pharmacy share this is for non-mail orders you'll notice that blue shield of california

has four different costs they can apply to they are different pharmacy pharmaceuticals depending on the type or what their formula is and city plan has 3 and kaiser permanente 2. >> and so we'll come back to this page are, if you will, just keep this in mind that is a good reference point when we talk about the issues that surrounds speciality drugs so first start but out with blue shield i'm not going to you would like to acknowledge the health plans are supportive ♪ presentation providing the information, and, secondly, not focusing on the commercial populations at u h c it is small we're looking at the two largest health plans of blue shield and kaiser permanente so for the data period january one 2014 to

december 31st you'll see their speciality drug was 26.2 >> excuse me. >> would you give me a number on that rough number how many million dollars at hand. >> we'll get that and the percentage is two small to know but the issue at the end of the day when you tell me that is 20 percent more than last year 20 percent of $2 million is one thing but 20 percent of $20 million is a big chunk off money so it will be helpful to have a. >> very good point i don't have it ♪ deck but i said to point out if you look at what i would call the more common curtains that is your rheumatoid arthritis, your example s and cancers that is that represents about 44 percent

of their specialities spent and hepatitis c >> one is cancer. >> right i was going to the next page and talk about that you'll find that really represents point zero 5 percent of blue shield's population is spending that 26.2 percent we're not talking about a large co-holster but talking about diseases that you are all probably familiar with ms, cancer and you know, of course, hiv and hepatitis c. >> and so as we go forward i want you to remember here for

blue shield for speciality drugs they're paying 20 percent of the costs up to one hundred dollars. >> is that per year. >> that's per prescription. >> then for moving on to page 6 and i'll catch up here we have kaiser permanente experience i'll point out here this is slightly different time period from its at same 12 months but rolled forwards six months sorry it represents 31 percent of their drugs spend it in speciality drugs 35 percent is spent on hepatitis c and others and 51 percent of their

additional costs are spent for cancers, ms and anti aikt reiterates you, however, the first page two tiers with 4 or $15 so right there in and of itself presents the challenge that we have before us with speciality drugs how should they be placed and where should we go what is a speciality drug we've talked about this before but basically, it is a drug where manufacturing is very complex and requires special handing and usually a different root of administration through the mouth, it is very high per unit here on behalf of the appellant and on your page 6. >> yeah. >> the specialty drugs 31 percent for kaiser permanente you know what is the

prescriptions on blue shield's is 8 percent, 36 percent of speciality - >> okay. >> you're saying point zero 5 percent was the specialty drugs but what prescription does thirty percent e.r. 34 percent for cape and i'll photo i didn't ask for that when i got the status i'll make sure that is in the final presentation very good question thank you. >> then again, we have clinical that gets that is required and currently about three hundred speciality drugs with 6 hundred in the pipeline of course, you know most of them are related to cancers this is why speciality drugs is a focus of cms but you have a

significant impact of hepatitis k c on the medicare population it is on everybody else's focus one of the things as a result of speciality drugs you used to have the benefit managers that were working together i mean that is causing tension because now the pharmacies is taking money from the medical side that is a difficult pie is only so big. >> so i'd like to. >> commissioner has a question and he was confused by one of your statements on page 7 it may require a health care provider everyone - >> he, he was matt haney the health care provider is required

in order to administrator it. >> okay. >> not all drug requires a health care provider to administrator. >> you might want to clarify. >> any other questions before i move on. >> i'm skip slide 8 and go to slides 9 in effort of time so i went to blue shield and asked him what are your current considerations you have 4 tiers their security tier structure is one through 4 with a higher tier with a higher co-share and wrrment based on the drug effectiveness and that speciality drugs are placed into tier 4 are they were considering for 2014 a fifth tier and it would be available for

all groups now i can say in the literature i see people going to 6 tiers i asked kaiser permanente they were very nice enough to talk about their approach and they feel it is presenting a challenge to the whole u.s. system and i bring that up because you noticed on page 10 their bottom bullet is they're advocating for lower prices with pharmaceutical manufacturing and working with at stakeholders to that that katrero park has a history or working with other shareholders and been effective to make it a efficient move forward so when technology come forward it is adapted unformly the fact they're at the table working with other advocates to try to

address this means we at least have strength in numbers at that - in that political process and like blauld has position exert panels reviewing the speciality dug use make sure that is working, they make sure they use others non-drug theefrpz when available but really the issue is what is parties in the marketplace? they currently have two tiers for that system they like that if you're only paying $15 and kaiser permanente and 50 at blue shield's if anyone needs a speciality drug what plan that might you choose is that making you will say you know xafshl i mean blue shield a fifth tier

they're looking at adding an additional tier for speciality drugs in 2016 and what offer to us if we choose in 2015 at this time u h c currently has a $45 co-pay on their third tier in the middle 24/7 kaiser permanente and blue shield's they are no plans at the present time though in the backroom as they're one the largely palmer suicidal benefit managers to add an additional tier or a co-pacing pay but not in the plan now in conclusion you have to remember the population that is using speciality drugs is very small but they're using a great percentage of pharmacies and the estimates if a number of different sources is that

speciality drugs could steeped 50 percent as early as 2018 one of the issues not none the table and this may be aware bio similars are out the first for neutrogena is available people with not automatically switch for a generic and other advancements like the area hypertension looking at pharmacy tier from the area what is reasonable and compatible will be a critical decisions point are there me questions and additional questions >> i want to thank you as a physician in serve practice with

one carrier giving me a last time donated cards with 5 formulas just for medicaid in the 90s, the medication for upper religious pretrack infection this is an evolution of what is for a long time and there are all these gimmicks that pharmaceutical companies that offer documents and they're being challenged by the federal government and the attorney general because they're providing the staff to lie about enter criteria i don't know how that fits in this comment that is a huge deal in the drugs are getting direct consumer

advertising as someone that has to watch tv but the modern value to those companies a implementation advertising for multiple sclerosis not in the top 5 groups but advocating to the consumers on tv it. >> it brought - i'd like to document the research but basically only 6 percent of the population uses the coupons stays on a brand drug for a year along a person that didn't use it and gets trefrdz to the generic lower costs a significant issue as you may know not loud in medicare and medicaid not all physicians and

members understand they can't use the coupons it is a challenging problem. >> my good wife said when she sees an ad did you listen to the side effects would you take that. >> (laughter). again any other questions? >> okay thank you very much all right. >> neil island i'll ask you to understand the head can only comprehend what the hand whether endure (laughter). >> good afternoon you've heard much of this before this is an update. >> there will be that is my cue to be extremely succinct a

wlat afternoon commissioners i'm here to update you from january 8, 2015, the impact of the excise tax for i'll briefly describe wear we're talking about the expertise don't describe what we're talking about does anyone need a brief education what an excise tax is. >> we've had that. >> what's the bottom line we have on pages one, 2, 3, 4, 4, we go through all of this and since we did the assessment used the premiums and went through the cycles some of the premiums went through a rigorous experience to lower that that was generating a tremendous

amount of expertise so we went through a subsidy presentation and subsequent agreement at the board and so those premiums and what is projected are lower so let's go to page 4 and see where we are actually page 6 for 2018 one number went up this grid is blue shield early retirees as you may know we increased the rates for 2016, 11 and a half percent for blue shield took a recreate increase a that increased that rate and therefore that plus what we see in 2018 have made this number higher the number is pretty much where we were with kaiser permanente and the lower number it bans the fact that the city rates have been brought down as we did in the january meeting we

shared there are rules we finally overhead in the early part of 2016 that for those you can blends early retirees which we saw were expensive and the medicare we'll blend the numbers we need guidance there are terms last week similarly situated plans the exact same benefit of that and so forth we are really not trying to make major adjustment to blends how to be able to blend so page 7 says if we can blends all of our you know assessment of the expertise for 2018 is for early retirees we have early retirees we

basically eliminating all of the tax for 2018 which is a fantastic situation for us we want to blends that's what we want to do and when we know exactly how to blends he'll come back and say that is what it looks like i want to say as we do rates and benefits when we present the numbers in june we present then bear what we determine and what it means excise tax wise and i will suggest when you go we do that just to give us the context on the basis what that would be if it were blend and not so we see both numbers. >> glad to do that a subs recognize that is the way to go it will be useful to document okay. had this not happened this would have been the higher. >> we'll do that after the

guidance pickup truck. >> so with that, because the rigor the board we document everything understood. >> so the policy decision done by i mean by the blending because sometimes there noticing there is no final giles. >> the people the experts in the companies have assured me the best understanding is the best quarter of 2016 we're ankyawaiting this information and lots of people dealing with hethd and the other people that do this kind of work we want to know about blending this is a lot of money and looking at other ways of dealing with that sending the early reertsdz to exchanges they don't want to do

that so they're waiting no final guidance. >> we have to remember the nature is a tax that means revenue to the government when they see a dramatic shift of millions of down to a shift that may influence the outcome. >> question, sit here 3 more hours why they'll consider it or not but they are considering it hopefully guidance we like with that, i want to say one more thing and we'll move on we need to turn to the awe pefrngs peculiar we've conducted the regulations you'll include those we went back and actually took the sense excess and added to

the project calculations so with that, it is slightly increases the tax so we have look at it as a first task would we eliminating this too much of an impact to the tax you'll have to do that and my understanding is that discussion should not and most likely will not be had we're goito eliminating the h h a first, the assessment put the maximum amount we didn't get the elections in time to present that material we caveated and say a percentage so we did that so what did this mean at the end of the day where are we with what we would like to be our realty turn to package 13 on

page 24r7b if we blend and you have to be determined the stementdz path for 2018 is 4 hundred and 65 thousand dollars that's it. >> so if we accomplish those goals otherwise can't blend through s f s a the tax tsa is $11 million plus if the things turn out to be which maternity happen not within that kind of range blending has a profound impact on our excise tax assessment this my most current update any questions. >> questions or comments. >> this is very clear to me appreciate that i actually thought that was very helpful.

>> thank you, sir pleasure. >> a topic that will be. >> yes. commissioner lim. >> bring back previous to marie as far as the subsequence we're better off than the others 9 counties because they're way too high than us excise tax point. >> 100 percent agree and it as an awe up to the time objection, sir well done. >> we're now going to go choosing wisely and katherine come forward and identity 50ur name and affiliation. >> rebecca. >> they brought up choosing wisely and the california committee on reducing waste and

excessive cost is using choosing wisely measures i thought that would be helpful we'll be electrical want to include them in our contracts next year not all of them but 3 main ones but this is an incredible all of this is available to the public online it is remarkable so. >> hi is this on. >> no you'll have to use the other one pull it way down and in front of you. >> thank you for having me. i know we're overcame i'll try to keep this brief and to the point for those who are not familiar with the choosing wisely caption campaign to get patient and health care providers to talk about the use it can be harm and excess costs for over use of italy biotics

and religious picture and low back pain, etc. i'll talk about the choosing wisely campaign what customer reports and the materials you can use that are covered and the covered benchmark are the employees of the city and county of san francisco and that it you choose to adopt that i'll talk about the 3 taefkz that the california statewide work group on overuse is using those 3 tauvengz you might want to consider looking at so to get started overuse a huge amount of over wastes millions and this is a combines of the providers offering health care not needed and, of course, due to cultivate norms of turfs on

television the patients are getting this information choosing wireless from the american boards of external medication foundation it is a knock it out of the park to promote conversations will medical overuse between patients and providers to step back the reason the consumer reports is involved is similar how did reports are known helping people make important decisions what refrigerator to buy we're helping people make decisions by asking questions and what the safeties item to search is it the safety or the one that costs the at least expensive and similar with protecting is it is the right and safest and something that will turn the best investment that's why it consumer reports is involved we've worked on the first

article in 1996 we worked on ac slefr people think we jumgdz into that we've been working for quite a long time the way that chillies wisely work the america board of foundation went it out other societies to the professionals, etc. and said we propose each of you come forward with 5 medical tests are treatment over eve doing within our society and come up pubically and put them on a list as you can see those are the lists everything was well documented and in april 2012 when the campaign began the 9 society that came forward and said pub say the tests that are overused

it is quite bold the over 70 parents and also some non-medical like dentists and therapies over all 4 hundred tauvengz the societies talk about overuse and as consumer reports we've been hammering away at a hundred of them i'll say talk about 3 of them the california statewide working group has worked on. >> so as you can see here a consumer report we've created collateral you can create with all available with no costs unlike the customer service consumer prescription all of the public health is in front of the the people where no pay wall it is for free we've been willie brown work with the medical societies with posts posters and

public service announcements and volunteers you were hundred people use when they talk to the doctor do i need this treatment what are the risks and the costs we believe that by asking those questions the providers and patients will really be able to engage with conversation about overuse i want to talk about 3 areas for example, choosing wireless openly petroleum is a overuse the state of california is working an two greeters one in northern california and one in southern california currently and opium is one we're looking at if you were to go ahead at the board and adapt choosing wisely one you might want to look at go is if sync request

what the state is looking at this flier is for all the topics on the consumer reports two page easy to read brochures in english and spanish starting to consider others language likes korean and chinese they're talking about what the risks and harms and costs why you may want to think twice and on the backside the blue box if you break it fix it we're saying for example, don't out openly workshops here's other techniques the second topic area is the low back pain medications for someone that as a garden variety of low back pain and for 6 weeks it is unlikely they need tests

that whether leads them down a long path and exposure to radiation and the final topic overuse of c sections for pregnant no risk to the mother and baby dollars the c sections again, i put up this example here. >> choosing wisely i've had a huge pickup in the mainstream and medical journals as you can see in nine out of ten usa today and voltage and men's journal, etc. we've got a huge reach across the country consumer reports work with 70 pardons like aarp and other smaller

health care acholic beverages in addition to the grants that are working on choosing wisely there are 7 grants two in california they have a minimum have to health care systems within the grants anytime 14 across the country and in each one of them must within the next 3 years decrease overuse by the choosing wisely by 80 percent from baseline all of them are working on italy boefkz and respiratory attachment treatment and some cho's choose low back and etc. >> i wanted to pointed out the los angeles counties of public health they're part of the grants and doing fantastic work in reaching folks in los angeles

county and finally he wanted to say we have a campaign within in choosing wisely an app a special website and video series if companies want to roll outburst choosing wisely to the consumers that is a way to do that quotes of lessons learned from using chulz wisely i'll be happy to answer any questions. >> rebecca give us our full name. >> rebecca rocketing child the senior leader at consumer workshop. >> your proposing we use this all online is that the ideas. >> you can use it openly we can build you a micro site for

all the information that is co-branded we can roll to employees or work with the specific plans we can give us tefrlz so that pds and posters and videos so a huge mulch the tells i'll recommend if you consider it pick a topic or pick the overhead 5 questions areas that i talked about with the posters that generally works better than accept and expend outer 4 hundred topics that is ooechlg. >> you send members e-mail and ask them about that. >> you can send to members newsletters and materials hardcopy or e-mails if i work with particular clinics or

doctor's office or the hospitals find the materials hanging that'll whether it they'll pick up the materials online and offline different ways wearable to work with you directly to think about how your members month benefit from it. >> i think the thing i'm struck by a rather robust communications police radios with the members there are ways something like that if we decide to proceed will be integrated into things we're doing wellness stand point and things online so on other questions for the boards otherwise we'll make a recommendation to katherine. >> i think as adult abuse i've seen this process evolves it is brilliant because one of the

impedes is the physician themselves and the focus fact it comes if the society and the rapid acceleration such a i persuade this i've seen adds for a bio long for my condition i get reports and the aarp and all that so it is not enough to me it is put it out there in a once a year you know memo toe members remember so how do you actually what kind of recommendations from our 0 program can we think about that is real don't go into seeing your doctor for low back pain how do you see that. >> it is a good question the campaign is shifting the culture bureau or for the providers and

general consumers to that maybe going into the tests and asking for the italy biotics is not the best thing to do get people to been shopping you'll never go randomly buy a car or washing machine why are you taking this medicine so get people to think about this from a consumer prospective and actively consumers i'll note that while i and consumers reports the fupgs foundation is wlookt both angles we're trying to change the culture. >> i read a presentation on this on the committee to reduce the over use many hospitals know how to assess their electronic health roared one phyan