mr. burrell is doing at care first has popularity locally. so it has credibility. and one of the main features is that there is help given to the primary care provider to nurses to manage the more complicated and more costly patients which i think gives confidence that this is not an effort to deny care to people in order to reach the target, but to manage the cost of high interventions in a more cost effective way, the question i would have for you mr. burrell or anyone else on the panel, you mentioned that you oversight to make sure that quality is maintained. but there's always a fear that the bonuses are based upon dollar amounts so therefore are we just denying people needed care rather than providing the quality, how do you assure that the necessary care in fact is given? >> we have five different ways, five different categories of quality measures that each physician in the panel is measured on and the panel as a whole, relating to access, gaps in care, appropriateness of care, and we have one category we call engagement. and this is the degree to which the

mr. burrel is doing has credibility with it. one of the main features is that there is help divgiven to the primary care providers and nurses for the more costly patients which i think gives confidence that this is not an effort to deny care to people in order to reach the target. the question i would have for you, you mentioned that you want to make sure that quality is maintained but there is a fear that bonused are based on dollar amounts so are we denying people care? how do you assure that the necessary care is given? >> we have five different ways that each physician in the panel is measured on. and we have one category that we call engagement and this is the degree to which the physician is actually engaged in the care to the chronic diseased patient. are they too busy, will they deal with the nurse? are they engaged? you cannot get an outcome in our design unless you have overall quality scores that indicate that you are providing quality services and engaged with patients that need you the most. less than 10% of the pat

mr. burrell here. and he has gotten into this primary care area i think in a very interesting way, particularly bringing providers and patients in together around prevention. and to me that's really the ball game. i mean we understand that most of the health care bill in this country goes for chronic disease. i mean well over half of it. and we spend it picking up the damage of heart and stroke and cancer and diabetes. and you're trying to figure out a way to bring your providers and your patients together. and reward the patients. and i think that's particularly good. since you and i talked, senator portman and i got together with the cleveland clinic and the oregon health sciences center and have actually proposed financial rewards for senior citizens under medicare for the first time, we lower their blood pressure and lower their cholesterol and stop smoking, reduce body mass and the like. and i think in the context of the chairman's question about primary care, tell us a little bit about what you'r

mr. burrell is doing at care first has credibility. one of the main features is that there is help given to the primary care provider through nurses to manage the more complicated and costly patients. that gives confidence that this is not an effort to deny care to people to reach the target but to manage the cost of high interventions in a more cost- effective way. you mentioned you have oversight to make sure quality is maintained. there is a fear the bonuses are based upon dollar amounts and we are denying people needed care rather than providing quality. how do you assure that the necessary care is given? >> we have five different categories of quality measures that each physician is measured on and the panel as a whole. we have one we call engagement. this is the degree to which the position is actually engaged in the care of a chronic disease patient. are they to visit? do they take the call backs? do they deal with a nurse? are they engaged? you cannot get an outcome incentive award in our design unless you have overall quality

mrs. burrell responded by saying she did not want to me with a lawyer. we all understand the reputation that lawyers have in some circles but it was a problem for us. there was no way to get her in the room with the design in front of us and work something else -- something out. we find ourselves in front of you tonight. unfortunate. i should make it clear that we're tonight still willing to consider alternatives but we believe that whatever alternative might be adopted by the board or agreed to by the parties, it must eliminate the problem and the prospect of a degrading of the few and the privacy at the second level. i want to bring to your attention an e-mail that ms. burrell wrote to dr. maxon's house tenant, house sitter, i guess you'd call him in october of last year. i will read it to you and then i will show you the mail itself. it is died -- dated october 23, 2011, 9:00 a.m. >> i appreciate your e-mail. we certainly do not want to add to mary's stress. i understand and hear your concerns and i assure you that we will have permits in place soon.

mrs. burrell responded by saying she did not want to me with a lawyer. we all understand the reputation that lawyers have in some circles but it was a problem for us. there was no way to get her in the room with the design in front of us and work something else -- something out. we find ourselves in front of you tonight. unfortunate. i should make it clear that we're tonight still willing to consider alternatives but we believe that whatever alternative might be adopted by the board or agreed to by the parties, it must eliminate the problem and the prospect of a degrading of the few and the privacy at the second level. i want to bring to your attention an e-mail that ms. burrell wrote to dr. maxon's house

mr. burrell, you were talking about all the issues with regard to patients who have medications that perhaps are conflicting with what they need. it just strikes me that so many of these things of duplication and medical errors could be eliminated if we had a system where people's medical information was available, sort of irrespective of where they access the health care system. and it strikes me, because i was at the hearing the chairman referenced where we asked the panel about where we were on a scale of one to ten, and maybe that's not a good way to measure it. but everybody said in that two to three range and i think the issues are the standards of inoperaibility which we don't seem to have come up with a solution yet. but everybody talks about this issue in anecdotal form about what it costs to add to the health care system. it seems like so much of this could be fixed. i don't know again how we achieve that. i know that it was discussed a lot. has been discussed a lot in the past. but i'm very understand satisfied with the progress we're making toward that. the question i had with re

minimal economic bloc of the basic agreement and mr burrell sidelight on how we integration of russia w t o what influence we have today. elaboration or for the new. treaty of partnership and cooperation thank you. know it in a letters beginning with a w t o. how do you see i have seen the risks for separate sectors of russian economy. when we are here to w t o there are reasons but the instruments which we use with the requirements of a double to earl make us think by implementing those tools in our economy we can minimize those risks for separate. directions of industry that is agriculture agriculture engineering. car industry etc several instruments are beginning to be used. in full agreement with the w t o requirements and other w t o member states are using these instruments as well that is first second during talks including talks with the european countries we agreed that you william. on several directions of octave it is in several sectors our economy is how we will use the so called transitional period that we will join to the requirements step by step by lowering the level o

mr. burrell here and he got into this primary care area in an interesting way. and patients together on prevention. and most of the health care bill, chronic disease. they extended, picking up part stroke cancer and diabetes and bring the provider, and reward patients and it is particularly good. we got together with the cleveland clinic, and financial reforms. to lower their blood pressure. cholesterol, body mass and the like. and in context to the chairman's question about primary care, tell us a little bit about what you are doing to bring together your provider's and patients to start giving prevention and behavioral change and powering patients. >> it starts with awareness and a health risk appraisal which we offer for free. and the awareness is a big behavior. we ask to share with primary-care doctors and transfer that consent to the primary. bent effect on primary thinking sometimes. we start with financial incentives to participate and move from financial incentives for outcome. you see that you are overweight and the risks that you have. one thing to se