Town Hall Meeting

Comments and Q&A during Joint Plenary

AHRQ 2007 Annual Meeting

September 28, 2007

Carolyn Clancy:

Thanks very much, Barry. I think you can see pretty clearly that, not only does CMS have a dog in this fight, so to speak, but they've been an indispensable part to creating and supporting what we can recognize as infrastructure to improve quality across the country.

So, as we're thinking about how do we get to the Secretary's vision of community-based collaboratives where there's strong collaboration between the public and private sectors—kind of sounds familiar from our past three days of discussions—you can see that our close partnership with CMS is going to be pretty indispensable to making any of this happen.

So, you're going to be hearing in the very near future about the Department's plans to establish a network of what we're calling Chartered Value Exchanges. In Federal acronym land, that means it's CVE's for short. The point is actually to try to get down to where care is delivered, because that's where it needs to be improved, so if you remember Don Berwick saying that, "At the end of the day, only those who provide care can improve that care."

Having national goals and a national framework for where we want to go as a Nation is critically important. Making it happen is pretty local, or to paraphrase Tip O'Neill, since I'm from Massachusetts, "All health care is local." We at AHRQ are very excited to have an important role in chartering these value exchanges, and we're looking forward to making an announcement, and your being here means that you will be hearing all about it.

In addition to that, to be a Chartered Value Exchange, you first have to express your commitment to the four cornerstones of value-driven health care, and in so doing you become designated as a community leader. So, 85 community leaders, communities across the country, have expressed such a commitment, and 56 of those 85 are represented here this morning. So, we're very, very happy that you could attend, and could all of you who are representing community leaders please stand and be recognized?

So, I really want to thank you for your hard work so far and assure you that this is only the beginning of our partnership with you. A good friend and colleague said to me, not too long ago, "You know, this is really exciting, what we're trying to do to improve quality, because what we're really doing is changing the landscapes by helping people build the right relationships, because that is what is going to improve care in this country."

So, Secretary Leavitt is going to be joining us shortly to talk about his vision for value-driven health care and explain where the Chartered Value Exchanges fit within his vision of a value-driven health care system that includes community leaders, that includes a vital collaboration between the public and private sectors in each community, to try to get us to address some of the fundamental problems we have in providing quality of care consistently and reliably.

To say that the Secretary has been visible and vocal in driving this program would be an understatement. He has talked continuously about a need for urgency, has been in many, many communities across the country, and regularly reminds us about the need for deadlines and also reminds us that this is not purely an academic endeavor. We're not just drawing up a grand plan. We're actually trying to make this happen.

And obviously, and I think Barry gave you a good feel for this, he does this with a pretty strong sense of urgency, because no organization has more at stake in the improvement of health care quality than the Federal Government. From CMS, which has a huge role as a payer of health care services, to the Office of Personnel Management, which provides insurance coverage for Federal employees, and members of Congress and their staffs, which is really important to the Department of Defense and Veteran's Affairs, the Federal Government has got a very, very big stake in trying to get to a health care sector that provides more quality and value.

In fact, the Secretary often says, "We don't really have a system, we have a sector." You know, if any of us want to call each other on our cell phones or e-mail ourselves, or friends and colleagues from our Blackberries, it doesn't matter who your carrier is, right? From a T-Mobile, I can call someone on Verizon or any other carrier or send them a Blackberry message. That doesn't happen in health care. Every thing is unique and specific, depending on where that care is taking place. And we're not going to get to a kind of system until we do have a framework that we all buy into and that gets implemented and that it actually happens locally.

So, the Secretary, as you will hear, is committed to driving the necessary evolution of the system through what he calls the four cornerstones, and he's going to tell you much more about that in detail when he arrives. We're very excited that so many communities have come together to embrace the four cornerstones. Now, embracing the four cornerstones is a step one—it's like an awareness of the issues, right, that we heard about the stages of denial yesterday, so I guess this would be step one of recovery from denial, about the quality challenges that we face. But it's the beginning of a long journey together. We're really looking forward to a time when information that comes from the communities can be used locally and nationally to improve the quality of care.

So, as I said, we will be chartering these value exchanges soon, and we're very much looking forward to having some candidates from the current group of community leaders. So, you will be at the top of the blast e-mail as soon as we have got the process in place.

As you visited, throughout this meeting, the Innovations Café and chatted with your colleagues and learned a lot about the tools and experience that we've had the privilege of supporting, I hope that you can see AHRQ's commitment to improving the state of health care in this Nation.

We're also very strongly committed to working with all of you to make sure that what you need from AHRQ is available when you need it, and we want to engage you in a dialogue and very much want to hear your suggestions about what would be more helpful to your efforts to improve quality of care. So, as you're riding home, whether that's locally or sitting at the airport and flying away, and you have last-minute thoughts or additional suggestions for us, we're very interested in hearing them.

But we also are hoping that this has provided an opportunity for you to engage with each other and, in particular, the groups that share common goals. So, I'm going to borrow a phrase we heard yesterday from Tom Kline, Iowa's Medicaid Medical Director, that he used during the plenary session when he talked about he and his colleagues, other state medical directors interact, he said, "Share senselessly, steal shamelessly." He said that they came up with this slogan in talking about the true value of collaboration. So, in shamelessly stealing from Tom, I'm urging you to do the same—to steal shamelessly from each other, push hard to collaborate, and work together to build consistency as we move towards better outcomes at affordable costs for everyone.

I've said it before this week—we can't do everything that we need to do unless we are kind of rowing in the same direction and working together.

I wanted to also recognize Eric Thomas, if he's here. Eric Thomas yesterday received one of the Eisenberg Awards for his research on patient safety. So, as an AHRQ grantee, Eric, we plan to take credit for everything you do well into the future. These awards are administered by the National Quality Forum and the Joint Commission, so I wanted people to know about that. (applause)

I also wanted to announce the Director's 2007 Award for Outstanding Intramural Research, and this goes to two of my colleagues, Chad Meyerhoefer and Sam Zuvekas of AHRQ. The title of their work is "The Shape of the Demand Curve—What Does It Tell Us About Directed Consumer Marketing of Antidepressants?" There have been a number of studies in this area, millions of questions about, is this a good thing or a bad thing? What does it do? You hear lots and lots of anecdotes, and Chad and Sam came up with a very innovative strategy for examining this particular issue, so if they could stand? Well, Steve Cohen, you can stand on their behalf as their center director.

So, without wanting to steal the Secretary's thunder, let me ask if there are any questions here for where we're going and what are the next steps? And if it's something that he's going to announce, I'll tell you, just wait a few minutes.

We couldn't have been that clear, I just don't believe it.

Tom Williams:

My name is Tom Williams from the Integrated Healthcare Association of California, but in your roadmap you mentioned that you're not just measuring quality but costs, and I know you've been working on how to do that and looking at these episodes of care as units of measurement potential. There's a lot of work all around the country around us, and I'm just curious where that is, and, that's my question.

Barry Straube:

Okay, thank you, Tom.  For those of you who don't know Tom, IHA, is the Integrated Healthcare Association of California, from whence I came.  I was doing a lot of work on pay-for-performance and payments and other rewards, higher quality outcomes; they've done some phenomenal work out there.  I think, Tom, that the whole efficiency area, there are several ways that we're working on that.  One, I think first and foremost, through the quality alliances, there are particularly through AQA, formerly the Ambulatory Care Quality Alliance.  Kevin Weiss and others are working in the measures workgroups and subgroups of that on trying to define cost of care measures and efficiency measures, if you will, and that's a great forum to have that occurring and, of course, we could get broad stakeholder input.  There's some work being done from the National Quality Forum, also.  At CMS, specifically, we've been doing some preliminary work and have contractors looking at the various commercial vendors that have developed efficiency grouper methodology, and we're finding that they've all done a lot of hard work, very interesting status right now.  Nobody seems to be anywhere close to where we would all like to see us get in terms of having even the methodology down pat.  So, we have a number of contracts and pilots that we're going to be starting in the summer of 2008 that will be testing some of the commercially available grouper systems and looking at how those might be used.  So that's going to complement, I think, what's happening at AQA and to a certain extent will happen at HQA. 

I think, again, the opportunities in the QIO program, that's another venue that, once we're able to announce what specifically is going to be included in that, there may be some opportunities to work on efficiency grouper measures in that realm also.  So, those are the main focus that I think we have.  There's an incredible interest, of course, by everybody, not the least of which is the Hill, that is looking, yesterday, to have grouper or efficiency measures available, and actually our boss, Secretary Leavitt, who will be here, he's even ahead of the Hill.  He'd like us to have had those about a year ago and is always frustrated when we have to tell him it's not coming as fast as he'd like. 

Carolyn Clancy:

Tom, can I just ask you, since I can brag on you, you can't brag on yourself...I'm always pleasantly surprised by some of the innovative efforts that you and your colleagues are leading.  Just one more example of where California is sometimes ahead of the rest of the country.  Can you tell us about what you and your folks are doing?

Tom Williams:

Yeah.  In terms of efficiency, we've done a lot of work with the quality measures, but our purchasers and the health plans have really pushed us to start to measure the cost side and try to calibrate the two, and so we've started to go down this road of using efficiency groupers.  We're aggregating data across all the health plans and are going to apply the episodes of care against the aggregated data.  But it's very difficult that a lot of issues with the methodology and there are a lot of stakeholder issues and sort of the main debate that we're having; the roaring debate right now is, do you standardize cost?  Do you use actual cost?  Do you use a combination?  Obviously the purchasers and the health plans feel if you're not using actual costs, you're really not measuring costs.  Providers feel that if your physician group is attached to an expensive hospital then you're being unnecessarily punished, so there's just a lot of activity in this area. 

Carolyn Clancy:

I have someone I need you to meet at the break, so I'll find you then.  But thank you for sharing that.

Kevin Cavanaugh:

Kevin Cavanaugh from Somerset, Kentucky.  I'm assuming that one of the bases of consumer-driven health care is that patients have choices, and you had mentioned the increasing evidence for the inverse relationship between costs and quality, and that's oftentimes found in non-competitive environments.  And in view of that, I'm wondering if you have any recommendations or comments on the policy that some states have, actually most states, of a certificate of need?  Thank you.

Barry Straube:

I guess the politically correct answer to that is that I work for the Federal Government and can't comment on individual state policies and this is, again, I'm a career, not a political appointee, so I have to be balanced between both parties, too. But currently, of course, the current administration is more heavily focused on allowing states to have as much freedom as possible to determine what goes on there.  So my official thing is, "Well, it's up to each state to determine the pros and cons of that."  I came, you know, I practiced when I was doing nephrology and transplant medicine in San Francisco, for years we had, in the early part of my career after I got out of my fellowship, a certificate of need process in California, and it was very, very cumbersome and created delays in getting programs set up that could have been set up more rapidly if those C.O.N.s were not in place.  California eventually went away and dropped the certificate of need, and I think that, in fact, it's a much more efficient system now, where programs can get up and running, albeit not without some barriers anyway.  I think we have had situations where we have oversupply, on the other hand, of facilities in California, and I'm sure that's true in other states.  So, it's really that conundrum between oversupply and yet wanting to have some control at the state level.

Carolyn Clancy:

So, Jim Rohack, since you're the Chair of our Advisory Council, can I put you on the spot for a minute? Because we were having a conversation about this yesterday, and I thought you were being very eloquent as it played out for states.

Jim Rohack:

When we take a look at Texas, which, like California, when the certificate of need program was eliminated, we saw an increase in specialty hospitals, we saw an increase in focus factories, I think Regina Kersinger refers to it as. And as a result of that, we now have areas that, as they say, we want to provide better care and provide partnerships between doctors and hospitals to create new ways, new focused ways, to provide better care. I think that the challenge that you have with certificate of need is that, in many situations, the person that seems to make the most money is the legal profession—for both sides; they're both being paid to try and justify why you need to change. And I think, as I listened to what Secretary Leavitt said, is that it's going to be local innovation. And if the local innovation somehow has to justify itself to a government entity to be able to build new hospital beds or do something different, then you've stagnated change and you've stagnated the ability to move forward.

Now, where we will have to go is the justification of this process will work, and if it does show that this does work, which, I think in some areas AHRQ hospitals have had data of better heart attack rates. Then CMS will have a difficult situation down the road if, indeed, the encouragement is better care through focused ways of delivering care in a rapid way, will they continue to reimburse in systems that prevent innovation from occurring. I don't know—Barry, we're not going to answer that question right now, but it is one that I think the onus that we're on now is certificate of needs for those systems that still have them—is the care better in those areas as a result of it?  And now if we get value exchanges and better ways to measure that, I think that it will be a better argument to say: is this something that is an anachronism of the past? It certainly will control costs, because we know that, if you don't have a hospital, you don't have any way to do a test, and, thus, you don't have a way to spend any more money. So, again, we're in for some challenging times.    

Current as of July 2008