Question and Answers (Q&A) Session with Secretary Leavitt during Joint Plenary

Town Hall Meeting at the AHRQ 2007 Annual Meeting

September 28, 2007

Carolyn Clancy:

Secretary Leavitt has time for a couple of questions and if you could come to the microphone.  Raise your hands and we'll bring you a microphone, I see, thank you.

Margaret Stanley

Hello, Secretary Leavitt. Margaret Stanley, Puget Sound Health Alliance. Can you give us a timeframe on CMS crunching the numbers and sending them out to the local communities and what kind of reporting that would look like please?

Secretary Leavitt

No, but Barry can.  (laughter)

Barry Straube

Very quickly, Secretary Leavitt, as I said earlier, would have liked for us to have done this a year ago, but we will be announcing, probably in the next day or two, the contractor that we are awarding to actually work with the Chartered Value Exchanges to provide this information.  It'll probably take several months for them to get the methodology down, and I would anticipate it'll be in the early Spring that they'll be able to have the beginning of these measures.

Secretary Leavitt

Nothing in this business happens fast enough for me.  (laughter)  But we are making progress, and they're doing it well and right, and I appreciate the care with which they're taking, but hurry up, Barry.  (laughter)

Ragu Ram

My name is Ragu Ram.  I'm a family physician in Buffalo, New York.  I think we've done a wonderful job in this country training our primary care specialties at value-driven health care.  Unfortunately, I think our reimbursement methodology doesn't share that same value.  What sort of approach can we take to improve the methodology that reimburses primary care practices?

Secretary Leavitt

Let me just say, I agree with everything you said and acknowledge that this is a chicken or egg problem.  Until we have information that begins to demonstrate the value in a way that people can begin to follow it, the reimbursement system and a command and control system won't follow it as rapidly, because a lot of politics gets involved in it.  And it's not just politics on Capitol Hill; it's politics within the various professional sectors.  And that's the reason that there's so much power, in my judgment, in a system that provides information and leads people to quality.  Because people will pay for quality.  And the system will begin to change its macro-economic approach.  I know this is frustrating... it's frustrating to me.  But, we're working hard to create an alternative to it, and I believe once we do, those reimbursement changes, that macro-economic equation will begin to shift.  There's a lot of these.  The primary care is a good example, but there are a lot of macro-economic shifts that have got to be made here.  One of them is, "How do we deal with this problem, if the people have to invest in the systems of electronic medical records, aren't the ones who openly get all of the benefit?"  Somehow, we've got to create a system where those who make investment also get part of the value that comes from this change.

Now, I have confidence that will happen.  It won't happen, it may not be perfect or pretty, but it will get there.  So I guess I would say that my belief is the first thing we can do is get this system into place, and the system will drive the equities.

Kay Jewel

Hi.  I'm Kay Jewel. I'm a physician in Wisconsin and a consultant.  When you talk about the CVEs I'm assuming that each one will be using the same measures, so they won't be local.  Will there be a national reporting?  Or will it be local reporting?

Secretary Leavitt

In order to be a Chartered Value Exchange, there are a set of criteria that's been laid out, and we can talk about that in more detail.  But if I just put it simply, the number one criteria is you need to adopt the standard quality measures that have gone through the process of the AQA and the National Quality Forum.  And that's the national standards.

The neighborhood strategies is we want you to do that in a way that, we want you to innovate to do it.  We started off with six—we call them the BQI's, Better Quality Information. And you know, there's one in Wisconsin, there's one in Minnesota, one in Boston, one in Phoenix, one in California, one in Indianapolis.  And they're all doing it slightly different, but one of the things we're now moving towards is all six of them are beginning to use the same quality measures, and so if you're going to have a Chartered Value Exchange, one of the commitments that you make is that you will use those standards.  And so we're using the brand of Chartered Value Exchange as a means of knitting people's commitment together to use those same standards.

Now, we know that there are people who are developing other ways of measuring quality that, and maybe that need to be expanded, and so we want to create a means by which, in this network of Chartered Value Exchanges, there's a way to advance those to where they can be adopted nationally.  Will we be doing national reporting?  I'm going to ask Barry and Carolyn to answer that—I think we probably will on certain measures, and we'll start sharing information.  The thing I expect this network to do—basically 3 things:  1—I want it to be a learning network. I want to have meetings like this where we learn from each other, where we share technical data;  2—I want it to be a means by which we innovate more quality standards; and, 3—I want to make sure that we're all informing each other.  And so, having the charter and the brand of the charter, I hope, will begin to make clear a common path, putting it together in the network will begin to create this synergy like we've talked about.

Kathryn Jones

Good Morning, Secretary Leavitt.  I'm Kathryn Jones from the University of Nebraska Medical Center.  Coming from Utah, I know you appreciate the wide-open spaces we have there in Nebraska.  We have 93 counties, 22 of which don't have a hospital.  So, I'm wondering what the Chartered Value Exchanges will look like in our counties in Nebraska where we have one critical access hospital that provides the care for all those folks in that county, and how we'll use that Chartered Value Exchange to drive quality of care for places in rural America where really, frankly, there is not competition?

Secretary Leavitt

That's a great question.  I hope we can all figure that out together.  I recognize the difference between what goes on in rural communities.  As you say, I've governed a state where there were some communities so rural that you had to order a haircut out of a catalog.  And health care has to be provided as well, and they have to go someplace else for it.

And, I think, ultimately, what we're going to have to do is get it very simple and recognize that.  But the key to it is going to be the electronic medical record.  Because those communities, whatever health care source they have, making them part of a larger system will begin to create some kind of pricing and quality measure that doesn't exist now. 

I think I dodge that properly.  Truth is, I don't know the answer, but I do think we can figure it out.

Louise Probst

Good Morning. Louise Probst, Business Health Coalition in St. Louis.  Thank you very much.  I wanted to say on behalf of... communities here, I want to say thank you for your leadership.  The Federal Government is doing great work in health care, and every opportunity I have, I tell people to hold on, because there's a lot of good things happening.  I also want to thank you for putting health care in the broader context of what's going on.  I also grew up in the 50's, and I know the gift that I think our generation had of living in a world where you knew what it meant to be American and we were proud of it, and so, I think it's important to understand the impact of health care and other things.  Now for my question, which is technical. Since CMS has decided that it's going to measure the quality of things centrally, will they also have a responsibility or feel that, to actually share that data back with the physicians, or is that solely the responsibility of Value Exchange?  I assume doctors are going to be wanting to come to you and get that information, I'm wondering if you had thought about that?  If you'll have a role in having the support line for physicians or how that will work?

Secretary Leavitt

Barry, do you want to respond to that?  Or Carolyn? 

Barry Straube

Sure, I think that obviously the Value Exchanges will be sharing information like this.  But we'll be able to calculate a national rate so that people could compare themselves to that.  We'll be able to have a regional rate—could be at a State, could be at a local regional level and the local level.  Probably initially down to the physician group level, not to individual physicians right away.  So we will be sharing that information with Medicare information.  The Secretary mentioned Robert Wood Johnson Foundation efforts, which will align with what we're doing, so we'll be able to combine the two to get a combined effort in the short term.  The Secretary has made it very clear in the long term, he'd like us to expand and be able to offer information far beyond the initial measures that we've chosen to do initially.  And that will be shared with physicians, quality improvement and other providers. It will be used for consumer choice, and it'll be used to determine incentives to try to improve care.

Secretary Leavitt

Could I just recognize that we're going to learn a lot, and the best opportunities we haven't even thought of yet?  And the market will begin to present new opportunities, new ideas, and new innovations, and what we have to create is this basic infrastructure and this basic network, and then, you know, I think it's quite possible we'll, you know, you could start off with hundreds of Value Exchanges and over time, it may, the market may say that doesn't make a lot of sense.  Now that we've created more trust in this system, now people have more confidence in it, we might find Value Exchanges beginning to merge.  We might begin to see Value Exchanges making the very natural connection with organizations for health IT, and many of them may say, rather that have the health IT network development being separate, let's start merging those.  As long as we're dealing with common standards, then we can begin to see efficiencies.  Some of you have heard this sort of hokey analogy, but it works. I'm walking through an airport, I think in Indianapolis, and there's a racecar that is on display there—I think from the Indianapolis 500.  And I thought to myself, that's what people think I'm talking about when I talk about this system of health care that will provide everybody with access to this powerful information.  That is, in fact, the vision.  But in reality today, we've got ourselves a little pile of wheels, a steering wheel, and a Briggs & Stratton motor, and we're trying to build a go-cart just to prove we can make this work.  And once we've got proof of concept and people begin to create a set of standards and confidence and trust, then it will begin to grow and mushroom, and it will evolve into the race car.  And it may be that we don't have as many.  It may be that rural America finds a different way to do it, but once we're empowering the standards and driving the concept, we'll invent a system that will be the most powerful system of health care on the planet, because it's turning decisions over to people who care the most about the decision, and that's the consumer.  That's a powerful force, and it is the uniquely American force that's driven our entire country to the level of prosperity that we currently enjoy. And it's what is absent from health care today.

Carolyn Clancy:

I think we have time for one more question.

Georgine Stowt

Hi, Secretary Leavitt.  I'm Georgine Stowt, a preventive medicine physician in Davis, California, and your story about your colonoscopy precipitated a two-part question.  One, did you decide to get it?  And, which one did you choose and why?

Secretary Leavitt

Yes, I did.  And so did my wife, and we ended up in different... I found one in Washington, D.C., that I was able to get under an arrangement that suited my purpose, and Jackie did go to Utah and have hers there.  And, under HIPAA, I can tell you no more.

Georgine Stowt

Your story reminded me of a story from my practice a few weeks ago, where a man I was treating for his obesity, and he was doing very well, out of his own pocket, paying for it, of course, "I said, oh now you're 50, how about the colonoscopy or the screening?"  And he shared with me a story similar to yours, that it would be $5,000, and he was making a choice between dealing with his obesity or his colorectal screening. My question relates to the vision of the future.  Do you see a vision where prevention will be prioritized and we don't have to choose among the various valuable procedures and services with respect to our investments?

Secretary Leavitt

I believe that once we have a system that provides a means of electronic connection, quality measures, a way in which people can exercise judgments on costs, and motivations for better quality and lower costs, we're going to see the market drive us to that point.  I think people will naturally see that prevention is where the money is and that it will begin to move us to primary care physicians.  It will begin to move us toward more prevention.  It will begin to move us in a way that is toward lower costs and better quality. 

I'd just like to say. I've told the story about my colonoscopy a few times, and I keep getting new information. You know, people come up and say, "You know, you can come here and get it for a lot cheaper than that."   But one employer said, we wanted everybody to get a colonoscopy so we worked out a group deal, and we got it down to just less than a $1,000. And then I had another person say that, "Well I was in Japan..."  And, you know, what they do in Japan is a little different than we do here.  They've concluded that they could, rather than have a physician do the entire procedure, since it's all done electronically anyway, they could have a room where they have many different monitors with a physician monitoring all of them at the same time, and they're doing them for less than $300. Now, I'm not here to advocate for that.  I'll have physicians all over my case. What I am... They've made a decision about value and cost.  They've concluded that, based on the risks that they believed were there, that it isn't necessary to, that the risk of puncture may not, they've made decisions based on that, and they're now able to give that colonoscopy that I was quoted $6,000 for, you know, for $400 or $500 dollars.  Now, is there an economy in that?  I don't know.  How will we find out?  Well, we'll start gathering information.  Why don't we have it now? It's because it's all manual, and before it's actionable, it's 5 years old.  That's the system we're talking about, that's the power we're about to unleash.  That's the reason we're working so hard on this hole. And we're just about ready to see it pop out, and all of you and the workers and I look forward to standing side-by-side with you, laying brick by brick, and we're going to make the vision come that the people of this country want, and that's better health at lower costs for every American.  Thank you.

Carolyn Clancy:

Let me just close with a couple of points. In our excitement about trying to figure out what it's going to take and how can we support, centrally, local efforts at the kind of innovations Jim just described, that you've heard Secretary Leavitt describing, we can lose sight of the fact that Chartered Value Exchanges remain a very near future-tense item. We will be letting all of you know when the criteria are finalized. And the questions that I heard from Margaret Stanley, from the woman from Nebraska, and so forth, I think are all critically important questions. And I think the Secretary had it right when he said there's not a clear, easy answer, but I think our collective working together to get these answers right will be very important. One of the challenges that we will have centrally, and we'll also need to get feedback from you on, is figuring out a framework in which foundations supported investments in local technical assistance, the Value Exchanges, the learning networks, and the quality improvement organizations can make sure that their efforts are synergistic at the local level rather than a set of tangled lifelines, if you will.

So, this is very much a script in progress. I, myself, love the idea of a first AHRQ-a-palooza t-shirt. We'll let you know if we actually get a chance to complete that idea. Thank you for a terrific session.

Current as of July 2008