[This Transcript is Unedited]
National Committee on Vital and Health Statistics
Subcommittee on Quality
November 17, 2011
Holiday Inn Rosslyn at Key Bridge
1900 N Fort Meyer Drive
CASET Associates, Ltd.
Fairfax, Virginia 22030
M O R N I N G S E S S I O N
Agenda Item: Welcome and Introductions
DR. MIDDLETON: Welcome to the Quality Committee breakout. I guess the first thing we should do is go around the table and make introductions. Welcome to Dr. Jonathan White. Jon White, welcome. Jon has volunteered to come in and fill in for Matt Quinn while he is away. Jon, do you know everybody? If not, give a sentence or two.
DR. WHITE: I know a lot of you. My day job is that I direct the health IT portfolio at the Agency for Health Care Research for Quality. I have been there for seven years. I used to by Matt Quinn’s boss, but the man has moved up in the world.
DR. MIDDLETON: Introductions?
DR. HORNBROOK: Mark Hornbrook, Kaiser Permanente, member of the Committee under populations and quality; no conflicts.
MS. GREENBERG: Marjorie Greenberg, National Center for Health Statistics, CDC, and Executive Secretary to the Committee.
DR. COHEN: I am Bruce Cohen, Massachusetts Department of Public Health, new member of the Committee.
MS. GREENBERG: Not so new anymore.
DR. COHEN: Veteran of the Committee. Sophomore member. No conflicts.
DR. NICHOLS: Len Nichols, George Mason University. I am also on the Population Subcommittee; no conflicts.
MS. KLOSS: Linda Kloss, member of the Committee, member of the Subcommittee, and co-chair of the Privacy, Confidentiality, and Security.
MS. JACKSON: Debbie Jackson, National Center for Health Statistics and Committee staff.
MS. COOPER: Nicole Cooper, NCVHS staff.
DR. TANG: Paul Tang, Palo Alto Medical Foundation, member of the Committee and Subcommittee and no conflicts.
DR. MIDDLETON: Thanks, Paul, for getting up early and joining us. We wish you were here.
What I thought we might do today is go through just very quickly, to get the juices flowing, the NAHDO Summary of Quality Activities very briefly and then talk about the Quality Subcommittee roadmap and upcoming activities. We have a draft for review of hearings surrounding harmonizing for Million Hearts: Improving the Life Cycle of Quality Measures. I think we should also discuss what the Chair asked us to consider yesterday — quality hearings on ICV 10 and implications for measurement, quality management, et cetera.
By way of a brief recap of where quality is, at the NAHDO meetings, we had a chance to give the overview that you all heard about, waiting for Marjorie’s coronation. It was really terrific.
MS. GREENBERG: I actually received the award that your boss received last year, the Elliot Stone.
DR. MIDDLETON: It was really terrific to see. Congratulations, Marjorie.
MS. GREENBERG: Thank you. It was great to have you guys there. It was funny because last night at dinner Justine was recalling that when I called her to recruit her for the Committee, trying to sell her on the Committee, I said, well, we are really like a family. I didn’t remember that I had told her that, but it is a fact. Welcome back to the family, Jon. It was nice to have my extended family there.
DR. MIDDLETON: At the presentations for NAHDO, we got a chance just to review Quality Committee activities over the past decade. It was terrific to see all of the work that this committee has done on behalf of NCVHS. I am happy to share these slides, but I thought I would just touch a few of the highlights now to get our juices flowing about where we have been and where we need to go.
In the early part of the last decade, we had hearings and talked about the business case for enhancing administrative data for quality measurement. We talked about refocusing the quality workgroup on performance, measurement, quality assessment, and —
DR. TANG: Blackford, are these slides somehow available?
MS. GREENBERG: I think Debbie Jackson sent out the slides to the whole Committee on Tuesday night. These are your and Blackford’s part of the presentation.
MS. JACKSON: You have them, Paul.
DR. TANG: I do? Okay, I will look.
MS. GREENBERG: Look under Debbie. She sent them Tuesday night — the whole set of slides and these are embedded in there.
DR. MIDDLETON: I am only going to touch on the quality ones and only a subsample of those, Paul, just to get ourselves oriented.
Anyway, the business case on measurement, refocusing quality on performance, 2005, hearings on the potential impact of the EHR, 2007, hearings on the administrative and clinical electronic data, 2008, the medical home, hearings with the populations subcommittee, and 2009, meaningful measures supply chain and building measures that matter for our nation’s health. There has been a variety of big reports and letters from the Subcommittee, which you are all familiar with.
As we think about that history and look forward to the next decade, some of the thoughts that came together were these. Basically, the challenges for the next decade is how do we harness the potential of this extraordinarily increasing dataset and sources of data of different types to improve health and health care in a meaningful way? How do we focus leadership and expertise on data aggregation and mining methods? How do we improve outcomes assessments from those broad new array of data?
Secondarily, how do we put the patient or the person, really, at the center of measurement? In our last set of hearings, we talked a lot about this patient-centeredness. It is somewhat of an overwrought term, but how do we really change the perspective on measurement to what matters to the patient/what matters to me and all dimensions of their decision making? How do we place the person at the center? We need to place the person at the center to engage them, activate them, personalize their health care delivery and health care assessments, and, of course, place them at the center of a health care team that is revolving around them for care and support.
Thirdly, how do we think about coordinating and monitoring development? A prior letter made a recommendation about a national coordinating center for quality measure development and oversight. How do we improve coordination for measuring and monitoring health status, quality, effectiveness, health services, and optimize the opportunity for capturing relevant individual and population health data from the record — both EMR and PHR, ultimately, as well?
The new sources of data we have been chatting about include many new forms of consumer-source data, as well as the EHR data. How do we reuse these data in important, meaningful ways? How do we improve the quality of quality data? How do we make sure that data integrity considerations are thought of way up front, upstream where data is captured so that data integrity can be maintained and, frankly, the prominence of the data — where does it come from, how many times is it used, is it modified in any way, et cetera?
How do we actually begin to think about a quality measures knowledge base or knowledge management with respect to quality assessments? Certainly, the NQF will take the lead on this, but what are the futures that we might consider with respect to maintaining a measures library and improving the measure development life cycle, as we talked about already?
Those, I think, were the big pointers that we have been considering in our prior deliberations. Let me pause there and ask for other commentary and feedback on people’s perspectives of the last decade and where we need to go. Mark?
DR. HORNBROOK: Did you happen to say anything about moving forward on patient report? I caught a hint of it, but I didn’t know how much you emphasized it.
DR. MIDDLETON: Only obliquely, in terms of patient source data.
DR. HORNBROOK: That seems like something at least pretty visionary. Everybody, as a patient, as a caregiver, ought to be doing functional health status outcomes just in time and regularly as part of their medical record.
MS. GREENBERG: Actually, I will just say that, turn the compliment, that the Committee’s presentation was very well received. Actually, you had to leave after my coronation, but —
DR. MIDDLETON: Not because of it.
MS. GREENBERG: Hopefully not, but there were two really interesting sessions in the afternoon. I am sure they will posted, as well, and related to quality. Several people referred back to some of your comments. They were listening and definitely taking it all in. They were amazed at everything the Committee does and also they thought the Committee was very funny.
DR. MIDDLETON: Well, it was Walter. Let me tell you — I try to make a couple of jokes, but compared to that guy.
MS. GREENBERG: I never saw Walter be that funny before. He did kind of an imitation when he started off. He said I don’t have the 9-9-9, I have the 10-10-10 and then he started saying it is 10 standards for this and 10 for this and then he said and what’s the other 10? And then he went oops. It brought down the house.
DR. MIDDLETON: It was his timing.
MS. GREENBERG: Yes. It brought down the house. They were glad we were smart. They were glad we were on the cutting edge, but they really liked that we were funny.
It was a state reactor panel. One of the big issues that was raised by Pat Meriwether from Illinois — I don’t know if you are familiar with her, but she has been in the quality area in Illinois State Hospital Association and now, I think, in the QIO — was functional status. Actually, several of the things that people were raising as kind of in the future were things that we have talked about in this particular subcommittee. That was positive.
DR. HORNBROOK: It is just that when you get a perspective of the population and you say I have so many dollars, where am I going to spend it, people who have functional losses are the high users. If they are not yet high users, they soon will be.
MS. GREENBERG: She talked about social determinants, which, of course, we are dealing with in several different ways in the Committee, functional status, goals of care — we have talked about that here, also –, environmental issues, trust, et cetera. I think those were very relevant.
MS. KLOSS: As you went through the challenges of the next decade, it seemed like it seemed like we were kind of mixing some things that are building blocks — you know, kind of essential building blocks. One of them that I would like to see us kind of throw into the mix is some more standard approaches to determining the robustness of the data quality or data quality measurement, the integrity of this data.
I think maybe it might be helpful to differentiate kind of the building blocks for this versus the goals, the visions, and the opportunities and kind of blend those as we go along or do some of each. I think there is just a lot of wheel spinning going on with regard to just not knowing how to collect the data, how to judge how good it is, and just some fundamentals.
DR. MIDDLETON: This is one of the things, I think, Arnie Millstein referred to in his testimony or presentations at the last hearings. His strain or his concern is about that very issue. Starting from the get go, how do you improve the entire quality management life cycle? We don’t attempt to do it with some of the fundamentals. If we do, we do it in very different ways and thus the data is all over the map.
MS. KLOSS: There is no consensus on how to do it.
DR. HORNBROOK: The interesting thing is that sometimes the provenance at the raw, first, first data collection is outstanding. You bar code a drug product and get the NDC code number and you have everything you need to know about that drug product. All you need to know is what the prescription was written for, which can also be modified.
Then it starts getting aggregated and pretty soon you may only know the therapeutic class of what that person got. Somewhere along the line somebody made that simplifying aggregating decision because that is all they needed to know, but then the person who is programming and using the data has been separated from the original raw data. I am just saying I have seen it many times across many health plans where when you make decisions to put data into an aggregate domain for use by analysts, there is a lot of simplification that goes along just because programmers don’t want to and don’t understand the micro-level detail.
DR. COHEN: Sort of following up, I was struck by your comment use and reuse. There are multiple target audiences for this information. There are the clinicians. There are the plans. Then there are actually the patients at the individual level and at the collective level. All of the data are there. It is packaging them in a way to make them not only accessible, but useable by the different target audiences.
To me, when we begin talking about outcomes, it is individual decision making and it is population health. Those are packaging quality information very differently than decisions for clinicians and for the plans.
DR. MIDDLETON: Yes. This is a great central theme. I don’t really know any — I have no better way to say it, Bruce. I think you said it very well. I have actually been reading recently about patient-centered medicine, personalize medicine for this grant that I was telling you about. We may see the evolution of clinical decision making go, as I was alluding to at the NAHDO, from kind of population-based reasoning, post-flexnerian kind of era into the — starting with individual decision making, flexnerian, then population based in post-WWII, and then back to individual, highly customized and individualized decision making.
That changes the way we analyze quality from kind of crude individual measures based on no science in the early 20’s, early century. Population-based measures arrived in the second half of the century. I think in the first half of this century, we are going to see a return to this notion of individualized medicine — whatever you want to call it, patient-centered, personalized. The quality that you receive with your unique genome compared to what you receive with your unique genome, et cetera, is going to be different than saying what is the quality of care delivered to the diabetic population. We need to get around this STAT.
MS. KLOSS: And the rigors of the quality of that data are directly related —
DR. MIDDLETON: It is totally different. The quality of your individual data I have to access for you.
MS. KLOSS: But it better be 100 percent right or close to it.
MS. GREENBERG: Like the patient identifier, if it is driving care, it is not good enough that it is 95 percent. That raises such an interesting question of how you then — if everyone is unique, how you then get to population measures?
DR. MIDDLETON: And what is quality?
MS. GREENBERG: Yes, what is quality? Exactly.
DR. TANG: This goes back to the measures that matter hearing and this notion about stratifying the reports, rather than risk averaging everything to nothing. That may be — this whole crystallization may be a very fruitful area for this committee. It has been raised in other settings, including policy, but no one is driving it. It seems like something that NCVHS could take a lead in because of our health statistics, et cetera.
DR. MIDDLETON: Yes, I mean, what our national survey data with respect to personalized medicine? Does the NHANES or any other of the main instruments really have to take a new look at what they are measuring.
DR. HORNBROOK: One of the things that is interesting is that your genome is not fixed, right? You can acquire mutations over time. Part of cancer is acquired mutations, as well as inherited mutations that turn on/turn off the oncogenes so that your cells keep dividing forever and they never die and they grow fast. You go through life and your acquired mutations can be both random because the cells keep dividing and sometimes they make a mistake and your body doesn’t get rid of the mistake. The mistake lives. Or it can be behavior — cigarette smoking, walking under radiation, chemo, pesticides, lots of things.
DR. MIDDLETON: We like mutations, actually, because that is our survival advantage. If we didn’t mutate, we would not involve. There is maybe some intelligent design here going on, but I am going to leave it at that.
DR. HORNBROOK: So one can imagine that I used to think, well, gee, if I just got the genome map and put it in my medical record, you would have all of the genetic data you wanted. As soon as you learned about it, I could go back and apply it. Unfortunately, the longer it goes, the more your genome has changed.
DR. COHEN: Does that help me make the decision about whether I should get that PSA test or not? That is the bottom line for me at the individual level and at the population level.
DR. MIDDLETON: I think this is the emerging conflict or a possibly emerging conflict. When populations statistics and evidence suggest you do one thing for the entire population without consideration of the specifics, et cetera, of an individual versus what your genome guidance might say — when those are at odds or potentially, what do we do?
DR. HORNBROOK: The individual still has to make the decision, right? Even when there is equipoise on the data, you are just going to flip a coin or you are going to believe one is more than the other.
DR. MIDDLETON: The other side of the whole genomic thing, which has been so fascinating and I don’t want to take us too far down this rat hole, but is that all of these assessments, all of these measures and these decisions will be increasingly made in the context of patient preference.
MS. GREENBERG: That is just what I was going to say. There was a very interesting session and they showed — it was a great line. You know Michael Pine? He was showing the statistics from different hospitals. He said this is the hospital in which you are going to have the best survival rate, but you wished you had died because of everything they did to you. It was a very good line.
Also, what it was — on one axis was survival and on the other was comfort. This one was the top on survival and the bottom on comfort and that is why you have the best survival rate, but you wished you had died. It was very interesting.
DR. COHEN: There is a real analogy to the population health issues, too. When we talked about community indicators, the data can present communities with certain choices, but it is really community preferences for their priorities that should dictate what interventions happen. Data are a tool and an input into that decision making process, but are not the determining factor. To me, it is the individual versus the community around the decision- making process. That is sort of the nexus between what I think we are doing here in quality and the population health folks.
DR. FITZMAURICE: May I throw something out there? All of this is right, but I want to go slightly diagonal to the discussion, which is that there is a lot of stuff happening out in the country right now around how care is being paid for and organized. There is a lot of it happening at the state level.
A very interesting development to me is it is coming together in very different ways, depending on the current political philosophy in the state. What you are having is a very varied natural experiment, ranging from Vermont to Virginia, where all of the stuff is coming together in very different ways. In the context of the data, the rules that apply to that data — by the way, there is a lot of investment being made in the information infrastructure to support that.
It will be very interesting over the coming year to hear about how those developments are occurring and what tax each one of them are taking and to see how that plays out over a period of years.
DR. HORNBROOK: Just one trip backwards. We won’t have much in the way of genetic therapies unless we reform the FDA criteria for new drug approval. Genetic therapies only do one pathway and your body has multiple pathways. In order to get the safety and effects from this, you have got to put together a multi-drug paradigm. Drug companies, of course, want blockbuster drugs. They don’t make a lot of money on one genetic therapy.
DR. MIDDLETON: This is really central, too. Actually, it is the sort of dovetail or the flipside of our own sort of individualized quality assessment stuff. I couldn’t agree more, Mark. Think about the clinical trial. We are just going to assess whether this agent affects your hypertrophic cardiomyopathy profile because you have one of the six well known variants. That subpopulation is only 100,000 patients, as opposed to half the population with hypertension.
DR. FITZMAURICE: You are talking about not just the therapeutic aspects of a particular regimen that you are on and not just the individual safety profile, but the interplay of those.
DR. HORNBROOK: One suggestion is that the drug companies have to create consortia to come together, each of them pack-case the products that they are pushing on the frontier, and go together, as a package, together, cooperatively, which means lower profits for each one or shared profits. It is a whole different industrial model, but I don’t think it is going to evolve without government leadership.
DR. TANG: After we reform the health system, we will reform the drug companies?
DR. MIDDLETON: We might need the new drugs, first, Paul.
DR. COHEN: How does it work in other systems that are not so profit-centered? Is there any thought for more collaboration among drug companies or is it just driven by the American market?
DR. HORNBROOK: The American market provides most of the profits around the world. Other markets follow. They are sometimes in advance because some of their entry criteria are somewhat less. Some of the countries have cost-effectiveness and we don’t so you have to prove that your new drug is not only safe and effective, but also cheaper in terms of overall therapy.
The drug companies just optimize to each of the markets. They get the maximum profits possible out of Japan, out of Australia, out of Austria, et cetera. Even the EU isn’t coming together and trying to collectively bargain with the drug industry yet. I think there is a structure there for doing it, but it hasn’t happened yet. Each of the countries wants to control their own health systems so far.
DR. NICHOLS: Yes, countries are funny that way.
MS. JACKSON: The term that you mentioned just now when you were talking about that was frontier in looking at drug companies. It is amazing to see the whole frontier with the influx of where the information is coming from. Also what happened at NAHDO was a description where a gentleman got a phone message and it beeped off and then he said, well, I am sorry for the disruption, but I just found out from my Mom the information that she had gotten on Facebook about the things going on at my house.
MS. GREENBERG: Yes, about his kid having tonsillitis or something.
MS. JACKSON: Which he didn’t know about, but his mom was on Facebook and said what is going on with the children?
MS. GREENBERG: His wife had put it on Facebook. It was unbelievable.
MS. JACKSON: There is information coming in from all over the place. It is almost — when you are looking at the individual, the person-centered health, it is coming back to persons from all kinds of technical ways that hadn’t been important before.
DR. MIDDLETON: I think that is going to be one of the major challenges in confronting the tsunami is to ferret out the signal from the noise. It is just going to be overwhelming.
DR. HORNBROOK: The whole health reform issue is are we going to bring the distribution of the haves and have not’s just down — everybody shifts the whole distribution down so that everybody gets less in order to control the real growth of GDP going into health care or are you going to bring the top down and the bottom up so you get more equality? Can this country deal with dealing with inequality?
If you go to the UK, it is a social value. They will stop progress in order to improve equity. They do not care about bringing the top up or the whole distribution up. They care about bringing the bottom up. They put a lot of resources into taking care to the people who do not have access.
DR. MIDDLETON: That is within the system?
DR. FITZMAURICE: Within the National Health Service, yes. They still have the private on top.
DR. FITZMAURICE: Right. The rich people at the top can choose to go outside the system.
MS. GREENBERG: That doesn’t sound like the American way.
DR. HORNBROOK: It is not the American way. When they send resources over to Wales to deal with very rural villages that have diabetes running amok and hardly any physicians, you know they are taking it seriously. Whereas, we just let them go or let Medicaid handle it.
DR. MIDDLETON: That does allow us to maybe talk about the elephant in the room that we need to figure out ways to measure quality and value. There is one elephant in the room. A beautiful pin fallen around Marjorie’s neck.
MS. GREENBERG: It is from South Africa. It is not a political statement.
DR. MIDDLETON: How are we going to get at this issue? Where does the NCVHS need to be to afford leadership around this issue?
DR. HORNBROOK: I think exactly where we are at. Inside Kaiser, we can tell you all of the inputs. We can look at all of the injections going into each patient. We can look at all of the pills going into each patient. We can look at each doctor visit, hospital stays, hospice visits, whatever. Can I tell you who is healthier? Very crudely. I know who is alive and dead. I know who has had a cancer recurrence. I know the number of days from the first cancer to the second cancer.
I can talk about cancer for days, but I cannot tell you about their functional health days. I cannot tell you whether they are happy or unhappy.
MS. GREENBERG: You don’t collect any of that?
DR. HORNBROOK: No. That puts you at a financial disadvantage to a competitor. If we paid for a systematic patient reported outcomes system, which I think we need, and nobody else is doing it, you have a cost increase that nobody else is dealing with.
DR. MIDDLETON: Well, said another way, it doesn’t matter. None of that matters because payment is not sensitive to any of those measures.
MS. GREENBERG: It matters to the patient.
DR. MIDDLETON: I hear you.
DR. COHEN: Only if it reduces costs to the system.
MS. KLOSS: But maybe it won’t be paid for until some of that data begins to be available.
DR. MIDDLETON: Exactly the point. Where do we need to put the hockey puck? That is what we need to do is think about a roadmap beyond health care reform, beyond genomic medicine, all of these things. We need to think about the steps we want to deliberately take, more or less coherently and intentionally, to move this discussion forward.
DR. TANG: You know, Blackford, I think there is an approach that captures a lot of this discussion and that could be useful fairly quickly. If you think about how can you measure individual improvement, sort of functional status and that mix, if people are incented to improve the number of people that they improve in the whole health — their health and functional status –, then that would at least align the incentives of a clinician with each person in their population.
DR. MIDDLETON: Wait, Paul. Say it one more time. I didn’t quite get it.
DR. TANG: I am trying to say is there a composite of clinical health and functional status? If we measure it by individual, rather than population averages and rather than risk stratifying everything, then we have a closer measure to making sure every person counts in a population. In effect, that one thing could help point your sights on optimizing it for each person and it also works on the disparities. It sort of works on everything at the same time because it redirects your focus to what can I do for each individual. Does that make any sense?
DR. MIDDLETON: Yes. I am with you.
DR. HORNBROOK: You want a credit score for everybody.
DR. TANG: I want a credit for every single person. Not everybody is at a place where they want to be a 10 and not everybody says they want to be an eight, but if I direct the appropriate response to the 10 and the appropriate response to the eight, I will get a better score, but fictionally, what we have done is we have motivated the physician to work on each person for their goal. See what I am saying?
DR. NICHOLS: One thing this is making me think of is I had this boondoggle trip to South Africa last year to go to the World Cup because an insurance company there has a wellness module that they wanted to market in the United States. It is a big market share. It is a big company. They had Uwe Reinhardt, Bill Frisk, Mark McClellan, me for comic relief, we got to bring our wives, and they gave us a week in country, World Cup Final tickets. They price was we had to spend a day listening to their pitch and then explain American health reform to them.
MS. GREENBERG: This sounds like the kind of trips I take.
DR. NICHOLS: Here is the deal — here is the relation to what Paul just said.
DR. TANG: By the way, who is speaking?
DR. NICHOLS: This is Len Nichols. Basically, they have a health risk assessment algorithm. In South Africa, you can require these things. Everybody does it. Mark and I go to our docs after a health risk assessment and they look at us and they take our individual histories, et cetera, and they develop a pathway. If I do what I am supposed to do, which is basically not the muffin, more sit ups before I got here, all of that, I get points. If I get enough points, I get to get a goodie like green stamps.
This company is filling up — I am not making this up — two airplanes a day with people taking trips that they have earned. They spend two percent of premium on the promo and they are saving five percent off trend three years in a row. My point is the individual risk assessment is the pathway that gets you to the linkage between the functional status and the clinical observation. It is kind of an interesting little twist.
DR. MIDDLETON: Is there a patient identifier — national health identifier?
DR. NICHOLS: I think they have no problem with that sort of thing over there.
DR. MIDDLETON: You know why I ask? This sort of approach, back door to individualization of data, may actually get us beyond some of the paranoia about patient identifiers. Do you see what I mean? Do you see what I am saying?
DR. NICHOLS: It is a great pitch. I am right there with you, but what I can say is you are never going to reduce some people’s paranoia. I do think this avenue is worth actually perhaps investigating.
DR. HORNBROOK: There are a number of companies in the United States that are doing that on their own in designing their health benefits. They are putting in BMI, exercise activity, various lab tests, blood pressure, and cholesterols. They are giving you a rebate on your premium based on your health behavior and your performance in the metrics.
The problem with that, of course, is it undermines the risk-sharing pool for health insurance because the well people pay less.
DR. MIDDLETON: So here is the usual clinical refrain. The usual clinical refrain is of two forms. One is my patients are different. Number two, this patient actually is different. Whatever your norm population models, the credit score idea doesn’t apply. I would take the credit score idea, which I like, at a population level, and really, as Paul suggests, bring it down to the individual level so that it is meaningful and adjusted in all of the ways that it could be criticized.
MS. GREENBERG: I think there are ethical issues, too — blaming the victim. If it were easy to lose weight, easy to do these risk behaviors, we would all have done them.
DR. NICHOLS: But see, that is what is beautiful, at least, I think, about some of these structures. I don’t know if I can say definitively the one in South Africa is the best in the world, but I will say —
MS. GREENBERG: It is one of the most beautiful countries.
DR. NICHOLS: The point is you and I might start at very different places. We are rewarded for behavioral change. Yes, I am going to weigh more than my 23 year old research assistant, but I am going to get an equal number of points if I do what I am supposed to do.
It is not penalizing the victim. It is encouraging them.
MS. GREENBERG: If you have to pay higher co-pay because you didn’t lose weight and the whole risk — what you were talking about —
DR. NICHOLS: But that is what is fascinating, again, about the South African example. By law of Nelson Mandela, there is no price difference to the patient. It is not allowed, but they do have these bonuses for those who do well. It is all carrot, not stick.
MS. HORNBROOK: Now, the question is is it fair because the people who get these bonuses, are they more advantaged than the people that —
DR. NICHOLS: So my test empirical observation was my half day safaris and I got this Afrikaner guy in this jeep going around looking at the white lions. I asked him if he had ever heard of this company. He says, oh, yes and he starts talking about the trip that he and his wife are two weeks away from taking and they are all excited. This guy is 200 lbs overweight and he is excited about this thing so it must be empirically valuable.
MS. GREENBERG: So mother, here, or queenie, if you would rather go with that — anyway, what I am hoping by 9:30 is we will have this subcommittee, who every time I come to it I get all excited because I really love all of these areas that you are exploring, but we will have decided about — you will have decided about next steps. It says 9:10 but — are we leaning towards one or more hearings or workshops?
DR. MIDDLETON: No, that is very helpful.
DR. FITZMAURICE: Before we move on completely, all good ideas. What I have not heard from you is how is NCVHS different. You all know and many of you are on committees looking at these question. What is different about NCVHS that can focus the subcommittee on aspects of this?
MS. GREENBERG: What is the added value that NCVHS can provide?
DR. HORNBROOK: The interesting thing is when you start moving these data into the domain where you give the physicians treating the patient a profile, a QWB or and HUI score, that they filled out just before the physician saw them and it was processed into some sort of a color profile. You have to train physicians on how to interpret those scores. Of course, if you also add in disease-specific functional status, in terms of urinary function, incontinence, or sexual function if you are a urologist, you are starting to get things that physicians do already in regular, intuitive practice, but they do not document it, except by writing text notes in the chart. All of a sudden, we have quantitative data that can be extracted because all of this stuff is electronically scored. Then the physician, of course, in looking at —
MS. GREENBERG: You do do that or you do not do that?
DR. HORNBROK: This is the dream. This is the dream of moving functional health status from not just a population measure, as we have been doing for years in our health status surveys, to a clinical domain to get the physician to recognize it is possible to quantify patients’ individual functional behaviors and how they change over time.
If the patient is saying something different — this time they felt a certain way about their ability to get up and get around and it turns out it is not because of their disease, but because they have some new source of pain or they answered the pain question and the score went up a lot compared to their usual profile, then there is something to talk about and make sure the patient doesn’t forget about it or is not going to cover it up.
DR. TANG: I really like what Mark is saying and we talked about this and meaningful measures. I think it was Jon White that talked about, well, what the Committee, their role. I think it is back to timing and timeliness, but the meaningful use kind of stuff, which really is our entrée, in terms of how do we get some of our ideas inserted into practice in time for it to be used in the reformed health system.
Let’s say we choose the delta measures, the by individual kind of measures, and we include the functional status measures that Mark was just talking about and we get it there in time to be wrapped into meaningful use stage three, which is really on the way towards CMS’ new program. Other people have talked about this, including us, but nobody is driving it. Do we, at NCVHS — and I assume we do — have the statistical sophistication to be able to actually formulate some concrete exemplars for these kinds of measures and get this inserted in the process of working its way into the EHRs and then into these payment programs?
Do you see where I am headed? Right now, the phase III stuff, we are trying to shoot for the middle of 2012, which, of course, we can’t meet. The rule will not come out for another year after that. If we, NCVHS, can hit the streets by the end of 2012, we can start getting inserted into this process that starts becoming part of that world. I am just saying if we meet the timeline of the train that is moving, I think we can increase our chance of being relevant and being used.
DR. MIDDLETON: That is very helpful, Paul, to set up the timing. Let’s turn now to really resolving our next set of hearings topic. We have a draft proposal before you to review. I think this discussion has suggest, perhaps, some slightly different directions or new directions to add to this topic consideration or to perhaps shelve this topic consideration and really focus on this idea of the patient-derived measures, functional status, and preferences, possibly even a credit score idea to speak in non-technical terms.
MS. GREENBERG: Can I just ask John, though, who has been away from us for a while, do you have an answer to — from where you sit, do you see gaps? Given what NCVHS is able to do and not do — we don’t want to duplicate what other people are doing —
DR. FITZMAURICE: I worry less about the gaps than I do about the unintentional duplication. Everybody has a reasonable sense for the big issues, right, and kind of what the big issues are. We touched on some of them here. The issue that I wind up seeing not totally repeatedly, but somewhat repeatedly is that people will talk about the big issues. Sometimes it is the same aspect of it and sometimes it is slightly different aspects of it.
I just think, as I look around the table at the people who are here, I see enough people who are connected to other things to be able to say, okay, policy committee is talking about this, standards committee is talking about this, the AMA is talking about that, ECPI, the National Quality Registry meeting that is happening across town right now is talking about this. Of all of those things, here is something related to the big issues that nobody else is talking about that falls within the data and statistics — or the purview that NCVHS does.
Paul just gave a great example. I think he is spot on. I don’t think anybody is addressing that particular thing. I think we can probably suggest other things. Does that make sense?
DR. HORNBROOK: I mean in Europe, they really use preference-weighted health status measures in order to get a scalar measure of health that they can use in a cost-effectiveness ratio. If you get the SF36, there is no way to legally add it up to a single scalar score. People do it, but it is illegal because it takes each separate domain and gives it equal weight.
There is no preference weighting other than that one specific preference map. When you ask people, a general free living sample of people in the country, they do not count every domain of health status the same. Some are more important than others.
You are also asking the people, who are otherwise healthy, except for the small people who are sick in your random sample, you are not asking the patients, who have totally different preference weighting when they have the symptoms right then and there and they are willing to mortgage their whole future to get rid of pain. That is not an appropriate allocation system for getting medical care expenses allocated to the people who are making the decisions and who are not going to pay it. Somebody else is paying for their preference for being staved off from pain or dying.
Preference weighted health status — if you go into the Netherlands and you go into the UK, they are very comfortable with using preference weighted health status to help them make health allocation judgments, health status allocation judgments, and budget decisions. In the United States, SF36 is prominent. You get a utility score and people just sort of forget about it.
If I want a measure of output of a managed care system, it is not the SF36 profile measure. I need a utility measure to be able to compare the health generated out of cardiology from the health generated out of oncology, out of primary care, et cetera, et cetera. I also need a course eventually to be able to say when do switch from curative care to palliative care and worry about comfort as the only goal. How do we get a measure of preference weighted comfort care and quality of death? That is a whole population measure. How do you measure the quality of care of an infant, who cannot talk, but the parents talk on behalf of him? You need a whole system, eventually, for a whole population that is taking care of people from cradle to grave.
You also need to realize that any health status measure for a population, if the population doesn’t change, goes down inevitably. If you keep repeating a health status measure over time, it drops. What you are talking about is not making people healthier. It is keeping them from dropping as fast because when you age everybody inevitably loses some kind of health status. If you wear glasses, then that is a drop in health status. If you get hearing aids, then that is a drop in health status.
MS. GREENBERG: Will you quit describing me?
DR. HORNBROOK: The Health Utilities Index picks up the fact that if you wear glass, you automatically get a drop from 100 perfect health. It is sensitive to that change in vision. Other health status measures you could be blind and it wouldn’t pick it up. The theory in medical care is that the physician, looking at patient in the exam room, takes all of these data in as part of their gestalt of assessing the patient. That has been working successfully for generations. The problem is none of us have any sense of what is going on. It could be totally on average or it could be really, really outrageous.
DR. MIDDLETON: Did you have coffee in the last hour?
MS. GREENBERG: When we make him king — he is right on. How do we get from here to there?
DR. MIDDLETON: I love it, too, Mark. The question on the table then is what do we really want to do in February? This is not that far away. I think we could actually take the Million Hearts thinking, which was thinking about how do we impact a well-defined cohort through improving quality measurement life cycle, measures to impact cardiovascular disease, et cetera?
Maybe that could be slightly twisted, updated, and enhanced to reflect some of this thinking? Is it really the individualization of quality measurement or is it really enhancing value-based quality measurement? It is bringing those individual —
DR. HORNBROOK: Some people would argue that is family. Many of those people do not live in totally isolated worlds all by themselves as sovereign individuals, who make all of their own decisions. They are married. They are partnered. They have parents. They have grandparents. Health can be a family context, even though we, at HIPAA, say it is totally individual. In reality, it isn’t.
The context of the family, relative to the context of individual’s functional health status and overall well-being really starts putting together a better roadmap of what you should do for that person. Sometimes the person who is most in need is not the patient, it is the person they are taking care of or vice versa.
DR. MIDDLETON: I mean I would suggest the family, the nomenclature, might be weighted in certain ways that is not appropriate. Really, it is social support.
DR. HORNBROOK: Yes, you are right. I am using family in a general social, not a biological sense.
DR. TANG: I love what Mark was saying. Can we get — you mentioned individualized quality measures. Can we get some testimony about that? Can we get educated about the state of the science about that kind of thing in Feburary?
DR. MIDDLETON: So here is the list of things that were crossing my mind, Paul. I think that is the right tact, actually. I think that would be interesting, useful, and forward looking to where the puck needs to go. Preference-weighted health status measures, a scalar measure of health, preference-sensitive clinical decision making, utility measures that can be used to distinguish good health production versus bad health production, value-based quality measurement, and quality assessment that is contextually aware and all that kind of stuff. Those are a lot of big issues.
DR. HORNBROOK: Have we ever, Marjorie, put a preference weighted measure in a national health survey sponsored by NCHS?
MS. GREENBERG: There is burden of disease stuff that we have played with. There is a lot of controversy around this, you know, weighting what is more important and all of that. We have kind of resisted some of that. Other countries have done that much more.
DR. HORNBROOK: Canada put the HUI in their national health survey. It allows a lot of different analyses that we don’t do.
MS. GREENEBRG: We could have people come from the National Healthy Interview — NHIS.
DR. HORNBROOK: That is what I am thinking. Statistics Canada.
MS. GREENBERG: Well, we could have Statistics Canada on the phone. We can’t pay international travel. Actually, Statistics Canada is going to be here next week. We have this interchange every year between Statistics Canada and NCHS. We could have a panel on that. There are people, obviously, who know what they do in other countries. I think we have been known to have people actually come on their own dime, as far as from Europe.
DR. NICHOLS: Could we meet by the border and have them walk over the bridge?
MS. GREENBERG: We had a meeting once in Niagra Falls so the Canadians wouldn’t have to get international travel approval and the U.S. wouldn’t have to get international travel approval. We were trotting across the bridge. It was kind of crazy.
DR. MIDDLETON: To keep us on track, we are going to quit in 15 minutes.
MS. GREENBERG: You have 25.
DR. MIDDLETON: No. We are going to take a break for 10 minutes.
MS. GREENBERG: Okay.
DR. MIDDLETON: Well, at least one of us will. I am sensing a slight — let’s make the assessment now. What is the directional intent of the Committee? Is it to go down the path towards the quality measure life cycle, which has a bunch of issues and I think is extremely interesting. Arnie Millstein really laid down the gauntlet and gave us a challenge or do we want to think about what is this next world of quality assessment that is individualized, values-based, et cetera?
MS. GREENBERG: And what issues does it raise?
DR. MIDDLETON: They may not be mutually exclusive because we could perhaps do one or the other first and then the other second.
DR. FITZMAURICE: To what degree is NQF addressing the quality measurement life cycle? What would NCVHS add to that?
DR. MIDDLETON: Paul, do you want to answer?
DR. TANG: It is on the radar for that, too. Somebody was just saying — I wonder if that is too big and it doesn’t have as big an impact in the shorter term? What I mean by shorter term is we need to get inserted into the quality — talk about life cycles — the quality measure supply chain to essentially future CMS programs. That has to happen very soon.
I think the big delta we are talking about is trying to flesh out in more detail and understand more the state of the method of these individualized quality measures.
MS. KLOSS: When you think about the timing, assuming that we have crossed the ICV 10 bridge in 2013 —
MS. GREENBERG: And that it isn’t a bridge to nowhere.
MS. KLOSS: We are going to be looking beyond that in terms of how we augment the value of the data beyond that and certainly functional — other aspects of classification are very relevant to the Committee. I think the timing from that standpoint is also good, not only meaningful use, but looking forward in classification.
MS. GREENBERG: Actually ICB 11, which I cringe when I say the word, but it is attempting to be a 21st century classification. It has a content model. It will have functional properties based on the ICF in it for actually every disease.
DR. COHEN: So maybe this is stage four meaningful use?
MS. KLOSS: I think it starts raising the industry’s awareness of thinking beyond morbidity and mortality classification to functional measures.
MS. GREENBERG: When I think about what this committee does well, it certainly addresses very technical issues — if it has to — well like Standards is doing. We have the capacity to do that to some degree, but it is very good at shining the light on things, getting visions out, trying to move the field forward, bringing people together who need to be talking to each other. All of those things I think can be accomplished in a well designed effort — and identifying gaps.
I am very sensitive to what John is saying. Sometimes that has almost paralyzed the committee because this one is doing this and this one is doing that. Given the fact that things aren’t where people want them to be, it seems there is a role here for the Committee. Larry, you have been very quiet.
DR. GREEN: If you go down past two, which, personally, I think makes a lot of sense, I think NQF’s problem is the life cycle of quality measures. I don’t think that is NCVHS’ problem, personally. If you go down the second pass, I would agitate for two things. One is recognize the direct linkage to the work that the population subcommittee is doing.
MS. GREENBERG: That was mentioned right before you came in.
DR. GREEN: That is another harmonization of the total committee’s work that I think is value added. Of course, what Populations would want to see come out of a hearing and this sort of work is what I have heard several members of the Quality Committee talk about — the roadmap, the roadmap to measures that matter to patients.
Scale that to measures that matter to neighborhoods. If you have the granular part of this right, part of the join work could be to begin to draw the roadmap about how you take items one, 11, 13, and 27, and that becomes an index marker that can be validated as a measure of whether this neighborhood is going the right direction or something like — that could be the concept.
A second thing I would agitate for, which builds right off of what — I could have just let Mark keep talking for another hour or two.
MS. GREENBER: Maybe we will just do a hearing with Mark.
DR. GREEN: That is a good idea, actually. When he was talking about family — I am a family physician, but we family physicians have never operationalized our name. The very definition of primary care, as this neglected phrase in the context of family and community, and, buddy, folks, that is the action point. Health is not won and lost in the operation room. It is won and lost in the community. What determines what happens in the community is a person’s family.
Family is a group of people who live together and say they are a family. We know that. You don’t have to study it. That is the way it is. But we don’t measure it. You are going to think I have lost my mind here completely, but we lack a taxonomy for the typologies, the people, the way people live their lives, and how this varies across the life cycle. It would be so important in my opinion for the Committee to avoid going down the disease pathway and to stay focused on whole people in context.
When you get to a community level, half the people living in that community are going to be 20 something or less. We do not care about them, basically, which is the damn truth, because they are cheap to the health care delivery system. What we do know is that between the ages of one and five, if they are not loved, there are problems for the rest of their lives. What we do know is that if we do not take care of them properly when they are adolescents, that is when they drink, that is when they smoke, that is when they go off the rails, that is when we lose the tax base, that is when they become unproductive. This exercise would do well to have a different answer for kids under five, kids up to the time they go through puberty, post-puberty to about — I think adolescents now ends at 33.
To go back to Mark’s point, the measure needs to reward or incent dying quickly. That is a little too rude and crass, but there are four ways we die. There are better ways and worse ways. We could do so much better, but how would we know if we were doing better? I just wish we could adopt — that may be happening all over the place and I just miss it. I don’t know an entity that can think about data elements and scale it up to that type of information that can actually be a value measurement than this group. I think this group is the right spot for that.
DR. HORNBROOK: Have any of you done population-based research in households? Have you done home visits?
DR. GREEN: Yes.
DR. HORNBROOK: I have done home visits. You can go into houses that are extremely, extremely expensive —
DR. GREEN: You throw almost everything they teach and are measuring and is in the EHR out the window because you see what are we doing?
DR. HORNBROOK: I have been in houses where everything is totally, totally up to the ceiling because they are a hoarder. On the outside, it is a $3-5 million dollar house, but inside it is a whole different story. I have also been in houses where grandkids are dealing drugs and they are holding grandma and grandpa hostage because they are using their social security to buy drugs. I have also seen people in bed, bleeding because there is nobody else to take care of them.
We have also had situations where there is abuse going on and there is somebody who is totally guarding access to the house and you cannot get past the front door. You cannot even get the other person on the phone. The important thing about Kaiser is we can find people individually. If there is a husband and a wife, we can go straight to the wife or vice versa, rather than going through the person who has to be the gatekeeper. You discover that, in reality, there are a lot of things going on that doesn’t show up anywhere until you physically encounter it.
DR. MIDDLETON: So let’s run with this. This is something like the value-based individualization of quality measurement — working title. What do you want to do? What are the four questions we want to ask experts?
MS. GREENBERG: Are you deviating now from the Million Hearts?
DR. TANG: Could we have a paper, Marjorie, before the February meeting? I think there is just so much information and we will have missed all of that if we just have people talk to us.
DR. MIDDLETON: I missed the first part of that. Could you say it again?
DR. TANG: Could we commission a paper in advance of the hearing really on this whole individualized/ localized quality measure?
MS. GREENBERG: Do you know anyone who could do that?
DR. TANG: I don’t. Maybe this doesn’t exist in a full bodied way, but if it doesn’t, it would be great to get us up to speed on that.
MS. KLOSS: Could you even just start with a literature review or some annotated bibliography?
DR. MIDDLETON: What about Eric Schneider?
MS. GREENBERG: Why do I know that name?
DR. MIDDLETON: Harvard School of Public Health.
DR. TANG: He is a good person. I don’t know who would do this kind of stuff.
DR. GREEN: I have a conflict of interest, I started the Graham Center, but the Graham Center works this type of territory all of the time. Chances are — Len, you may be working this territory?
DR. NICHOLS: Well, I just met the Graham Center people. Here is what I would propose, actually. Let Larry and Mark write a short piece on the questions we should be asking and, in the meantime —
DR. GREEN: Did he say let?
DR. NICHOLS: We’ll incentivize it later. I am not making this up. I think you two could do a joint key note on what are the questions that would add tremendous value to the conversation.
DR. MIDDLETON: Just one or two pages. Just what are the key questions.
DR. NICHOLS: And then we will pursue — because I actually just met the Graham Center guy, Phillips? Robert Phillips?
MS. GREENBERG: Yes. He is a friend of the Committee.
DR. NICHOLS: He is right on the edge of this. I agree.
DR. GREEN: I think that a line of work that they have done for the last decade is trying to get to a depravation index to be used for comparative analysis at a neighborhood level. They know all about it. They could define the limits.
MS. GREENBERG: Okay. A few thing — you want to put this aside?
DR. MIDDLETON: I think what I’ve heard — check me if I am wrong — I think what Paul suggested is that we have a window of opportunity to not look at the quality measurement life cycle, but to actually fit our work into the life cycle of quality measurement by opportunistically looking at the things that the policy committee and reform needs to have happen before the notice of proposed rulemaking in the 2013 time frame.
DR. TANG: Then you should take — the quality of work group put out these quality concepts around which there was already a contract let out by ONC. Important is just to get that letter, which is on the web, and maybe have our experts comment on that. It certainly includes functional status. It includes the idea of delta measurements, et cetera.
MS. GREENBERG: And the Policy Committee doesn’t have a structured way that it is getting people to comment on that?
DR. TANG: We are thinking of having another hearing. Right now, we are in the quiet period where, basically, there is this contract that ONC has with a couple folks to develop these things. There is nothing else that we are doing right at the moment. That is where I think NCVHS can weigh in. As long as we can do it by the end of this year, meaning 2012, they will be open to that kind of input.
DR. FITZMAURICE: Paul, it is John, some of the nuts and bolts stuff may be happening as OCSQ out of direct line of sight of what you are doing. It might be worth checking in with Kate Goodrich.
MS. GREENBERG: Where is OCSQ?
DR. FITZMAURICE: It is at CMS.
MS. GREENBERG: Could you do that?
DR. FITZMAURICE: Sure.
MS. GREENBERG: If you want some — well, we have deputized these guys, but if you want some type of consultant to do literature review or something, we need to get on that, also, particularly if you want that done before a February hearing.
MS. JACKSON: And that is going to populate and advise you for the hearing — that is the concern I had. When we got that last literature review, it was kind of going on at the same time as you were organizing the hearing. I thought you wanted that information to advise. If we are looking at a February hearing, you are looking at inviting people in a couple of weeks. I have been in contact with Matt and he said, well, I am glad that I didn’t start inviting people for this Million Hearts that was supposed to be you were looking at in early December. Things are kind of in flux. We need to stay on a path so we can get what you want.
DR. TANG: How about we do it in parallel? In other words, if we can identify likely experts, we talk to them ahead of time, get coached on who we should hear about at the same time as they are writing our commissioned paper?
DR. COHEN: Is February too soon to be pulling all of this together?
MS. GREENBERG: Of course, I haven’t mentioned yet to the Committee that if our Committee of 12 there on the Hill, the Super committee, punts, we could be in dire straits from a point of view of budget. If we are already talking about February and that might be a little too soon, have we considered tying this onto the March 1-2 meeting?
DR. TANG: But the only thing that that does is it delays our being able — so we get input and we have to go through our Committee process. It seems like you delay by one month out ability to act and get something out. I am not saying we are pushed into that timeframe anyway because of the timing, but it seems like we need as many opportunities to talk as a subcommittee and committee so we can get our product out into the streets in a timely way.
MS. JACKSON: You have a conference call next Tuesday if you wanted to develop some homework and do some connection or preparation for that. We are all set.
DR. MIDDLETON: I think the charge to us all from Marjorie and Debbie is really once we arrive at a decision, let’s stick to it and make it happen. This was I think done without the whole Committee in the way that deliberating is very useful to talk it through. I think we have a plan. Let me just recap where we are because we are going to run out of time.
I think the intent is to think about this notion of, for lack of a better term, the working title of value-based individualization of quality measurement. Mark and Larry have agreed to sort of tee that up with a bit of a framing paragraph, perhaps, and then some key questions that we might like to ask experts about values-based individualization of quality measurement, functional status assessment, preference-weighted health status measures, and all of the stuff that we have been talking about.
I would ask everybody on the Committee if they have notions about who might be experts to talk to or hear from in this regard, send in your names STAT to Debbie. We will review that list and hopefully your notions on the call Tuesday.
DR. GREENBERG: Tuesday you guys are having a call?
MS. JACKSON: Yes.
DR. MIDDLETON: At that point, I think we should try to come to closure on at least working title and concept areas and begin to think about experts and dates. I think we can pull it off.
DR. TANG: I’m a little nervous about your introduction of the modifier value-based. Not that I don’t believe in value, but just that it complicates things so much if we are going to do value-based at the individualized level. I don’t even know how to approach that. It is just going to hold us up in terms of trying to get stuff out.
DR. MIDDLETON: Well, we did talk about preference weighted health status measures.
DR. TANG: That is fine. You can get that from the person. I am nervous about getting value.
DR. MIDDLETON: I didn’t see a distinction, but what do you think.
DR. GREEN: I think you have a different definition of value in your head.
MS. KLOSS: This is a complicated topic. I think we would be wise to be very descriptive in what it is we are studying.
DR. HORNBROOK: We need some way to frame the discussion of how to get more value for your money out of the fixed dollars or even less dollars we are going to have for health care.
DR. MIDDLETON: Maybe now I understand where the confusion was. When I say value-based, I mean patient preference. Can we say — I guess that is subsumed by the individualization of quality measurement idea so I am fine. Let’s leave it there. Preference-based individual — but then it is kind of redundant.
DR. NICHOLS: Only in your mind.
DR. TANG: Individualized has a lot with physiology, as well. I think they are two concepts.
DR. MIDDLETON: So you like having preferences and individualization in the title, Paul?
DR. TANG: I think so.
DR. HORNBROOK: Then you get back to personalized medicine. That is individual as you can get, individual and time specific.
DR. MIDDLETON: The preference based individualization of quality measurement.
DR. HORNBROOK: And you need to do the conceptual framework that distinguishes between the patient’s preferences, the family’s preferences, and societal preferences.
DR. MIDDLETON: That is a research agenda, in itself, that would be interesting.
DR. HORNBROOK: I have a colleague that has been focusing on that for years. You also have the clinical trials functional outcomes assessment, which gets you into all of the value measures in disease-specific.
DR. MIDDLETON: So you are thinking already about kind of the four dimensions of the problem around which there will be questions and experts. I can hear it in your head. I hear voices often.
DR. GREEN: Speaking of that, we should make explicit that we want this hearing to accommodate what are typically isolated as mental health measures.
DR. COHEN: I think again I’d like us to keep our eyes on who this is for. I think there are four perspectives. There is the clinician perspective. There is the plan perspective. There is the individual perspective, how they are going to use the data. Finally, there is the community perspective and how this affects population health.
DR. MIDDLETON: Those are our favorite customers.
DR. HORNBROOK: And, of course, Medicaid and Medicare. Medicare is nationwide. Medicaid is state/regional.
DR. FITZMAURICE: As Deputy Co-chair, I want to make sure Blackford gets his break. We have to stop.
DR. MIDDLETON: We are officially adjourning the subcommittee.
(Whereupon, the subcommittee adjourned.)