Transcripts For CSPAN3 Politics Public Policy Today 20141202

I think this will move it forward. If youre a patient, you care about your metric. Its wonderful were monitoring if doctors give quit smoking advice to patients. Im not a smoker so it doesnt matter to me. What you want to know is i know somebody whos about to have heart valve surgery. They want to know which doctor in their city performs the most heart valve cities and how many patients are alive a year after that. The fact we cannot answer that for that patient today or tomorrow or even next year, like, thats the question we want to answer. Its not like, do your diabetics have their a1c under control . Im not a diabetic, but if im diabetic and its under control for me, i dont care if your other patients are, i care about me. Were a me culture but we have to make sure the data releases can be customizable so the person interested in their own health and their own situation can get some answers from it. Charlie, at the same time, patients are complaining all the time about high copays, deductibles. We spend billions of dollars a year in unnecessary care or marginally useful care. And this conversation and this data release gets us closer or gets us away from spending all of those extra dollars that we dont need to spend. No question. So i think it does come back to haunt the individual patient. If your copay is going up, your deductible, the cost of your insurance is going up. The reason is, were spending too much money. How can we provide highquality care. We have to factor in koos long with outcomes. We have a question here. Tell us your name, where youre from and your question briefly. Yeah. My name is bea young, i live in maryland. First, i congratulate you, transparency of data system is great, but i wonder how far can you go, how do you deal with you didnt get data from internal system because the nurse did not give it to you or you did not even maintain the system the information you receive from patients. Its very critical, very important. Currently today theres a letter about who are the physician in which hospital in which area, the checkbook or reference you or government agency, theres nowhere you can find it. A lot of they use false name [ inaudible ] so how do you catch the system, the real information that you should need, like from computer, consumers or patients. A lot of nurses dont even give patient treatment if they ask for it, the record. They dont give the record. If they do, they give it fraudulent record, fraudulent charges. That type of thing. Things are very critical, very essential. For you to compare a patients, physicians and real professional and fake. Because a lot of emergency staff, they ask why are patients give the liquid to the patient so they can perform the procedure. And if you ask any physician for proof, they say, no, they dont have it. Let me try to wrap this up so we can get go ahead. So, misdiagnosis as well as patients all the various reporting system and other procedure that i i got up. I got it. This touches thank you. This touches on a couple of things our other panelists might get into it, especially our last panelist. A lot of our work started with the physician data set. But as were hearing, there are so many streams, and you touched on this, wanting to know about the Referral Network as the net set of data that could be important to triangulate. Were talking about painting a better picture on the complexity of health care services. Do any of you have some comments on we mentioned hospital, we talked physicians, drugs or devices, other pieces of this puzzle which are much more complicated than what weve touched on. So her end point, when youre talking about Physician Services and Medicare Part b, thats a payment going out the door, sflit when youre talking about part d, prescriptions filled, at a pharmacy, they log a prescription being dispensed, maybe its not bes dispensed. Theyre being paid for it being dispensed. When you talk about a referral, there are two different claims that are made. When you talk about quality metri metrics, chuck, im sure can you get into this. The quality of electronic records, the quality of paper records leave so much to be desired, when youre trying to adjust for things like that, were a long, long way away. And thinking about different settings. Hospital, hospital, physician offices and then thinking about er settings, intermediate care settings. The complexity of all this can be so overwhelming it could cause you to say, why bother releasing anything because we cant do all of it . It seems like the first was the hospital data, which you talked about. And thinking about physician charges because of the florida case. Know weve also got new to me was the information around dialysis and some of these other services we do have data released on. Are there other transitional care or care settings we think we really need to have better transparency around that would be important for patients to have . Well, not to well, let me plug the commonwealth publication on this. For those who havent unsolicited. There are two things that need to be stressed. First, the physician data has to be integrated with the hospital data, with the pharmacy data, to look at any of this data in an isolated way, in a way it addresses some of what youre bringing up. To do it isolated doesnt give you the right picture. Have you to put it all together. And comparisons are really difficult, but as the commonwealth publication pointed out, until we get into real detail about outcomes and Health Status and demographics, well never really be able to make good comparisons or the perfect comparison. So, hopefully one day we can get there. And were moving in that direction right now. Im going to do a lightning round to ask very quickly, ten seconds, 15 seconds. What has what has been released to date . What have you learned from it . Something just to give our audience in the room as well as on the website something that may have surprised you about what has been released to date. Ill just go ahead and kick it off. I will say the thing that did surprise me is exactly what charlie touched on. This was actually mo to not my patients necessarily but hi more physician colleagues and Health Insurance plan colleagues kind of say, this is really exciting and interesting and wed really like to get into that. Something that surprised you or something you learned from this release process. So, im a geek. I like looking at patterns. In the physician data, just looking at how Different Services were concentrated or not concentrated in certain specialties. I think the other thing the thing that surprised me the most, actually, was how few cpt codes physicians built. If you had woken me up in the middle of the night before i started the project and said, how many cpt codes are physicians billing, the average primary care physician, i would have said easy, 50, 60 a year. Maybe more. For many for a significant chunk of physicians, they are billing 10, 15, sometimes even less. But theyre some of them are really cranking through the cpt codes but they are specialists. So, that was the Biggest Surprise to me. Perfect. I had grown up as a Health Reporter lerping about differences between hospital referral regions and how important hospital referral regions are. I think what i learned through here is just how much variation there is within those hospital referral regions and you can literally go one street over and the quality of doctors as measured by services they use, drugs they prescribe is so vastly different and it makes a difference to look up an individual doctor. Chuck . I looked up my data. I thought you were paying me more. I have to take a cut off the top. Thats nialls new job, gets a cut off the top. I have to compliment cms because i think you got it right in my case. But ive been doing this for more than 30 years. And it it was really hard for me, despite all of that experience to make any sense of it and i began to imagine, well, what are patients thinking . How do they figure out whats going on here . Thats a perfect segue for some of our future conversations. Join me in thanking our panel. And weve got let me do this. If i can ask our second panel to come to the stage. Im going to have Paul Ginsberg from usc schaeffer policy, who also has an extensive background and bichlt o, im not going to read, as well as a number of publicationings related to research in this area. Hes going to be leading our second panel. Let me make sure i dont get in everybodys way here also take off ill have paul oh, good. Paul didnt need to use the stairs. Paul, sit down and then well remike. Well see if we can swap out some glasses for you guys. Paul will be leading the discussion on implications and perspectives from researchers, policymakers and payers. We teed up a few of these in our first discussion, but i think well have a robust one with the second panel. Thank you. Thank you. I think we can start now. Really pleased to be moderating this panel. I think stu at the beginning of the conference set the tone about this is transparency. This has been a long time interest of mine. Ive always believed some of the confusion about transparency comes from the fact that we talk about transparency because of its aspect of sunshine. We believe Public Institutions but other institutions, their operations ought to be more transparent. We also talk about transparency in terms of it being useful to different types of entities. We think of patients, consumers. When we think a little further, we think about physicians, hospitals, health plans, researchers and policy makers. And this panel is really about what the three different audiences can do with this information. And we will given with jay white, a very distinguished researcher, talking about what this means for researchers. Then ill hear from lew sandy, an executive with the United Health group, talking about what this release can mean for health plans and lawyers who are their clients and some of them do it themselves. Then well hear from bruce with a long policy background to speak from the perspective of policymakers, what can they learn from this information that will help them in their work of making policy down the road. There are two contacts id like to ask the speakers to think about. One is that as we were going to talk concretely about the april data release that Niall Brennan was describing to us, but were not going to dwell so much on what was in the april release but also to talk about what could be in further re future releases and whereas niall couldnt talk about what will be in the next release, they can talk about what they want to see in the next releases to make it more useful. The other context is this is not these releases are not the only game in town. You know, with chapin as a researcher, he can go through the process of paying a lot of money and taking a lot of time to negotiate a data use agreement with cms and get some of the data thats really raw behind this release. Li lou with United Health care can either work with a qualified entity or apply to become one and also has another channel. This is also part of the context. Im going to stop my talking. Thank you, paul. Its really terrific to be speaking with you all today. And i think the first question i want to get into it whether this data release of the physician charge and payment data is a big deal. Again, im coming at this from the perspective of a research. We had a couple conversations at rand, salivating over this new data source. What can we use it for . What questions can we ask . We figured out, well, there isnt much new we could do with research. Any Research Questions we would want to get into the claims data that we do all the time. Does that mean this data release is not a big deal . Not at all. I think this data release is really important and is a step forward. Why is it important . Number one, i think the release of this data has laid down a marker. For decades as niall mentioned this, there was an injunction in place that prevented cms from reporting what individual physicians were being paid by medicare. By releasing this data, cms has said that balance between physicians right to privacy and the publics right to know whats going on in the Medicare Program, its now officially tipped in the direction of the publics right to know whats going on in the Medicare Program. The other thing thats important about cmss release of this data, theyve laid down a marker and said, we can release data for a specific physicians and cpt codes without running afoul of hip a. If you do research, hipa is a fast barrier reef that you have to learn to navr gate. And cms has charted a course others can follow it now. Thats the first important thing about this data release. The second thing is these data by themselves, arent informative or telling but data becomes useful when its put in combination with other data. As cms releases more data over time, well start to see trends. Now that we have the physician level data, we can confimbine i with the hospital level data for geographic regions and get a fuller picture of whats going on. As other data sources become available identifying physicians by npi or National Provider identifier, we can start combining this cms data release with those other npi level data. And conceivably at some point private Sector Health plans will begin releasing data if its released in a format compatible with the data cms is releasing, then you have a threedimensional picture of whats going on in the health care sector. The other last point i would make is that this data release is a small step but its a step in the direction of building our Data Infrastructure to understand where we are and whats going on in the world and to help us make better policy choices as a society. And i think one thing we forget is that our Data Infrastructure has been built through conscious, sustained effort. And concepts like Gross Domestic Product, we take that for granted. We track how its going up and down over time. Its grown by such and such percentage. The concept of Gross Domestic Product was defined and the tools formering it have been honed over decades and we devote significant resources to tracking that. Thats a tool for the use of businesses, government, individuals and so on. Its a collective Data Resource that has been built through effort. And i think that is an incredibly valuable effort. I think the cms data release is one piece in that valuable effort. In terms of where were going next, what i would be interested to see, the private sector is kind of the black box. Medicare is starting to lay all of its cards on the table. But in terms of prices, practice, patterns, geographic variation in the private sector, is more challenging to get a hoojdz that. And to the extent we can get private sector data releases that are structured in the same format as the cms medicare data releases, then we can start comparing prices, start comparing Practice Patterns, identifying geographic identification patterns in both of those sectors. That to me would be the most fruitful and probably also the most difficult avenue to go. Ill leave it at that. One question fof you. Probably better serves many of researchers needs. Any thoughts about how that process could be streamlined, could be made more efficient as ab an aspect of the transparen initiative . Well, the data could be made cheaper. We pay taxes for a reason. We pay taxes so the federal government can provide services that shouldnt have a high marginal price attached to them. Data is one of the thijs that should be made freely available even though it takes a lot of resources to produce that data. Once you make one copy of the medicare data claims file, so, the price could be made lower. The turnaround time could be reduced. Thats a significant problem. Hipa, thats just a fact of nature at this point. Have you to satisfy all the privacy constraints. But the turn around and the price, i think, are barriers to research that could be lowered. Thanks. Lou . Well, thanks. Thanks, paul. Appreciate the chance to be here. I appreciate stu and the Commonwealth Fund for sponsoring this. What i wanted to do is talk about what is useful in this release, what are some limitations and some of the suggestions, to your point, paul, about where do we go from here. First thing i do want to say, as i really want to commend cms for their efforts to promote transparency and the use of these data is refreshing. And its incredibly important. It will evolve this idea of evolution over time is an important theme of this event. You know, even in this current release, there is some utility in this information. Weve heard a little about this today already. I think its useful in raising awareness of variation. The pervasiveness of variation that we see out of the data. Useful in understanding the variations in that data. Useful frankly, its so obvious, doctor cutler mentioned this, useful in bringing transparency around what things cost. Just the basic information there. And i think claims data useful for some thing, not so useful for other things but it has useful dimensions around volume, around the service mix. Im not in practice anymore. Im a general internist but i looked up some of my friends to see what their practice pat ites looked like. Their practice would be heavily concentrated in a senior population. Its important, and it will provide useful insights in its current, limited form. Now, what are the issues and limitations . I think the most fundamental one is health plans have learned over the years that looking at raw claims data is really more an enter size in high hypothesis generation. You cant look at a raw data table and say, aha, theres an outlier, lets do something its really more a hypothesis you have to triangulate around, look at multiple data sources, look at trends over times. And then have a further exploration, particularly it may involve, this is something health plans do regularly, have a conversation with that physician to see you might find an outlier that statistically is an outlier, but they actually are referral practice and have a unique set of services they only theyre the only ones who provide that in a region. I think hypothesis generation is the way we should think of raw claims data. The second thing, as i said, a lot can be done with claims data, but it requires analysis. All of us will say, its not just putting the raw data out there. Starting with some simple analysis, some simple descriptive statistics can be very useful. Percentile rankings as we her from pro publica, standard deviations. Then there are even more sophisticated uses of claims data through the use of Technology Episode groupers and the ability to do case mix and risk adjustment. So, i think theres quite a bit that can be done with claims data, even with some of its limitations. And i think its an interesting policy question about how much the sponsor does, in this case, cms, versus having a raw data file come out and have third parties do that kind of analysis. Thats an interesting question. And i think in terms of physicians or any stakeholder, i think probably the most important at bud of this kind of data is the ability to make comparisons. And to do that, you have to have credible data. Dr. Cutler mentioned physicians want to compare themselves naturally against other physicians in the same specialty. That would be logical. And i think thats another thing that health plans have learned over the years. And that relates to my third suggestion or limitation, is that what we have learned over the years is particularly when releasing data around physicians, its a good idea to run what i call Service Bureau function. The ability to serve the stakeholders and in the case of physicians, to answer their confess about the data, for them to be able to look at it and correct it, if there are some errors in it. Physicians are very data hungry, interested in data. If they view it as credible, but they want the ability to do what they call drill down. To drill into the data in a way that makes sense to them. All of this is what i would call a Service Bureau function and the things United Health care has done, as in our premium designation program, weve done since 2005, we have a physician portal that has hetus data on it open to all physicians in our network. This Service Bureau function is an important suggestion how to enhance things going forward. Lastly, let me make a few suggestions for where i think this could go from here. I think ive said some of these already. First is to just clean up the data and offer some simple descriptive statistics for all stakeholders. I think thats a reasonable thing for the sponsor to do, even as others can do other kinds of analysis. Second, i agree with your point, the ability to combine data, data sources to get an important view, in this particular case, its really quite a limitation that you cant get the full picture of what the physician is doing in medicare. We have found in the commercial private sector that we might find a physician expending a great deal of resources in the office but if you look at total cost of care or episode basis, theyre actually quite efficient. The reason is, thats their practice style. You wont see that without the ability to integrate and combine desperate data sources. You know and it was already mentioned, the Health Care Cost institute, thats why we thought it was so important to contribute data to the Health Care Cost institute as a multi payer incident. Thats an interesting for example at a couple of levels. It originally started as an effort really to just be a tracker of private sector costs trend data and utilization data. As was mentioned, once parties got together and they started putting the data in, the hcii said, we could use this for transparency purposes. We could start to look at quality data in addition to just cost data. As some of you may know, thats an effort thats been announced and will be deployed in 2015. To some up, theres a lot of opportunity. This is the beginning of a new era. Transparency is the realm. The current release has been useful in some respects and limited in others, but i think it will evolve and strengthen over time, particularly if it moves along some of the directions that have been suggested already. Thank you, lou. One point you made that got me thinking. You were talking about one of the steps forward is to go from really raw, unanalyzed data to at various levels analyzed data. As this is evolving, were on track to have physician value modifiers in medicare, which will be presumably fairly analyzed data. I dont know what the transparency plans are, but assuming there are transparency plans, any thoughts about these two different tracts things are moving on . Again, whenever there are multiple initiatives going on, its an interesting challenge for any organization to sync them up. But i think and i think thats why its a great opportunity for someone like niall to have a broader view of all the broader resources, to use them internally and externally. I think in general the idea of moving i think probably the most important thing is moving beyond fairly rapidly beyond just a raw claims release into analyzed data that is consistent in its thematic direction. The measures might be slightly different but as long as, this is the domain, i think most people view a best practice, for example, is not just to release cost data without quality data, to combine those. And i think having so that any user can have a picture that integrates both quality information, to the extent one can have it, with cost data would be useful. Thats a partial answer, i guess. Thanks, lou. Bruce . My job thank you, paul is to take a broader policy perspective and the u. S. Congress and how they might benefit from this data release and subsequent data releases. And id like to start as well by keeg off stu guterman. Its easy for us to value transparency because were the lookers. We to want see more. But its the lookees, the residents of that black box who need to accept and even embrace the concept of transparency, if were ever going to really achieve it physicians and other providers need to get used to the idea of having their performance evaluated. As dr. Cutler has suggested to us, their willingness to do that is partially dependent on how accurate and useful the data are that are being released and how theyll be utilized over time. You asked, paul, for some suggestions of what we would like to see. I actually have some predictions about what we will see. Now, niall has not been able to say theyre going to release more data. Im going to predict they will. In fact, im going to predict cms and its contractors will correct a number of errors that the media organizations have pointed out. Missing data, poor specialty designations, other things of that nature. I think providers will contribute to that data. They have an insen stif knowing their information is going to be available to a wide range of lookers, they have an incentive now to make sure their specialty is accurately recorded. They have an incentive to match up the National Physician identifiers with the billing codes. I hope well have more kinds of different providers available for analysis in the future. Most importantly, as soon as we get that second data release, we have the beginning of what, chappen . A time series. Every economist wants to have a time series. Ill give you an example of how that could be useful. The Government Accountability office took in 2005 and 2006 data, the exact same database that cms released in april, and attempted to identify beneficiaries who are high utilizers of Service Given their Health Status. The correction for Health Status, as everyone knows, is not perfect but we were able to identify a group of beneficiaries that were high identifiers. Then we examined those same beneficiaries in a subsequent year. Did they remain being high ut lighters. They had a tendency to be high utilizers. A tendency. We identified the doctors as high utilizers given their mix of patients, Health Status and how many resources they consumed. Then we looked at the doctors the following year. They were twice as likely to remain high utilizers as their patients were. And ill be glad to give you a reference to that work and i cant go into all the details. Certain specialties and certain geographic locations. Its the kind of thing one can do, time series data one cant do with a crosssection. I worked for congressional support agencies for about 12 years. At gao i supervised the preparation of roughly 50 testimonies and reports to the congress, different congressional committees of jurisdiction over medicare and other health care spending. In case you were wondering, what do members of Congress Members reading, gao reports or newspapers and news summaries . Anyone care to guess . By the way, if you ask the same question about congressional staff, you get the same answer. So i look at these news organizations reports and analysises of the data cms released as another potentially important source of information. Maybe its not in depth. Maybe there are mistakes being made. But i think its especially useful when you consider that Congress Objects much of its information, many of whom are constituents that have a vested interest in health care spending. I remind you, of the five top d. C. Lobbies in spending, four of them are health care and the fifth is warp. To have another information source with incentive for producing information is useful. In fact, i would say that these news organizations publications are complements to, not substitutes, to the research congressional organizations do like gao, med pac, and rand under contract with cms, these are complements, not substitutes. I also would expect because these news organizations will produce the information to congress and give them ideas on what could be investigated in greater depth, there might be some benefit to the congressional support agencies to be asked questions that were raised by these news organizations to be investigated in greater depth by the organizations that have the resources and capabilities of doing it. My bottom line is this is not only a good thing. Its a necessary thing. It will produce more meaningful information as time goes on. We all believe transparency an integral part of health care reform. I look toward to the day where our database is not just cms production on medicare because after all, medicare, the entire story is utilization. Because prices are fairly constant except for geographic cost of business differences. You get into the private sector, you see a huge amount of variation so not only would you have the advantage to combine across different payers to get a fuller picture of what individual providers are doing, to get the private sector data into that mix and youll have a lot more opportunity to investigate very meaningful differences and how services are performed around the country. Thanks, bruce. You said something very interesting about how some of the media that, you know, was based on this release, you know, made its way to members of congress and staffs. And likely shaped what they were asking congressional support agencies to look at or even talking about policywise, legislativewooiz. Do you have a sense about interesting directions this has spawned . Was that the only interesting thing i said . The most interesting. The most. I dont really know. This comes under the heading of hope for. I did look up and saw that the hill, which is a publication for members of congress did pick up a number of these stories and reproduce them in their own media. But i cant cite a specific instance of where an issue was suggested to a member who then requested work of gao or any other support agency. Maybe in the course of conversation others will have ideas about that. Probably a good time to turn to the audience. Weve got time. Why dont you wait for a microphone. [ inaudible ] doctors, i dont think, are required to post online what they charge. And i was wondering what you would think of that . Its one of the few services that are important, that do not have the market visibility that you have in other areas. Do you think we should change that . This presumably is not a medicare issue because medicare physician i guess theyre very limited constrainted about what they can charge in medicare. Of course, those prices coming. I guess thats more of a question about private insurance . I dont know if you want to take that, lou. Yeah. I think its just the question reflects, again, the desire to have greater and Greater Transparency on all aspects of health care, including what providers charge. Two things. Even though theres no national requirement, i know at least in massachusetts, if theres anyone here from massachusetts, there is a new law that requires exactly what you suggest, which is the posting of crisis so that will be an interesting experiment to see what impact that has in that state. There may be other states, im just not aware of it. I think the other thing is, from the consumer point of view, and well hear from the Consumer Panel after us, i think what Consumers Want to know, our experience has been what Consumers Want to know is not what the provider charges so much as what am i what do i have to pay, which then relates to what is what is the charge in relationship to the benefit package i have, the network that i have and what does it mean to me. And perhaps even a whole episode of care. Exactly. Sort of if im choosing option a over option b. So, it will be interesting to see. That information is increasingly becomi becoming available, again, in the same transparency theme were in. I think the gentleman there areh a question. Thank you. I was wondering about the difference between the raw data you have to pay for and the data thats been released, is it primarily a question of consolidation so you download less data to answer the same questions . Is it primarily hipa . Is it some combination . If you go through the process of entering into a data use agreement with cms, you and you guarantee youre going to satisfy all the Data Security safeguards they require, which are serious, they will send you claims data that has a beneficiary i. D. , that has all of the age, sex, zip code of residents of the beneficiary that has the microlevel services. The cms physician public release only reports combinations of physicians and cpt codes with 11 or more services provided. Obviously, if you buy the microlevel data, you can see all the services. But its a major hurried toll set up Data Security systems that are impenetrable and hipa compliant. Capability to pull together all the Different Services that the beneficiary has had. And you have to promise not to release anything that violates hipa. Question back there. David costa. If the genie is now out of the bottle, from your perspective, what would be best next relative to cms data release . I can well, Paul Ginsberg actually mentioned the physician valuebased payment modifier. Id be curious, how many people, if i say valuebased payment modifier, know what im talking about . Some . A lot, great. If i had a wish list, it would be that the raw data and the final output of the physician valuebased payment modifier calculations be made available at the physician level. I dont know if thats realistic, but that would be taking this raw data dump that cms has just made and doing the analysis that a lot of the other presenters have been talking about. The idea hyped the payment based modifier is can be measuring quality and measuring efficien y efficiency, including all of the services physicians order, not just the one they provide themselves. So, i think that would be a significant step forward. I doubt its going to happen. Bruce . Well, i think a second crosssection, as i mentioned, would be very useful but it would be especially useful if cms could correct their errors in the First Release. So when they issued the second release, the First Release is more accurate and, therefore, you could make better comparisons over time. I think a theme a number of us have talked about is more comprehensiveness and more linkages of the data. For example, part a and other data sources so that you can have a more comprehensive view, either of an attributed population or of a more 360 view of what a physician is doing for the seniors that he or she is treating. If i could add one thing, this would be even more advanced, would be, grouping data into episodes of care to look at how a physician handles, say, a joint replacement or some other, you know, welldefined episode of care. To really be able to compare them to others. Yes, sir . Im frank with the Brookings Institution. My question deals with what this might mean for the Health Exchanges, particularly for each of your constituency groups, you know, policy makers, researchers and payers. You know, even though this data is only medicare, what might be some interesting future developments we might see with the Health Exchanges with more cms data releases . Thats a tough one. I think only in a general way, if you can learn things about, lets say, drug prescribing patterns as a general utility, then the exchanges might be able to use information of that nature. But since theyre not generally treating medicare patients, i think that theres a limitation in what yeah, i would echo that. Weve learned, and we have i didnt mention this in my comments, but we have since we provide services to medicare beneficiaricy, United Health care does, we actually have data ourselves on a medicare population. We have found we originally thought we could combine all those data with the data we have from the commercial marketplace so we would have larger sample size but we actually have found that these are different population. Its pretty obvious. The commercial population, the working age population, is different from the senior population. So, when we do quality measurement and reporting, for example, we use different benchmark levels of performance between the medicare and commercial populations. I think thats my guess is the same phenomenon would happen in the exchange population because that will be a different population. Particularly, it would be evolving over time. Thank you. Any questions . Oh, theres one back there. Rachel hornsteen, i work in data policy at hhs. Last year the office of management released the memo and one concern was the mosaic effect, how when you release different data sets and link them, theres the possibility of releasing identifiable information on beneficiaries or clients. Can you please touch on that . I dont have anything. So, this brings up the elvis doctor problem, which is if you report physicianlevel data and dont have a minimum number of procedures or patients treated, and if you report on the Practice Patterns of elvis doctor and Everybody Knows who thatis, then you can find out Everything Else about elvis. So thats the motivation for the 11plus minimum claim requirement. You know, theres obviously a risk that really sophisticated data analysts are going to be able to take this data release and consume it with other resources and figure things about individuals. My guess is that probably a bigger risk from hackers just getting into the cms mainframe, but i dont know. I think that were definitely in an area of risks and tradeoffs and there is a benefit to these data being made available. There are increased risks and the more data sources are made available in greater granularity, the more risk there is for people to combine things in novel ways and kind of undo the privacy protections. I guess, just as a researcher, i would say lets keep in mind the benefit of these data being made availability and not just go with always the safest approach. I think the principle of the greater good does apply here. And, in fact, even knowing the data releases, there whether always be some errors and some misinterpretations of the data. And there will always be a physician who is unfairly singled out as behaving poorly when the person hasnt. But you have to look at those are the costs, but you have to weigh the benefits against those costs. I think were of the mind that they are exceeded. Certainly privacy is one of the risks as well. Use our credit cards all the time even though our credit cards are for sale to, you know, through other world hacker websites. So our Financial System is constantly balancing the benefits of electronic data exchanges against the risks of malicious hacker activity and i think were you know, were gradually groping our way towards a similar kind of balance with health care data. Well, i think its time to thank the panel for their really good job they did. [ applause ] i guess well execute the same thing. Well transfer this to senior fellow at Brookings Institution who will be moderating the final session. Okay. Are we live now . I think we are. Now were going to shift the focus. Weve talked about this data release and several other data releases and talked from the point of view of researchers and health plans and the policy community. But what its all about is patients and consumers. And so now were going to shift the focus to the patient, the consumer, and talk about what they need to know. And i hope we can be a bit more visionary and expansive in this panel because we are where we are, but where do we want to be . I hope that these three representatives who work very hard on behalf of consumers over quite a long time can help us think about what do consumers really need, what do they need it for and how can that data be generated. To help us with this question, we have first robert krugof who is the president of the center for the study of Services Consumer checkbook. And we have robert restucia who is the executive director of community catalyst, a consumer advocacy organization. And we have doris peter of Health Rating center part of the organization Consumer Reports. And i think doris organization and robert krugoff rate lots of things. Not just health care. Thats where you go if you want to know about cars or toasters or plumbers or whatever. But now were talking about health care and a really important aspect of so many peoples lives. So well start with robert krugoff. Tell us a bit about what you think consumers need and what they might need in the future. Okay. Well, i think the first of all, i appreciate being here. And i believe our priorities should be to have good, raw data readily accessible. If the government can do that, thats an amazing, wonderful achievement. And fortunately i think the government has recognized this is important and has made significant progress. Im very happy about nialls recent appointment and loved the president announcing his appointment. Siting the commitment to frame works promoting appropriate external access and use of day to whether in agate or granular form. Thats what i think should be the governments role here. Unfortunately theres still a lot to be there are good things that have happened and theres a lot to be done. Ill give you examples of the good and the bad that ive seen in the government making Data Available over the years. Just sort of always gives me some anxiety that things might not go so well the next step around. In 2006 there was hhss denial of consumer checkbooks, requests we get claims so we could give consumers some information on the amount of experience each physician had with various highrisk procedures. And the government siding with the ama in an appeal after we won in the lower court. That was disappointing. The release of claims data that was much more restrictive than it had to be. The cms rules included anyone who wanted the medicare data in order to be Performance Measures nationally to have matching nonmedicare data in every region. Thats an enormous practical obstacle and it wouldnt have had to be interpreted that way. On the other hand, there was the great news this past april the governments release destroyed the privacy against release. So that was an enormous accomplishment, i think. And then that was followed by cmss quick action to get physician identifiers in the large data files that we and others have been using for years. Getting those identifiers right in there quickly was just exactly what needed to be done. And cms recently created the virtual data program to make those more accessible to allow them to be used remotely. Still more expensive than i wish for a Single Person to use. Although cheaper than trying to get those files straight up which would be in the hundred thousand or more range and quite unfortunate to cost that much. But there was some bad news when we were told this Virtual Research Data Center System could not be used to produce quality measures on doctors. Couldnt quite figure that one out. And so the door sometimes swings open or closes. But cms has to continue to work for openness in spite of opposition. The focus should be on making raw Data Available. Im not optimistic that the government should be should itself be a producer of Performance Measures. But it should be a supplier of diverse supporter, i should say of researchers to develop Performance Measurement methods and put them where they can be critiqued by purchasers, consumers. We want the data, we want the methods. But its fine if the government wants to do its own performance even in the face of provider resistance. But we worry that such reporting would be too cautious to give consumers simple information that will make it easy to choose providers that would best meet their personal preferences. Difficulty of compare website, the real lack of Information Development and information in the physician compare website. Give one quite a bit of reason for pessimism on the government doing the reporting. And contrast that to the creativity of propublica which finds a way to put this data in a form that consumers can actually use and to be responsive, difference response to you than to you and to be able to find the data. All that stuff i think really private entities. And what data is needed to support them for perspective let me share with you what we have seen from consumers. Of all the many times of Service Providers we evaluate, the consumers look at most often are ratings of doctors. Of course people say well, they dont look at quality ratings of doctors. Well, maybe they dont look at them, but they look at them twice as much as ratings of plumbers and autorepair shops and about 13 times more than they look at ratings of hospitals. So thats an interesting perspective. Weve also done tests of consumer interest in different measures of doctor quality. By far the greatest interest was in Consumer Survey ratings of doctors. And in results of surveys of doctors asking for their recommendations of other doctors for care of a loved one. Both of these types of measures were chosen at least three times by at least three times as many website users as ratings based on board certification and training or ratings whether nationally find evidence based medical guidelines for quality and efficiency of care. So where consumers are starting from may be different from what we might have expected. So now here are a few thoughts on possible measures for future expansion. And im not going to limit myself on you know, to talking about these large data sets. But just sort of try to think about anything that consumers might possibly find useful. So i think one measure is whether doctors effectively use Electronic Medical records. Such information can be collected via the meaningful use program. This doctor use of these things. And the importance needs to be forcefully explained to consumers that this really will matter to you or could matter to you. Another might be to explore with specialty boards so they can let doctors identify themselves as performing lets say in the top quarter of other doctors on the certification process. Thats something ive never seen done, but it seems to me it would be interested particularly because it might reveal something about doctors diagnostic skills and one of the problems i think is that almost all of our measures out there, process measures, Outcome Measures even dont get to the question of diagnostic skills which are so critical to having a good physician. Another opportunity would be more measures of clinical bad outcomes. In analysis weve done, weve seen at the physician level statistically significant levels in death rates, complication rates, readmission rates. This kind of information needs to be public. If we had better data, measures might be possible to assess whether a doctor is prescribing too many of some kinds of procedures identified in the choosing wisely initiative. A very important challenge is to report on patientreported Health Status and Outcomes Using similar types of measures. Calculated some of these type of measures requires assembling better data bases. Theres a continuing need to push for allpayer databases where it could be understood that it would be used for provider quality measurement. So talking about, you know, Large National databases like that, thats a great thing. As an allpayer data base, i should say. But participation and registries is important if the registry rules allow the data to be used on public performance. Registries can collect information that goes well beyond what youre going to find in claims data. It makes sense to find out, i think, whether public reporting which physicians participate in appropriate registries and explaining why participation matters could put pressure on doctors and providers in general to choose to participate. But the big opportunity is in Health Information exchange. For Performance Measurement and various other reasons. Thats it could be the heart of a lot of stuff. So that means we need to push for continuing expansion and standardization of information and Electronic Health records including patientreported information and push providers to share this information in large regional and national databases. A Public Measure telling which providers are participating in these exchanges might actually create incentives. Certainly the government needs to invest heavily in this path. Think of it as the interstate highway system for health care. Its a major investment and it really should be a focus. Finally ill focus finish on a relatively easy but strange path. Getting a database of survey results on individual doctors. A database which could be to the group level and site. But starting with the individual level doctor. Why the government does not push forward with this is baffling to me. We have a good instrument in our cg caps survey. This survey of variants give good information on how well doctors listen, explain things, keep track of a patients history, engage the patient in decision making. This is important stuff. A doctor doesnt listen, for example, the doctor cant do a good diagnosis. Or come up with treatment plans that fit the patient. If they dont explain well, they wont be motivated to do their care. As one article in the journey of American Medical Association put it, Effective Communication has been linked with better treatment plans, more appropriate medical decisions, and better outcomes. And measurements should be at the physician level. Dana and others in the journal of internal medicine showed that the individual physician, not the practice, group, or plan counts for variance in the communication aspect of Patient Experience. So why dont we have survey results at the physician level. We hear its too expensive. To prove this wrong, consumers checkbook did a demonstration in four metropolitan areas in collaboration with united thank you, lou cigna and local blue plans. Showing a large number of significant part for physicians. The demonstration showed this could all be done at a cost of about 120 per physician and still show meaningful results. That all have demonstrated across the type data. And that 120 could be cut to about 60 or 40 per year since its not necessary to do the survey once every two or three years. Although physicians can be enabled to do the survey more often if they choose. This is a big opportunity and one the federal government could make happen with a little support and encouragement. Thanks very much. Thanks, robert. Thats a wish list of very interesting things. So, commune catalyst is an organization focused on gives voice to consumers particularly low income consumers. We have historically been fighting to open up the black box in support of robert and consumers union. I think its important to look at consumers from two perspectives. One is the role of a user and payer. And other in terms of their Public Policy role. You know, with the trend towards cost sharing and health plans, and its become more important for consumers to be good purchasers. With the implementation of the aca, millions of people are looking at the exchanges in the market place to choose health plans. So i think weve had a lot of experience with that. And frankly i think theyre still either not looking at that black box or theyre looking at it through the lucite lens. Because theres a lot of problems. Consumers and unions consumer and payers even find the most basic information illusive. The urban institute recently came out with a report that is difficult to get information from many market places about websites, the market place websites about whether a health plan is tiered, what providers are in the network, and what are the cost sharing differences associated with those tiers. For the low income consumers who most of the people going are low income consumers, quality data is complex and more very difficult to understand. Its clear that one size doesnt fit all. Information needs of a 60yearold is different from someone coming to checkbook. In terms of what were talking about today, we need to start with getting the basics right. We need better information about who and whats in a network and what are the costs to consumers. Charlie mentioned the importance of accuracy. The data needs to be made more understandable for consumers, taking into account the wide ranges of differences. Community catalyst has been working to take up a single quality measure that could be broken down to component parts. Focusing on the particular needs of consumers. We agree with robert in terms of patientreported information. We see collecting patient activation as a quality measure and a focus on outcome. And finally in terms of consumers, they need help doing this. You know, the average person is not going to be able to make the kind of cost quality equations we need in terms of coming up with values, without support. Medicare beneficiaries get this sort of assistance through the state assistance programs. We have a Consumer Assistance Program thats part of people focusing on enrollment. We need to sort of think about expanding that program. So in terms of consumers in terms of Public Policy, theres important pieces to really think about. Community catalyst was one of the first organizations to push for transparency around the conflicts of interests of pharmaceutical companies and physicians. It was actually the courts that opened up. Charlie in propublica took that database and made it into an effective tool for looking at what the is relationship of a pharmaceutical industry to the physicians. That perhaps hasnt helped in terms of allowing the individual consumers to make choices about either their drugs or their providers. But its had a Significant Impact on medical schools and hospitals. From a Public Policy standpoint its made an important change. The other area we have been working on is around hospitals and Community Benefits. Hospitals want to keep what their Community Benefits are off in a mystery in the value of those Community Benefits. A mystery to consumers. Community organizations want and need to that have information. Weve been working hard to get a database of the information around schedule h which provides some of that benefit data with George Washington university. So were looking to move forward in improving that kind of data for consumers. Consumers need to understand on the basics of health care, the idea of some of the broader trends in health care are a black box to consumers. And the government and consumer organizations need to push hard for opening up that black box. Im from Consumer Reports and i direct the Consumer Reports Health Rating center. Our role is really into trying to translate that data for consumers and to try to put it in context and raise awareness of the problems of that data, bring it to light. Thats what we focus on. And so its really about having people use the data, not just having the Data Available. By using it, we are able to identify some of the strengths and weaknesses of that data. So at the Ratings Center where we work, a group of scientists and doctors and consumers and writers who take data from various sources and much of it is the government and translate that for consumers. And we look at the areas of drugs, preventative services, physician quality, and also health plan quality. So we have been doing this for about ten years. We reach about 20 Million Consumers per month. Even more through our partners. So not just through our own magazines. Youre probably more familiar with our work in the area of cars and electronics. We often complete with those areas and make fun of each other. Id rather be testing cars than hospitals. And we cant bring hospitals into the labs and all that. So its a healthy rivalry, but i was just looking up some data the other day and i was really excited to see that in our own measurement of how our readers use data and understand these stories, that our stories on Health Care Costs and quality whether its about physicians or about hospitals or about drugs, sometimes supersede or rank higher than stories about cars and electronics and washers. So its really a top of mind for consumers, these areas of cost and quality. Consumers can understand it and use the information. So thats another common question i get asked. Well, you know, consumers cant really use it. But consumers can use it and they do use it. And we hear from them about it. And we hear from them about changes theyve made either in the hospital that theyve chosen or the drugs they take. More importantly the discussions they have with their providers. A lot of our content drives people to have discussions with their provider about the drugs or hospital. So its important to reinforce that relationship. So the thing is we really appreciate what cms has done in releasing data. We advocate to continue that release of data. The important thing, though, that i see thats sort of been skipped over is the issue of safety and errors. Thats one area thats hard to measure. And we seem to have jumped from sort of processed the measures all the way to patient reported measures like whether you can climb stairs. But skip measuring Patient Safety and errors. Weve asked consumers in our own surveys about this and our last summary about 30 of people selfreported they experienced one or more errors in the hospital. And thats probably a huge underestimate. Because thats just what the patient noticed themselves. Maybe not what went unnoticed to them. So i really feel like that not only in the area of Data Collection but also in the area of how we measure safety and errors, that this is an important thing for us to focus on. Another way to get at this issue is through registry data. Registry data is probably the most powerful out there. Youve heard a bit about it in this panel. And i think thats an area where wed like to push more to get that Data Available to the public. Weve been able to be successful in a small area of heart surgery. Weve worked with heart surgeons that have voluntarily released their data to the hospitals. We have doctors and hospitals that are high performing and some that are low performing that release their data. Consumers can look at a procedure they may be undergoing like heart valve replacement or bypass surgery and find those hospitals and physicians that perform the highest in these ratings of quality. And those quality measures look both at outcomes and also at complications in a reliability way. Thats what we would ask that we sort of make more public and i think cms with the power that they have to require these sorts of quality reporting systems that they start making that more of a requirement in terms of being reimbursed by cms. And then some sort of more requests that i have is to not try to reinvent the wheel. I think cms has sort of required to do public reporting as well. It kind of makes a lot of confusion at the level of the consumer because those websites that are out there now that government puts out, Hospital Compare and things like that are very difficult for consumers to understand. And so i would suggest they focus more on the data and the quality of the data and requirements for reporting the data rather than the consumer side of things. Then the final thing which is kind of a little geeky is i would ask cms not to forget about infrastructure. Those of us who use the data have to deal with the structure of the data. The missing elements in the data that make it harder to release accurate and timely reports to the public. So thank you. Weve heard a lot about choosing doctors. We heard some about choosing health plans. Id like to ask each of you to say a word about how you would hope the feedback to the providers themselves and to the health plans would improve the situation over time. Because isnt that ultimately what we hope consumers having better information will accomplish . Any thoughts on that . Well, weve watches this with Patient Experience data most carefully and tried to work with some of the especially societies to figure to tell doctors how they can improve and where they can find resources to improve. I must say, i dont think weve been particularly successful in that, but i think thats probably because were not very good at it. We tend to be a measurement organization, not a Quality Improvement organization. But there ought to be potential there. However, i dont think and yes, that is one of the objectives. But i also think that one of the objectives is helping consumers find the good ones and that also gets you good care. There are two paths one can go down here. Yeah. I think that when you look, for example, the pharmaceutical data, i think that you have the professional societies stepping up and understanding that there are implications to the conflicts of interest and trying to address those with changing policies within the societies, within medical schools. And within academic medical centers. I think it is necessary to have a partnership here. I dont think the markets going to move us away from all providers who are quote, unquote, poor quality of care. Its not going to happen. We need to rely on a partnership between hospitals, doctors, consumers, to get it right. I have to say in our reporting of data, we really do see a big response by hospitals. First they get angry because they dont like to be rated. But then they tell us that theyre focusing on the things were reporting on. The more we report on things to change, the more they focus. That came in a complaint. You focus on what you want them to do. I thought thank you i did my job. So thats one area we see changes in. And we also see areas where hospitals will call us and say thank you, thank you we didnt know x, y, z. Those are the calls i really like to get so i know that people care about it. And then we also hear from hospitals about patients canceling procedures and surgeries and then losing revenue. So there is some market change going on. It may not be as much as wed like right now, but theres something happening. Both doris and robert krugoff talked about getting the raw data out there. You were quite vociferous about how the government should get the raw data out there. But the risk of putting out raw data that hasnt really risk of misinterpretation as we saw in this they data release that triggered this event. Or will be misinterpreted. You know, ive been troubled by that response. Weve had a lot of experience. We have a Health Plan Comparison Tool that weve tried to put out. We put out in the illinois exchange, for instance. We asked the federal government can we have the benefit, the description of benefits, the copayments and coinsurance for these so we can do an estimate of out of pocket costs for each plan. The best estimate for somebody with your Health Status, et cetera. They even made it in a coherent way most people dont have a chance of doing. And the government unlike the part of cms were talking about here, the government said, no, we cant were not going to give you those data. And then they finally said, well give you the data the day before open enrollment starts. These estimates take many weeks and complicated calculations to do. We get it the day before open enrollment. So the reason two reasons. One is the plans wouldnt like it. And the other is that we might put out something thats confusing. Or that is wrong. I believe in the market place of ideas that you put out something thats confusing and wrong and nobody listens to you again, then somebody sues you. I like that way of having the world work. And we take some chances on that front opposed to not giving the information out. Lest we get too focused on the government not releasing, Big Companies dont like it very much either. Right. I think its time for audience questions. And we have possible microphones. Theres one right question back here . Hi. Im lauren hershey. I was here about 18 years ago. So hi, alice. I follow medicine a little more closely given my aging process. And im curious to learn over the last couple of years, mayo clinic book, Cleveland Clinic book, there is something called wellness medicine that is happening. I dont know how to define it. Theres alopathic medicine. I never thought in those terms until a few years ago. Thats health care delivery. So my curiosity is to ask each of you three panelists, how do you evaluate whats happening . How do you measure it . And how do you describe it . Has this Wellness Movement been around for two years or six years or nine years . I dont want to connect it to some personalities on tv. I want to connect it to university of michigan where ive read about it or yale university. But the question is data. So if i move 10,000 steps a day, big deal. But its supposed to make me healthier. How do you measure that . Get my point . I think i understand what youre trying to say. I mean, weve that movements been around for a long time. If you just look at the products we have. Diet and exercise so you have that aspect of, quote, unquote, wellness. We take in the form of preventative services. How that can keep them healthier. I dont know if thats along the lines youre thinking of, but thats our focus. Thats the aim we take. I guess i see theres a trend towards payment reform that would move you in the direction, move hospitals and payers in the direction of treating a person more holistically. Its been around for a long time. I think its getting much more traction now. Some of its not medical. Exactly. So much of it is not. Its nutrition, its exercise. Exactly. And are there evolving systems for evaluating that from the point of view of the consumer . Well, if you think about the dual demonstration projects, i think there are evaluations going on now of that and thats really looking to take the medicare and medicaid payment, combining it and keeping people out of hospital and out of Nursing Homes and theoretically healthier. You know, thats something i think the Research Triangle is doing right now. I think theres a i think the visibility of patient selfhelp and nonalopathic medicine has increased over time with tv and every place else. A lot of news letters and things like that. I do think theres progress. And i do think many of the health plans are looking for alternative ways to help their members hoping that these will solve problems and reduce the health plans. And some of these providers, i mean, for instance, checkbook does evaluations of acupuncturists. Thats a more straight up sort of thing instead of some things you dont know whether the person is hitting the bottom of your foot right. Some are much harder than others to do. At least some of those you can get some meaningful feedback at least on the ability of the providers to explain things and or to give miracle cures. Ive had a miracle cure by an acupuncturist. One time i went in and they said you have to listen for all this type of stuff. Then he put on music and let me sleep for a half hour. I wasnt supposed to be sleeping but i was. He said how did that work for you. I said it was terrific. But when he was talking me i was just thinking, warm lamp and sleep, how can you beat that . I was thinking did i lock my bike out front. So people have different views on how this works. [ inaudible question ] yeah. Well, i think we havent done much in general that has not been as its a bigger and bigger part of the system in the economy. I dont see it as having the same level of visibility and measurability that were trying to see in the regular medical care system. Other questions . I have a question that comes from twitter. Is there any information about increasing Consumer Engagement through transparent cost and quality data . And how can we increase engagement . Sfl i can speak anecdotally. We see an increase from consumers in both the data that were providing out there and also with the consumers telling thinker stories to us. I think what can make it more useful would be making them more personalized and making it more about their daytoday decisions or the decisions theyre making about procedures they have enough time to make those decisions about such as maternity, childbirth, knee replacement, things like that. I think thats theres been a lot of literature about why consumers get involved or not involved in cost and quality data. I think from low income consumers its it is somewhat different. And you need to think about how to engage folks who have historically been insured. Its where we think consumer assistance is important. The Medicare Program has assistance in people choosing plans. We think that would really help. Yes . I know there are some providers and organizations that are in the business specifically to help people. And there are others that are in the business to make money. And im just wondering from your analyses, can you differentiate one from the other . I dont think we can get to the heart of their motivation, but i think we can look at their performance. And we can see are they, in fact, making People Better and are they keeping costs reasonable . Are they overprescribing . So i do think its possible. Even some of those things ive talked about this choosing wisely type, you know, assessment. Which is obviously very important. And we dont know how to do that. I mean, and were going to need better data to really decide you know, start identifying providers who are really abusing as opposed to just getting a bunch of referrals for somebody who needs that treatment. Before we wind up, let me ask each of you very quickly if you look ahead ten years, what would you like to see in this world of Consumer Information about health care and Consumer Choice . What what are the most important things that you think the world ought to look like ten years from now in this dimension . Start with doris. Ill go back to where i was before in safety and medical errors. I feel weve been trying to crack that nut for ten years if not more. So if ten years were able to have a way for consumers to understand their risk of medical errors in any particular hospital or any particular surgeon, that would be where id want to be. And there are fewer risky providers, one would assume. I think we need to consolidate information, make it easier for the consumer to use. I think we need to focus more on outcomes and the Patient Experience. I would agree that we have to push toward measuring outcomes. Different people are in very different situations. Somebody who has no chronic or acute condition is not much interested in outcomes except they want to avoid something going wrong. Somebody who has a serious chronic condition really is looking at measures that are very clinically oriented, et cetera. So those things have to be tailored as you say to the measures have to be tailored to the patients or to the consumers. Given the demographics, more and more people will have that. Thank you very much, all of you. This has been a very good panel and i hope that some of these things come to pass quite soon. Let me turn it back to well, yes. A round of applause for the panel. [ applause ] and then let the turn it back to kavita for some final remarks. Thank you, alice. Go ahead and stay because this wont take very long. I just wanted to thank all our panelists again and thank or excellent staff at brookings. A number of people who helped make sure that everybodys every was as comfortable as possible and also for the folks watching on the web. I just want to highlight a couple of things. I mentioned some of the work were already doing with this data set and data releases. Were going to have several more briefs that talk about topics covered today. And i wanted to be a little provocative in what might be coming after todays conversation. Weve talked about kind of uses that are not just consumer centric but what happens if some of this data is used to create High Value Networks that were seeing in the private market place as well as on these Health Insurance exchanges. And what if we could actually get researchers together and do almost kind of a crowdsourcing of valuable research cases or findings, things we all find interesting that we dont necessarily have one entity taking lead responsibility for but that we could work with nonprofits, research organizations, as well as consumers on what they find interesting and try to put that together in a way thats not contingent on what the government would do. And then finally i think doris kind of talked about a conversation thats been missing around safety and errors. It wasnt that long ago we had crossing the quality chasm and other colleagues who highlighted these problems unless we be remiss to think weve solved all of them, how can we be pointing towards places to improve and think about concentrating efforts from transparency in data to show people not just whats bad but what we can do to improve the health care in our country. I did want to point the conversation wont end today. We are going to be doing future publications as well as hopefully extending this in other ways. So thank you for your time and attention. And have a great rest of the afternoon. Take care. [ applause ] and live Coverage Today on cspan3 when the Domestic Violence Committee Talks about professional sports. Well hear from troy vincent and others. Thats live at 2 30 eastern. And in the hill reporting on boehner plotting twostep course on immigration to gop rank and file that would keep the government funded past the current december 11th deadline and also push back against president obamas executive actions on immigration. He plans to bring a bill to the floor this week and the house would then vote next week on a Health Officials have nr  eb Treatment Centers with more expected in the coming weeks. Xdi researchers who are trying to develop an ebola vaccine and the president s scheduled to deliver remarks just after 5 00 eastern. You can watch that live on cspan. Org. Next well hear from the head of the u. S. National Intelligence Council about how the Intelligence Community is adapting to new National Security challenges. This was hosted by the Atlantic Council. Its just under an hour. Good evening, everybody, and welco welcome. Our online audience, welcome as well. Were so pleased you can join us to look at an issue of critical importance and i think were understand i understanding this is becoming real world and an even more compelling fashion than we thought maybe even a couple years ago. And that is how the Intelligence Community responds to escalating threats. The relationship between intelligence and strategy is an area the Atlantic Council has focused on on interNational Security which are sustained analysis of Global Trends and our Foresight Initiative where the director and norm formerly e Intelligence Council. We pride ourselves on building a network of experts dedicated to understanding what the future holds. And then to think creatively about solutions and creatively about strategy for the future. Its not easy work. Often argues that strategy during the cold war was easy because you had containment of the soviet union, containment of communism, and then the tactics were difficult. And now he complains that were all tactics and not enough strategy. Of course intelligence is a lot about informing what our strategy ought to be. One of the best experts i talked to over the years on any number of issues but as you know im a recovering journalist of the wall street journal and you always try to turn to the smartest people to inform their ideas to help your own. I always liked stealing mr. Trevertons ideas. We met in europe i think more often than the united states. Recent events in the middle east and Eastern Europe have changed the policy conversation in washington and reinforced the importance of timely, accurate, and appropriately intelligence analysis. Very often it may seem the intelligence world is different from the policy realm. Looking from the case of wmds in iraq, the hunt for osama bin laden, just lists and lists. You can list positive cases as well. The next landmark Global Trends 2030 report forecast that we are living in a world of rising nonstate actors, revisionist powers and exponential change, i think were all seeing that accelerating faster than the thought it would. I think thats probably one of the most interesting findings of these Global Trends reports is if theyve underestimated anything, its been the pace of change. So, with that as prelude, we have the pleasure of welcoming a thought leader tackling this. Dr. Greg treverton. Hes previously served as director of center for global risk and security as well as a professor at the graduate school where he serves as associate dean for research. Prior to joining rand he was vice chairman where he oversaw production of the governments premiere assessments of international problems, the National Intelligence estimates. What years were you vice chairman . 93, 96. Okay. So i think i may start there. The director of National Intelligence James Clapper called you to do this job for your combination of analytical skills, broad substance of expertise, passion for the intelligence profession, and a deep understanding of the unique role and mission. I think well talk in this conversation, ill ask you a few initial questions and then well get into q a. And so clearly he call you the right man at the right time and i think thats absolutely right. So thank you for joining us. Thank you. One last housekeeping note. We have a hash tag for this event. Thats probably something new in terms of your appearances. So we encourage you to tweet away using the hash tag and i apologize in advance for this. Acdisrupt. Why dont we get started. Lets start with your time you were vice chair. Youre back now and there i think you were under joe nye who was the chair. So coming back into the building, coming back into this capacity, hows it different . Both in terms of how the place operates and then also substantively. Pleasure to be here. Appreciate the opportunity to talk about the Intelligence Community and Intelligence Task in general. The biggest change coming back as you can see, im a slow to rise. It took me 15 years to go from vice chairman to chairman. But its great being back. I still have the same phone number i had all those years ago. So some things change more slowly. The big change, really, is the operating environment. Before we basically only did more strategic work, not just National Intelligence estimates but more strategic in putting pieces together and into context and taking a longer look at particular issues. We didnt have much role at all in current intelligence. Thats a dramatic change. Now the nic is responsible for doing the intelligence preparation of the principles committees and the deputies committee. When did that begin to shift . It all really began with clapper, i think. When jim came in. And working out the arrangements between the cia and the director of National Intelligence. The cia still does most of the work on the president s daily brief, but now the dni delivers it. Ditto on the pcs and dcs. We turn to all the agencies for help, but we do the quality control, put them together when an Intelligence Community wide view of a particular issue is wanted. So thats the big change. It makes us on the good side makes us relevant. Means were in the thick of things. It means critically we know whats going on which is always a great problem in intelligence knowing what policy makers have somebody see what they want to accomplish over the next two years. But they have no idea about next tuesday. Trying to keep up with policy and those circumstances is a real challenge. The cost is that it is a hugely consumering effort. And so for the busy accounts like the middle east, like russia National Intelligence officers feel like they spend most of their time either preparing for meetings, going to meetings, or writing short response memos after those meetings. Last year we did like and arrange 15 National Intelligence estimates. We did about 900 pieces of paper. More than half of those 900 were memos, specific memos to susan rice about particular issues that came out of the dcs or more rarely the pcs. Dcs needed them more often than the pcs. Thats the big change. The thing that hasnt changed other than my phone number is the people. A terrific collection of officers and their deputies particularly. Just a world class set of people. I feel like i get to go every day to a world class intellectual salad bar and it really is a treat. Well, before we get to the substantive issues, where do you think you want to adjust that needle between realtime and longterm . That is the big challenge i face. Issue number one on my agenda is trying to think about and to the extent necessary, recalibrate that balance. Think about, and to the extent necessary, recalibrate that balance. It means finding ways to let people have time, energy to do somewhat longer or somewhat broader thinking. I had a really good deputy of National Intelligence officer in russia who said, i like getting to do this straty piece, longer term strategy piece. He said unfortunately i only had six hours to do it. So deep thought in six hours is probably not a great idea. So finding ways to let that more strategic, not always longer term, but putting things in context, finding ways to do that is really the big challenge. Now, happily not many of the questions that come out of the dcs are pretty straightforward. But many of them are quite interesting. Well get a whatif. What if we do this, how will these dcs, deputy committees. The main policy committee in the u. S. Government in the policy making side. As a practical matter, its the dcs that do most of the work, and sort of tee up decisions for the principals. Sometimes theyll ask us interesting questions, just the sort that id like to engage in with policy. If we do this, how will putin respond. Whats your assessment of how putin will respond. Those are ideal as a first task that i need to begin to develop a better count. Because its not the case that all those memos are only information and only the nies are more strategic. Theres a middle ground, trying to figure out exactly how our work breaks down. Thats the first task. Before going present tense into the future on substance, since youve raised russia, lets go back a little bit to when you were there before. Everyone argues, should we have known where things were going, could we have altered things, what is our role in the outcome were experiencing today. With my knowledge, and your knowledge in these areas, what is your take on when you were last at the nic, in terms of how we were looking at that . One reason im asking this is this interesting mixture of longterm trends and shortterm action. If youre trying to look at russia out ten, even five, certainly 20 years, its hard. But five, ten years, you may make smarter decisions about today. So take us back a little bit right now, and then how do you play that out right now . What sort of intellectual process did we go through then, and what sort of intellectual process ought we be going through right now . One thing that strikes me is this seems to me an interesting Inflection Point in global politics. Maybe the third in the last generation or so. One was obviously the fall of the soviet union, and communism. The second was 9 11. And 9 11 was easier because it seemed to come with instructions attached. So heres what you do. You go after these bad people. So this feels to me a lot more like the fall of the soviet union, the end of communism, where one geopolitical framework for thinking about the world is gone, but it hasnt quite yet replaced with another. It seems to me the first time when the soviet union fell, we very quickly said, thats over. And while i think that as a policy person at the time, i thought that the expanding of nato and all those things was a good thing to do. But we probably were in retrospect pretty dismissive. And part of putins attitude plainly is, it feels like he and russia were dissed by the west for a couple decades. And that obviously does have some effect. It doesnt explain him. But i think it happened because we sort of quickly went to, well, now thats over. The cold wars over. And now russias no longer a threat, no longer a major power, and we sort of jumped quickly to a different attitude toward russia that is in some sense part of the sweep of what were confronting now. Its interesting to think about. Sometimes we think that change takes a long time. If you look backward, the distance between the evil empire, and the fall of the soviet union, which is slightly over a decade, so it does mean that things can go very quickly from time to time. My staff here, im so glad you raised the point of Inflection Point. Were kind of living by that argument right now at the Atlantic Council in a way, drawing it out of the Global Trends 2030 report, where the Inflection Points listed there were 1919, 1945, 1989. And the argument being that at these points in history, decisions of leaders had outsized importance, because you were at a plastic moment in history where things could be molded and shaped, et cetera. You used different Inflection Points here. And this gets to my point of how is your job different than it was then. How big is this Inflection Point . Is it of this historical dimension, end of world war i, end of world war ii and the cold war . I think obviously, i dont know whether its as big as those other ones. It seems a very significant one in the sense that we are sort of scrambling around for a view, a lens with which to apprehend this world, to mix a metaphor, and that i think means a real challenge for intelligence, trying to help people build that lens, or that story. Ive come to think that intelligence is about helping people create and adjust stories in their head, and we know when the story gets too firm, we call that mindset and often results in what gets called in intelligence failure. But if theres not a story, then new information just kind of bounces around. Its a factoid. Its hard in policy to have a conversation. So one of the true churchill lines he was supposed to have said after a particularly undistinguished meal, asked what he thought of it, he said the pudding, thats dessert for the english, lacked a theme. Well, i think our world lacks a theme. So trying to provide a story or a lens, that seems to be a job a formidable job for us to do working with policy people. As i said, whether this ranks with 1989 or 1992 in importance, dont know. But it does seem like were again in a pretty shapeless world, where its easy to get dominated by tactics. How about regionally, as youre coming in, and how the world is different than it was then. What were your regional priorities you know, in this world of challenges, the middle east, ukraine, you know, the far east, south china sea, ebola, Global Financial stability, what are your how do you set your priorities in the job youre doing right now . And where would you set them both in regional sense and in a subject sense . We set our priorities by whats in front of us. The big crises that are going on that need to be handled, the challenge with those is trying to help people step a little bit up and say, here are the tactics, what are we trying to get out of this . Whats a realistic end game, offer at least end point to this particular set of crises . Not very easy. Hard to do. So those well define. I think for the remainder of the administration, of course, the middle east and russia are going to be dominant themes. I think we need to keep trying to raise peoples sights a little bit to beyond the immediate tactical to, what are we trying to do here, whats our ultimate point here given realistic possibilities. I dont get to have too many priorities in my current job, though as i said, somebody the other day, i spent my whole career avoiding the middle east. Thats over. As the kids would say, thats so over. Right . So ive learned a lot. Acdisrupt. Otherwise, on my personal list, i think china and east asia has to be at the top of the list of so much going on there, so much chance of multiple issues at play, connecting in ways, people making miscalculations. We know there are going to be bumps ahead in the road for china. We dont know how bad theyre going to be, but there are going to be some bumps. And there may be good ones as well. I think that whole combination of issues there, in a region that doesnt have Strong Security agreements, mostly bilateral with us and allies, so thats going to be at the top of my list. My own personal list is certainly cyber. From where i sit, we still havent calibrated the threat. Its very hard to calibrate the threat. Its very dynamic. Were divided in ways that make it hard to have a complete view. We have, you know, the military part of the government, the private sector that has all the infrastructure and does all the stuff. We have the government. And we have offense and defense. And working across all those divides, i think its no surprise that we havent really calibrated the threat. So thats high on my list. And then and globally offense is stronger than defense at the moment. I think we dont know. Its part of calibrating the threat. And then i as you said earlier, fred, i was really happy when the cold war ended, because it had become boring. It had become a sort of a managerial problem. And we knew that if we kept our Alliance Together and kept ourselves strong, we would win in the end. We didnt expect to win in 1992, or in our lifetimes, but we did win. So in that sense it was kind of