THE WHITE HOUSE
Office of the Press Secretary
------------------------------------------------------------------------
BACKGROUND BRIEFING
BY
SENIOR ADMINISTRATION OFFICIALS
September 14, 1993
The Briefing Room
4:12 P.M. EDT
MR. ANDERSON: Good afternoon. I'm Kevin Anderson from the
health care communications operation. I know most of you. This
is a BACKGROUND BRIEFING -- the second of five we are holding
here in the Briefing Room, with a twofold purpose. One is to get
into the various aspects of the proposal that the President will
be announcing next week, hopefully to fill in some of the
connective tissue that's missing in the plan draft that I'm sure
you all have several copies of by now. I understand that they've
set up a kiosk outside of the Cannon House Office Building.
(Laughter.) And if we could get royalties from that, we would
have the financing problem licked to be sure.
This a no cameras, no sound basis, senior administration
officials.
Today's topic, the focus is on quality and how we believe
our proposal will not only preserve, but help to enhance the
quality of care delivered in this country. We realize that some
questions may be off of that. We do want to let you know that
tomorrow's briefing, a time to be decided -- and the best way to
find out times for all these briefings for the remainder of the
week is to check with x2100, 456-2100 sometime mid- to late
morning. They will be able to give you the times.
We do plan on tackling financing tomorrow. So if you could
save those questions.
Our speakers today are -- and they will have some short
opening remarks and will take questions after that -- first, is
[NAMES DELTED]
SENIOR ADMINISTRATION OFFICIAL: Good afternoon. The
quality assurance system that we currently have relies on a lot
of checks, a lot of inspections, a lot of information that is not
necessarily disseminated to the people that really need it -- the
patients and their providers that are on the front line. And so
it doesn't really act to improve the quality of care. Despite
this, many Americans are satisfied with their care. So the goal
of the American health securities act is to actually improve
quality be making it consumer-driven, providing information that
can be used to make informed choices about the quality of care,
and to cut down on the administrative burden that's often
associated with the quality assurance system.
What I'm going to do is just give you an overview of the
structure. Then my colleague is going to talk about some of the
specifics of the program in terms of what we expect the quality
report card or performance report to actually contain and
accomplish. So just to give you an overview of the structure --
what's really important is that everyone involved in the health
care system will have some responsibility and involvement in the
improving quality. At the highest level -- at the national
level, there will be an national advisory council to the national
board that will be appointed by the President. And this will
basically be the policy-setting body that, in addition to setting
policy, is responsible for the evaluation of impact of health
care reform.
So this advisory committee will decide what measures
actually go into the report card, It will decide what kinds of
questions get included in what will be a national consumer survey
to understand how satisfied consumers are with their access and
outcomes of care. It will set a priority list for the kinds of
measures that will be developed over about a five-year period and
set an agenda for doing the research and development necessary to
make those measures extremely credible and valid. It will
provide an annual report on how well the system is working and
will conduct an evaluation of the impact of health care reform.
So, really, the policy and evaluation will be at the highest
level. The states then will be responsible for developing a plan
to make sure that they meet the guarantees for access and quality
standards that are promised under the American health securities
act. They will also be charged to assure that plans and
providers meet standards through licensure, and will provide
comparative reports on alliances and plans within their states so
that consumers can make informed decisions.
And finally, and most important because it's something
that's new, they will be developing a technical assistance
program that's flexible, depending on the states' needs, and will
actually provide a way of ensuring that providers, plans have the
kind of information and skills they need to actually improve
quality.
The alliances will be responsible for responding to any
complaints by consumers in a timely way and disseminating
information relating to the plans within their alliance. This
information must include the core set of measures as defined by
the national advisory committee, as well as any additional
measures that the state or the alliance feel is important for
their population.
There will be comparative reports so that consumers will
actually be able to see various plans and if the data is
statistically valid, how providers actually compare. They will
also -- alliances will also be responsible for developing
educational programs to ensure the consumers understand how to
use this information and it's not just being given to them
without guidance on how to use it to make their choices more
informed.
The plans then, the groups that are actually providing the
care will be responsible for actually collecting the data and
doing the measures, and disclosing that information to their
patients and consumers. They will need to report this
information, as I said, to the consumers, but also to the
alliances so that the information can be compared on a larger
basis. And they must meet basic conditions of participation --
things like not discriminating against people, against
maintaining their financial solvency and the like.
So the general structure then is that at every level there
are responsibilities and accountability for quality. The thrust
is to provide information that will improve -- that will allow
people to make the choices that will improve care, both by
patients and consumers and providers, and it will do this largely
by using a core set of measures in the performance report that my
colleague will now discuss.
SENIOR ADMINISTRATION OFFICIAL: I think that if I give you
some examples and a set of contacts for the notion of measures,
it may help a bit at this point.
We're talking about measures that could be aligned on, if
you like, four dimensions or four categories: Access to care,
the appropriateness of care, the outcomes of care, and the
satisfaction of the consumers with the care.
The basic measurement of access occurs through a combination
of surveys of consumers conducted in sufficient detail so that
you can say things about individual plans, and looking at certain
services which should be provided if care is accessible. And an
example of that is certain immunization services, for example,
and I'll come back to the details on that.
Appropriate care: This is looking at the specific services
that were rendered. And what is critical here is that one
focuses on services which have a strong scientific evidence that
they actually affect outcome. This is not services that there's
a general agreement it's nice to do this; this is things for
which there is very strong evidence that providing that service
produces a better outcome. Immunization, for example, is a
service. There is very strong evidence that immunization
produces better outcome for people who are immunized.
Outcomes are straightforward and familiar. There's been a
lot of discussion of these. It's critical that the outcomes be
adjusted for different in risks between different populations,
and there's a lot of experience now in to how to do this. And
it's critical that variation in these outcomes can be shown to be
under the control of the providers. There has to be something
the providers can do -- the plans can do, the practitioners can
do to improve a poor performance.
And finally, satisfaction. There are now standard,
well-established ways of measuring satisfaction, and I think we
take advantage of those well-established methods to start with
and refine them as time goes on. And again, satisfaction would
be measured at the level of the plan and with attention to
sub-populations, vulnerable groups, minority groups as well.
Now, let me give you a few examples of the kinds of things
we're talking about. I mentioned immunization; mammography,
screening for breast cancer would be another example. These are
what we call primary prevention. They are supposed to get there
before the disease is established.
Then there's the problem of people who already have a
disease, such as diabetes and high blood pressure. And here we
would be looking for, for example, in diabetes, steps to monitor
the accuracy of control, because it's now very clear that that
information permits better control and better outcomes. Likewise
with high blood pressure.
Then there are the acute care situations. Take the
obstetrical example -- cesarean sections rates, and more
specifically, for example, vaginal birth after cesarean section;
drugs administered after heart attack to prevent a recurrence;
therapies after a stroke to prevent another stroke. The total
number of measures may be on the order of 50. That's a stable
which will change over time. One is not committed to the same
thing forever. And it is a system which will refine constantly
as we learn more about how to connect the measures to achievable
improvements in care through the technical assistance program.
I think that's sort of what I ought to say, and why don't we
start answering questions.
Q Was that 50 measures in the access area?
SENIOR ADMINISTRATION OFFICIAL: No, that's 50 measures
across the board. And that's a rough number.
Q Are these alliances, as I understand, the alliances are
states, is that right?
SENIOR ADMINISTRATION OFFICIAL: The alliances will exist
within states. There will be at least one alliance per state,
but there may be several alliances in a state.
Q So each state will probably differ from one to the
other and to people who are moving about to one place to another
will have to get on the rolls at a different place and all that?
SENIOR ADMINISTRATION OFFICIAL: Yes -- are we going to have
a briefing on this?
SENIOR ADMINISTRATION OFFICIAL: There will be a briefing on
alliances and some of the other structural aspects. We want to
focus on quality as it relates -- your question as it relates to
quality I think highlights the need to have measures that are
state-based and alliance-based so that it can target the
particular needs of a population. And so there will be a core
set of measures. And then those core set of 50 measures will be
augmented by things at a state or an alliance level in order to
make sure they meet the needs of the population.
Q Will that increase your cost in giving health care to
people?
SENIOR ADMINISTRATION OFFICIAL: I want to make sure --these
report cards will be prepared on each plan within an alliance by
the alliance?
SENIOR ADMINISTRATION OFFICIAL: They'll actually be
prepared under the supervision of the national health board and
the national quality advisory council.
Q And then when they're completed each year, every
enrollee in each plan will receive in the mail --
SENIOR ADMINISTRATION OFFICIAL: One of the responsibilities
of alliances is to disseminate the information in these report
cards to people who are enrolling so they can enroll more wisely.
Q And they will include 50 different measures, so each --
I just want to get this straight -- each consumer will get a
report card on each plan within the alliance every year that has
50 different measures, and that's to help them pick what plan
they want to enroll in for the next year.
SENIOR ADMINISTRATION OFFICIAL: Equalized consumers
reports.
SENIOR ADMINISTRATION OFFICIAL: That's right.
Q Will report cards go to the level of individual
doctor's performance, surgeon performance, hospital performance?
SENIOR ADMINISTRATION OFFICIAL: Where the numbers are
sufficient to allow doing that in a valid way. Where the numbers
are sufficient to allow a valid statement, that will be the case.
Many physicians do not do enough of individual -- particular
individual things to allow a generalization about their
performance.
Q The information in the data bank, the national
practitioners data bank, is that going to be part of it?
SENIOR ADMINISTRATION OFFICIAL: That will not be a part of
the national report card, although that will continue as part of
the health securities act.
Q And it will be open to the general public, as it is not
now?
SENIOR ADMINISTRATION OFFICIAL: No.
Q It will not be open?
SENIOR ADMINISTRATION OFFICIAL: No. This is not our area.
SENIOR ADMINISTRATION OFFICIAL: I think we have to defer
that question because it's not within our area of expertise.
Q I don't understand the report card. What does that
mean? Everybody gets a report card?
SENIOR ADMINISTRATION OFFICIAL: Let me just expand a little
bit. What it means is that there will be a group of measures
that everyone will get a calculated report on, a grade, if you
will. It will be prepared, as we said -- the decisions on which
measures will be included is at the national level. The group
that actually collects the information is the plan. But it's
done under the specifications that are handed down by the
national board.
Q Is it the HMO that does it?
SENIOR ADMINISTRATION OFFICIAL: It's a plan by whatever
configuration, whether it's a fee-for-service plan or any other
kind of plan.
Q So the plan is going to provide the data that's going
to determine whether or not the plan is any good?
Q I don't understand --
SENIOR ADMINISTRATION OFFICIAL: Excuse me. I --
SENIOR ADMINISTRATION OFFICIAL: One at a time.
Q I had the floor.
Q Do the alliances have any role in the preparation --
the national board sets the standards and the locals provide the
information -- the plan supplies the information. Do the
alliances play any role? Do they do the actual printing?
SENIOR ADMINISTRATION OFFICIAL: The alliances actually
organize the information for their members who will be enrolling.
Q If a plan or an alliance is found to be negligent in
its collection of the data or falsifies data, are there
administrative or criminal or civil penalties if they don't meet
the federal specifications?
SENIOR ADMINISTRATION OFFICIAL: There will be a follow-back
behind the data to audit and ensure its integrity. I can't
predict exactly what the regs might read like on that, but there
will be a follow-back to ensure integrity.
Q If a plan does a real bad job in a given year, collects
spotty data, what's the check on that? Is there a penalty?
SENIOR ADMINISTRATION OFFICIAL: One of the conditions of
participation is collecting and disclosing the data in a way that
is described in the plan.
Q In theory, but if they don't do it in fact --
SENIOR ADMINISTRATION OFFICIAL: If they don't do it in fact
then they aren't meeting the conditions of participation.
SENIOR ADMINISTRATION OFFICIAL: They could be excluded.
Q Can you give us a sense of how much more information
providers are going to have to collect and report than they do
now, because it sounds awfully cumbersome and it sounds --people
have been talking about streamlining the process and this sounds
like it's going to take a lot more time.
SENIOR ADMINISTRATION OFFICIAL: They actually aren't going
to have to collect any more information than they do now. Most
of the information that will feed into the development of these
measures is already being collected by existing insurance
companies. The problem is it's being collected in a sort of
helter-skelter way and by -- with different specifications on how
you code the information, and so on, so that's it's not really
usable and aggregate.
What this will do is it will define the data, basically no
more than is being collected now, but will use that data in a
much more efficient way to improve the information.
Q Do you have an estimate about the number of hours or
whatever it would take to collect and prepare?
SENIOR ADMINISTRATION OFFICIAL: I don't think we can say a
specific number of hours. It would certainly be less than it is
now because there's only one set of coding standards and one
form. There's not the multiple kind of forms and rules that
doctors have to deal with now.
SENIOR ADMINISTRATION OFFICIAL: Let me make two comments
just to follow that up. Number one, the medical community --
that means physicians and hospitals and plans -- are crying for
standardization of the information they're asked to report by
different groups, and this is an effort to provide that
standardization.
Second, information is information that a plan which is
looking at what it's doing should be collecting in order to
manage internally. It doesn't mean every plan is now, but they
should be in order to manage internally.
Q -- plans to collect the information on -- or to provide
information on the appropriateness of care and the satisfaction
of its patients, is that correct?
SENIOR ADMINISTRATION OFFICIAL: We're expecting them to
provide information on the measures that are required. Those
measures will fall into the categories that my colleague
mentioned. And there will be measures in all of those
categories.
SENIOR ADMINISTRATION OFFICIAL: Let me be specific in
response. As far as satisfaction is concerned, my read is that
that's going to be a survey conducted either by the state or by
the national board. That's still to be worked out. It would
not, I think, be conducted by the plan, though that has I suppose
some possibility.
Second, as far as the plan reporting on the appropriateness
of its care, it will report a very specific number. The percent
of people who were discharged after a heart attack, who got the
particular medication, and who had the indications for that
medication. This will not be just "we provided real good care."
Q Who will determine then whether that care was
appropriate? How will you then be able to rate that?
SENIOR ADMINISTRATION OFFICIAL: The decision on whether or
not something will be included as a measure will be made based on
how well we're able to make that kind of determination based on
good science ahead of time. So it's not going to be made after
the fact. It will be decided on before based on the information
that we have in the medical literature. And that's part of the
reason for having a priority list of measures that might come to
play over the next five years, because in some instances there
are going to be measures that we all could agree we need to have
because knowing about that will improve the health of the
country, but we don't have the information or the specific
studies necessary to know what really works and doesn't work.
And in that case, we'll need to do those studies to get ready for
the measure to come out in a few years.
Q Will incidents of malpractice be one of the measures?
SENIOR ADMINISTRATION OFFICIAL: Probably not.
Q Why not?
SENIOR ADMINISTRATION OFFICIAL: Too difficult to measure.
Q On the access category, will you monitor how well
low-income people are gaining access to the system? Will that be
one of the measures that you use?
SENIOR ADMINISTRATION OFFICIAL: One of the specific parts
of the consumer survey is intended to sample persons who fall
into the category of not having gotten care -- historically not
have gotten good care. So the answer to your question is, yes,
we intend to -- the intent would be to look specifically at
populations who had not gotten care and see whether or not they
were receiving the benefits that were covered under the plan,
look at people that had perhaps been disenrolled, people that
were high utilizers of care. So specific categories that will
allow a better understanding of how well the system is working.
Q Does the person have the privilege of choosing her own
doctor, or does it have to go through all these cards and reports
and everything? Usually, the contact between a person and a
physician is private. How can we keep it private?
SENIOR ADMINISTRATION OFFICIAL: In each of the alliances
there will be the option for a fee for service plan which would
allow people to choose entirely where they got each episode of
care that they sought. There will also be plans where they
enroll and who is in the plan would determine it.
Q I still don't get my answer.
SENIOR ADMINISTRATION OFFICIAL: I think the simple answer
is, yes, there will -- (laughter) -- be the opportunity to choose
your own doctor.
Q You're involved in a similar measure like this with
grading the quality of hospitals at the Health Care Financing
Administration, and that effort was abandoned this past year
because the Administrator felt that it really wasn't an accurate
reflection of the quality of hospitals. Aren't you going to be
running into the same kind of quantitative and qualitative
problems with this undertaking?
SENIOR ADMINISTRATION OFFICIAL: I think that if we try to
use a single measure, such as mortality, without adequate risk
adjustment, we would be on very thin ice. And I think the reason
we have a board is to avoid having us get out on that kind of
ice.
Q Could you exemplify -- when you say that these plans
are going to get grades, are they going to get like grades in
four categories? Are they going to get and A,B,C,D, on a scale
of one to 10? What exactly -- are they going to get a percentage
score?
SENIOR ADMINISTRATION OFFICIAL: They are actually going to
get a grade in the sense of A,B,C. They will have to report
their performance in that measure. So, for example, for
immunization rates, they would have to report the percentage of
their enrollees between the ages of two and 18 who had completed
all of the age-appropriate immunizations.
Q So consumers are going to have to go through 50
different categories, or is there going to be some kind of
summing up for consumers?
SENIOR ADMINISTRATION OFFICIAL: There won't be a summing up
bottom line. And part of the reason for that is that most
consumers need different things from a plan. If you can envision
that a young family might be more interested in, say,
immunization rates and appropriate utilization of prenatal care
or caesarian rates, and an older population may be more
interested in some of the issues related to chronic care, or
outcomes related to specific conditions that are more prevalent
in older populations.
So the intent is to provide a variety of measures that will
give people the information, snapshots and probes into the
information that they need without providing a bottom line. I
think to provide a bottom line would be very difficult.
SENIOR ADMINISTRATION OFFICIAL: And however confident the
private sector will sum these up and provide a bottom line for
people.
Q Will you include a measure of how long people wait for
various services?
SENIOR ADMINISTRATION OFFICIAL: That's part of the access
issue. Exactly how it's measured remains to be determined.
Q Will this supplant the PROs or complement them?
SENIOR ADMINISTRATION OFFICIAL: Until Medicare is
adequately covered under the system, it will complement them.
Medicare is, at the moment, standing somewhat free. When
Medicare becomes a full part of the system -- and I don't know
when that's going to be -- the PROs would be abandoned.
Q So isn't that, in effect, then, they have to respond to
two different report card writers -- the PRO and this new
whatever you want to call it today?
SENIOR ADMINISTRATION OFFICIAL: I can promise you, because
the PROs are well within my personal area of responsibility, that
we'll try not to have duplication of that kind.
Q Let me ask you if it also could be inverted -- in other
words, will you be looking at plans that provide too much care in
certain areas, like too many cataract surgeries?
SENIOR ADMINISTRATION OFFICIAL: I think the key here is to
try to define what is appropriate care and not to focus in on
what's too much or too little. Because what is appropriate for
different age groups, different underlying conditions can be very
different. So we are going to -- the intent is to look at what's
appropriate, not what's too much or too little.
Q Do you know that before or after you start issuing
these cards?
SENIOR ADMINISTRATION OFFICIAL: That will be part of
determining what's going to be a measure.
Q Do you have a table for coming up with these measures?
SENIOR ADMINISTRATION OFFICIAL: We expect to have some of
them in place by the time enrollment starts in many states, but
since different states appear likely to come on at different
points, it's hard to work out the details; it will be state by
state variable.
Q After you collect all these data, are you going to have
to have substantial changes in privacy laws or can you just push
them through as a --
SENIOR ADMINISTRATION OFFICIAL: We believe that this is
fully compatible with the kinds of data collections that are
currently going on, that it wouldn't require special laws. But
there's a very real concern that data affecting individuals is
well protected. And there's been a whole work group working on
how to make sure that those protections are strong.
Q How will they be protected?
Q How will they be protected, right?
SENIOR ADMINISTRATION OFFICIAL: I think that's going to be
the subject of another briefing.
SENIOR ADMINISTRATION OFFICIAL: Incription, among other
things. Codes.
Q Is the report card the primary vehicle for maintaining
and improving quality, or are you planning to do other things
other than just keeping track of performance and making it public
that is intended to promote --
SENIOR ADMINISTRATION OFFICIAL: It's not just making it
public, it's giving it the alliances to use it as a basis for
negotiation, and it's given to providers and practitioners to use
as a base for improving what they're doing. But there are other
important components. There's a minimum step of standards that
everybody playing in this game has to meet. Physicians will have
to be licensed by their states, nursing homes will have to meet
standards comparable to current nursing home standards, plans
have to meet a set of standards of participation. This is to get
people information above that baseline.
Q Can you just explain a little bit more how -- the
average consumer is sitting out there in this alliance, right?
And there comes the time to pick your health plan. Is it going
to be long-distance phone companies or something? Are you going
to be getting all of these things in the mail, saying --
(laughter) -- I mean, is that what it's going to be like?
SENIOR ADMINISTRATION OFFICIAL: Do you read Consumer
Reports?
Q Yes.
SENIOR ADMINISTRATION OFFICIAL: Like that.
Q So we'll get like one document from their alliance that
will have all of these plans?
SENIOR ADMINISTRATION OFFICIAL: That's the idea behind
having a core set of measures and having the alliance put it out
at a time when they need that information for enrollment. And
the other thing I would just ask you to recall is I mentioned
there will be specific educational programs to make sure that
consumers understand how to use this information so that it's
interpretable.
Q -- standards sound very prescriptive as you've
described them, i.e., what percentage of patients go home from a
heart attack episode with prescription X? Doesn't that -- aren't
you trying to squeeze the care in a certain way?
SENIOR ADMINISTRATION OFFICIAL: No, not at all.
Q How does this interact with the outcome standard? It
should be a very different -- a more results-oriented approach.
SENIOR ADMINISTRATION OFFICIAL: Well, in this case, there
are about 15 or 20 double-blind studies showing the people who go
home on this drug are better off, have better survival than
people who do not.
The standards with all of them, every one last one of them
be based on a very carefully, professionally developed guideline
indicating what was appropriate. It is not in line just to pluck
standards out of the air.
Q But it becomes -- what you're talking about is a
national formulary then.
SENIOR ADMINISTRATION OFFICIAL: No --
Q The whole plan is going to be measured on whether it
uses Tagamet instead of whatever.
SENIOR ADMINISTRATION OFFICIAL: No, we're focusing on the
outcomes associated with particular episodes of care and whether
or not they meet the expected outcome associated with that care,
not on whether they have followed a specific formula for
delivering the care. The focus will be on the outcomes. I think
the example that was used is one where the care is felt to be
appropriate at this point in our understanding if they get a
certain kind of care. And that falls under that category of
another group of measures that we mentioned, the appropriateness
measures.
Q What are you going to do people? Are you going to
bring them in and educate them to all these words like core and
episode and all these things? And how are you going to get
people to go along with this?
SENIOR ADMINISTRATION OFFICIAL: Well, the plans will have
the option and the flexibility to do that in a way that they feel
is most appropriate for their population. So in some cases it
may be bringing them in and in others their may need to be other
mechanisms.
Q Suppose you have a state that is large, very large and
has a Hispanics in the South and blacks in the East and something
else in the West and all that are varied, what are you going to
do then?
SENIOR ADMINISTRATION OFFICIAL: We have -- one of the
things that the state will have to do is present a plan for how
they will accomplish that in their state. I think that the
intent here is to put the people that are right where the rubber
hits the road in control and let them develop the best mechanism
for doing that -- not to prescribe from Washington how it will be
done.
Q How long an open season do you envision every year?
And how long before that open season do you expect to get this
information out in order for consumers?
SENIOR ADMINISTRATION OFFICIAL: I think that it's --that's
a detail that hasn't, in terms of the length of the open season,
that I don't think we are able to comment on. I just don't think
it's been worked out yet.
Q But it's an annual process?
SENIOR ADMINISTRATION OFFICIAL: Yes, it will be an annual
process.
Q You've described an apparatus here that includes
national surveys, a large educational effort, a large survey
effort in an attempt to grade different health alliances. What
is the price tag attached to this?
SENIOR ADMINISTRATION OFFICIAL: We think that the price is
going to be similar to the current costs.
Q The costs of what?
SENIOR ADMINISTRATION OFFICIAL: Well, the enormous amount
of money currently going into a variety of quality assurance
measurement and reporting activities. The exact numbers are hard
to predict until we have much clearer definition of what the
measures will be.
Q What's the current number of cost?
Q -- being paid by health insurance companies and spread
throughout the private sector. You're talking about something
the federal government will foot the bill for and, therefore, it
would make sense that you come up with the number.
SENIOR ADMINISTRATION OFFICIAL: The federal government is
not going to foot the bill for the whole thing. Remember, one of
the important parts of this is that everyone involved has a
component for which they are responsible.
Q That's going to be built into the premium for every
employer just as they talked about for regional health centers
and that will be part of the cost of this will be built into the
premium that employers will be paying?
SENIOR ADMINISTRATION OFFICIAL: That will be part of the
cost of providing care under the new system, yes.
Q One of the criticism of this plan as a whole is that
it's sort of a Rube Goldberg contraption with pieces coming from
all directions. Do you think a 50 point report card that gives
no bottom line adds to that feeling, or subtracts?
SENIOR ADMINISTRATION OFFICIAL: I think that the report
card is going to be used by alliances and it's going to be used
by employers and it's going to be used people like consumer check
book, to assemble specific guidance for people. And I think that
that will reduce the confusion. I think if people had to work
out balancing all 50 items, yes, but they'll get that help.
Q Do you have any evidence that report cards like this
have been used to an advantage of consumers?
SENIOR ADMINISTRATION OFFICIAL: It's very clear they can be
used by employers to select plans they want to work with.
SENIOR ADMINISTRATION OFFICIAL: And I think if you look at
many plans right now are using this kind of a mechanism to
explain their performance on quality to their consumers.
Q Can you give us a couple of examples?
SENIOR ADMINISTRATION OFFICIAL: United Health Care came out
with a report card earlier this year.
Q You mentioned that there would be some information
about doctors, but then you passed over that. Can you get us a
little bit more information about what will we know about our
individual doctor?
SENIOR ADMINISTRATION OFFICIAL: It's going to depend on how
many services the doctor provides which come under one of these
measures. If it's two, three, four, five services you're just
not going to be able to say anything valid about that doctor.
Q But most doctors do more than that.
SENIOR ADMINISTRATION OFFICIAL: They do, but we have a
problem of -- for example, if you're doing a consumer survey you
have maybe a few hundred consumers in each plan. That may not
survey enough consumers of any one physician in that plan to
allow you to say anything valid about the individual physician.
Q Will they get a report on consumer satisfaction with a
doctor, or how many procedures he did that -- in other words, if
he's a surgeon, are we going to get any kind of a scorecard on
the outcomes of surgeries or anything like that -- naming names?
SENIOR ADMINISTRATION OFFICIAL: I think, as my colleague
said, the key is for the report that will be distributed to
everyone, the standard will be is it a statistically valid
measure for an individual physician or provider. Now, that's not
to say that within a particular plan or alliance they may not
choose to look at that kind of information as a way of improving
their quality and trying to identify areas within their plan that
they need to do better. That's for the individual plans and
alliances to determine. But as far as the kinds of material in
the whole report, it's got to be statistically valid.
Q Is the cesarian rate for an obstetrician considered a
statistic --
SENIOR ADMINISTRATION OFFICIAL: Again, it will depend on
the number within that plan. There has to be enough so that the
number has real meaning and you can put confidence on the number.
SENIOR ADMINISTRATION OFFICIAL: It is the kind of thing
that you would be likely to get valid and important numbers from.
Q But they are going to be given out for individual
doctors, is that correct?
SENIOR ADMINISTRATION OFFICIAL: If you can get a
statistically valid sample, not if it's onesy-twosies.
Q You're implying that that's not possible. Can you say
yes or no, it's not going to happen?
SENIOR ADMINISTRATION OFFICIAL: Well, I've said that I
think it would happen, for example, for caesarian rates. I think
it would be likely to happen for immunization rates. My guess is
it would be much less likely to happen for, say, treatment after
a heart attack or a stroke because the numbers get smaller. We
really would have to go over the measures one at a time to answer
your question.
Q Some doctor's names will be reported in the report
cards?
SENIOR ADMINISTRATION OFFICIAL: That is the plan.
Q You said you didn't know the answer, but your colleague
might. Is the information in the physicians data bank going to
be made public?
SENIOR ADMINISTRATION OFFICIAL: I don't think we can --
SENIOR ADMINISTRATION OFFICIAL: We truly don't know the
answer to that question.
Q If you are really interested in getting together any
kind of information at all, why are you so detached from the
practitioner data bank, which has already collected a lot of
information on things that consumers would really want to know
about their physician: How many times have they been sued? Have
they been denied hospital admitting privileges and why? Why is
that information not being coordinated directly and why won't it
be included in the report card?
SENIOR ADMINISTRATION OFFICIAL: Because we're trying to
focus on performance measures that are a valid sample and
describe how the plan is doing for its enrollees. And to try to
go after the traditional bad apple theory, that I know whether a
plan is good by whether a few of its docs have been sued, we
think, and I think general approach to quality not only in health
care, but in industries, says that's not the way to do it.
SENIOR ADMINISTRATION OFFICIAL:
If I could just make one other comment related to that. I think
that the other part to consider here is that we want this to be
usable. This needs to be something that consumers can really get
their arms around. And if you're putting out at a state level a
telephone book of all the information that one could accumulate
without some way of interpreting that information and really
making it usable we haven't really accomplished what we want to
do which is to give that information.
Q On that point, though, how is this information going to
be useful to a person who has a catastrophic condition like
cancer or a heart condition? How are they going to judge that
they are getting the best care for their particular situation
with what you're contemplating here?
SENIOR ADMINISTRATION OFFICIAL: Well, I think that if there
is a measure related specifically to that, that will be a very
good gage.
Q And what if there's not?
SENIOR ADMINISTRATION OFFICIAL: If there's not, then I
think that one of the things that this will do is advance us
towards a system that's better than what we have now. If you
think about how --
Q How would that affect a person who is immediately stuck
with a disease and they have to decide whether or not their
health care provider is giving them the best health care for that
disease or if they should go someplace else that might have
something better to meet their particular need?
SENIOR ADMINISTRATION OFFICIAL: As I said, this kind of a
report can't cover everything. I just can't without putting out
something that's so massive that it's not interpretable. But I
think what it will do through the specific measures themselves
and more importantly through the kind of educational efforts that
allow consumers to understand the questions to ask is that it
will empower them to know what kinds of questions to ask in their
particular situation to get answers to whether that's the best
care for them and the best provider or best doctor. The intent
is to empower the consumer to use the information better. And
some of that has got to be individual.
Q Do you have such measures now or do you need research
to develop these measures?
SENIOR ADMINISTRATION OFFICIAL: Many of the measures
already exist. As we mentioned earlier, there are plans that are
already using measures like this. But as my colleague pointed
out, this is not static. It will change from year to year. It's
going to need to advance as the understanding of calculating
these measures improves. And most importantly, it's got to
change with medicine. Medicine has new technologies every day
that need to be incorporated into these measures.
Q But aren't you going to have to phase these in
inevitably? So they're not necessarily going to be in place in
1997?
SENIOR ADMINISTRATION OFFICIAL: There are measures today
that plans are using that we can adopt, but they will need to be
--
Q All 50 --
SENIOR ADMINISTRATION OFFICIAL: There are probably many
more than 50 measures that are being used out there. What we
need to do is select the best ones that meet the objectives that
we talked about.
SENIOR ADMINISTRATION OFFICIAL: But the question was will
they have to be phased in, and the answer is yes, as we move to
more sophisticated and more precise measures over time. We could
measure tomorrow, probably, mammography rates, vaginal birth
after cesarian section rates, immunization rates. It's going to
be much further downstream that we'll be able to make precise
statements about certain kinds of acute care.
Q Are there ethics or lobbying rules governing those who
prepare the report cards to ensure that they're not --
SENIOR ADMINISTRATION OFFICIAL: The national board is
subject to a series of very clear conflict of interest
restrictions as to who can serve and what their interests can be,
and they're the ones who make the decisions.
Q But I meant actually for the -- do those rules --do
you know how far down the food chain they apply to individuals?
SENIOR ADMINISTRATION OFFICIAL: They apply to me.
Q Was there any consideration given to requiring each
alliance to have an ombudsman that could answer the kinds of
questions that this lady was just asking about?
SENIOR ADMINISTRATION OFFICIAL: It's not only a considered,
it's required. And there's a structure within which a state can
add to the structure a check-off so that members of the group can
say, "I want a dollar or two dollars of my premium to go toward
funding the ombudsman program for this alliance."
Q So a consumer can call this ombudsman's office and say,
based on these report cards, here's my situation; which plan do
you think I should pick this year and get some advice -- perhaps
not final "pick Plan C," but some guidance so they don't have to
look through these 50 different --
SENIOR ADMINISTRATION OFFICIAL: And education is an
alliance responsibility.
Q On this quality initiative, are there any plans to
educate the doctors on the latest -- the state of the art?
Because many doctors, frankly, are often way behind.
SENIOR ADMINISTRATION OFFICIAL: One of the things that will
underpin the quality measures is a dissemination effort on the
assessment of technologies, on clinical practice guidelines or
practice parameters, as they're called by some, and an effort to
develop a research agenda that speaks to the unanswered questions
--that is, what works and what doesn't work. So that all of
those mechanisms and actually one other increased effort to
develop new information on prevention will underpin the kind of
information that doctors will use to make their decisions.
Q How does your information get out to the doctors? Who
promulgates this information? Is this the national board?
SENIOR ADMINISTRATION OFFICIAL: There will be a variety of
mechanisms, as there are now. One of the functions of the
national board will disseminate the information through a variety
of technical assistance programs and perhaps clearinghouses and
the like.
Q Did you know there's a dispute between nurses and
physicians over the scope of practice? And can you tell us
whether the plan envisions a broadened role for advanced trained
nurses in taking over more of the primary care responsibilities
and doing more of the things that doctors do now all of the
country?
SENIOR ADMINISTRATION OFFICIAL: The plan envisions
maintaining maximum state flexibility over what is traditionally
a state determination.
Q You said education is the responsibility of each
alliance. Do you envision that the alliances will collect and
digest these reports and make recommendations to consumers, or
just act as an agent and deliver the report cards? Will they
make recommendations as to which plan they think is best based on
their reading of the report cards?
SENIOR ADMINISTRATION OFFICIAL: No, I think that they won't
necessarily make recommendations, but they will be required to
consider that quality information in their negotiations with a
particular plan so that if a plan, for example, is not performing
well on a certain measure, they will have the authority and
obligation to provide some incentives for that plan to get better
along that measure. But they are not charged with providing a
specific recommendation to the consumers in their alliance.
Q The draft plan talks about giving everyone a new
number, perhaps, or using the Social Security number. I'm
wondering why would someone need a new number and why --
SENIOR ADMINISTRATION OFFICIAL: I think that's an issue
that really is going to be dealt with under the simplification
and information systems briefing, and so maybe I'll just let you
-- we'll give you more details at that point.
Q Is that necessary to collect all this information, to
have an identifier --
SENIOR ADMINISTRATION OFFICIAL: There needs to be a number.
It needs to be a unique number. And there are some reasons that
you might not want it to be a number that is easily linkable to
other sources of information, and that's really why the Social
Security number is being discussed and other numbers are also
being discussed.
Q You might give everyone a new number in the whole
country?
Q My question is for you. There was a press conference
today with this new Coalition for Quality Health Care. And the
thrust of it was that most people would rather have an
independent monitoring board provide the assessment of quality
and they are concerned that if either the plans or the alliances
provide this information it will be less useful and perhaps less
accurate. You said that people can count on the fact that there
will be more quality. Can you respond to these concerns that
were raised today?
SENIOR ADMINISTRATION OFFICIAL: Actually, my colleague and
I were discussing that right on the way over, so if you don't
mind, I'd like to bounce that one back to him.
SENIOR ADMINISTRATION OFFICIAL: There clearly is a need for
a measure of independence. The National Quality Advisory
Committee, which is the national board's committee for doing
this, will be responsible. They are quite independent of plans
and alliances. They will disseminate the information. It will
also be disseminated by states and by alliances, so that the
independence really is there, I think. There will be a lot of
work with the details of how that independence works when it
comes to writing regulations, I'm certain.
Q I'm a little confused, because I thought that the
alliances were going to provide this information that they were
fed by the plans. Now you're saying that there's a national
board that's going to be --
SENIOR ADMINISTRATION OFFICIAL: The information goes from
the plans to regional data centers. The regional data centers
are accessed by the national board, by alliances and by states
with the data really very heavily protected from raids. And they
all are in a position to disseminate various forms of the data.
So you don't have to worry about the alliance pursuing its own
agenda and only disseminating the data it feels like
disseminating because some of it's embarrassing to it; that's not
something they can do.
Q Who will provide the 50-point report card, the
alliance?
SENIOR ADMINISTRATION OFFICIAL: The alliance will develop
the report card under a format developed by the national board.
Q What's key is, it's a format and a formula. There are
a lot of different ways that you can calculate these measures,
some of which may be a little bit more favorable than another.
And that's why, I think, the earlier meeting today was
emphasizing independence and why, under the Health Security Act,
the national board, through the committee, will decide what
measures, how they'll be calculated, what format they'll be
reported in. So, in essence, there is independence.
Q I just wondered if there were some -- there have been
some allegations that the existing insurance system short-changes
women in terms of health care in not providing a lot of
preventive health care. In developing your measures, have you in
any way tried to include things that might monitor for that or
somehow correct for that?
SENIOR ADMINISTRATION OFFICIAL: First of all, the measures
have not been defined. That will be defined by the national
advisory committee when it's appointed by the President. The
kinds of measures that are out there that people are considering
and using now definitely include preventive strategies and
measures.
Moreover, since one of the major intentions of this act is
to improve preventive services, they will absolutely be included
as some of the measures that will be in the report card.
Q Following on your earlier answer, who will pay for the
regional data centers? Is that something new that the federal
government has to develop and vote for?
SENIOR ADMINISTRATION OFFICIAL: Yes, it is. The bill is
actually relatively modest. Because all these people do is bring
the data in and put them on disk packs and things.
Q How much is the bill?
SENIOR ADMINISTRATION OFFICIAL: I don't have that number.
Q Is that included in the cost of the plan?
SENIOR ADMINISTRATION OFFICIAL: The cost of each plan --
it's considered a cost of running the system, and so it's
included in the overall administrative costs.
SENIOR ADMINISTRATION OFFICIAL: There is an amount, if
you'll refer to the back pages of your bootleg plan copies, you
possibly will find there a line that says start-up costs. And I
would imagine this would be lumped in under start-up costs.
Q Since you've made several references to the bootleg
copies of this thing and have directed reporters to specific
items in it, that being the case and since you all are doing a
series of briefings this week, why don't you simply hand out the
plan --
SENIOR ADMINISTRATION OFFICIAL: I don't know. (Laughter.)
Q -- to those of us who haven't found ourselves a good
bootlegger yet?
SENIOR ADMINISTRATION OFFICIAL: I don't know. Well, the
Bureau of National Affairs has published it now so it should be
on the newsstands by now.
What I have been saying -- those of you who have heard this
speech before forgive me -- about the draft plan that's out
there, first of all, there's a great deal of it. I wouldn't want
to characterize how many points in it have already changed. So
that's probably the most important reason why we're not releasing
it now. It's not totally and completely accurately the plan.
But as you have found, it can be an exercise in frustration
because it's a tool for internal use. There are huge chunks of,
as I call it, connective tissue, information that you kind of
need to fill in the blanks in order to envision how the system
works that aren't in there because they weren't really points of
contention during the months of debate and discussion we've been
having. The people we were sharing this with in the reading
rooms are people that are more up on that; they're looking for
specific items that are reflected in there.
So we are hurriedly preparing -- not hurriedly. We are
energetically preparing the kind of materials -- and we have had
a rather impressive materials plan for quite some time -- of the
kinds of materials that are intended for someone coming to this
basically more or less cold can better get their arms around.
Q So in the actual plan would the connective tissue be a
lot longer than the 246 pages you have?
SENIOR ADMINISTRATION OFFICIAL: I don't know. You'll
notice a lot of those 246 pages have a lot of white space on them
for purposes of subbing things in and out. In point of fact, I
saw the Bureau of National Affairs' copy the other day and they
had I think shrunk it down to four pages per page but the whole
thing was the size of an average magazine.
Q Will that stuff come out before the President's speech?
SENIOR ADMINISTRATION OFFICIAL: My understanding is the
plan, that it will be released on the 22nd. But again, the
embargo schedules and thus and such are all very much up in the
air.
Q Is there still a possibility that the white paper
might come out the day after?
SENIOR ADMINISTRATION OFFICIAL: There is a possibility of
that. Scheduling right now is a very fluid thing.
Q For planning purposes can you give us some sense of
what kind of travel schedule you have, the cabinet people and so
on, right after the speech?
SENIOR ADMINISTRATION OFFICIAL: I wish I could. And just
as a ground rule set by the war room commanders, mostly to avoid
confusion, both ours and yours, was that all the questions about
a public schedule, especially the principles public schedule,
have to be directed to 2100. They have got a much more accurate
read on what current schedules look like and will be -- our phone
people will eventually be referring you to their -- two phone
calls are more frustrating than one but we've got to do something
to manage what really is, as you can I hope appreciate, is an
overwhelming flow of request for information.
Q Also, given the importance of the speech, are you
going to try to have advanced text?
SENIOR ADMINISTRATION OFFICIAL: No comment.
END5:06 P.M. EDT