Bill Clinton photo

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?


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.


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?


Q: It will not be open?


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 --



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.


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?


Q: Why not?


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?


Q: Yes.


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?


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.


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?


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: 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.


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?


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?


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 --


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?


END5:06 P.M. EDT

William J. Clinton, Background Briefing by Senior Administration Officials Online by Gerhard Peters and John T. Woolley, The American Presidency Project

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