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Tuesday, April 12, 2005

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Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, Maryland
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8:00 a.m. - 3:00 p.m.


BRENT C. JAMES, Member (present telephonically)


MICHAEL O'GRADY, Assistant Secretary for Planning and Evaluation, Department of Health and Human Services

LARRY PATTON, Senior Adviser to the Administrator, Agency for Healthcare Research and Quality
ANDY ROCK, Department of Health and Human Services

CAROLINE TAPLIN, Department of Health and Human Services

KENNETH COHEN, Department of Health and Human Services


Approach to Our Task 4

Break 125

Approach to Our Task (cont.) 128

Lunch 204

Legal Requirements and Logistics 206

Other Working Group Matters 237


8:09 a.m.

CHAIRMAN JOHNSON: Good morning, everybody. Thank you for being here on time.

We've been waiting to see if Brent James would join us at 8:00 o'clock our time which is 6:00 o'clock his. But he hasn't called in yet. So we will begin, and proceed without Brent until he gets here. It would be our hope that we would be able to ask him to introduce himself, like we did yesterday, hear some of his thoughts on issues and so forth, and maybe even hear some of his thoughts on ideas that have been raised.

And then what we would do is get into the agenda items for our discussion today.

At the end of the day one of the things we'll talk about is to what extent would we want to use electronic communication such as this for our meetings. In other words, I suppose there are a variety of ways you could do this.

You could have television where you have the slides up on the screen and the conference call. Another is to have what I'll call videocasting, but that's the wrong term. But it's the idea of the picture that's on the screen. The camera is there. The camera takes a picture of us. He's got a camera at the other end, or she has a camera at the other end that takes a picture of the other folks. And it's kind of like a live TV program back and forth.

But we'd like you to give some thought to the advantages and disadvantages of that, and hear some of your thoughts at the end of the day regarding that.

And then what Catherine and I would like to do is go back with some of those who are going to serve as staff members to evaluate your comments along with cost items, and maybe some experience with other similar commissions to see whether or not we would want to do that.

If we were all dispersed -- let's say we had three or four of you who were dispersed and call in by conference call, that's going to have a significantly different impact on our group discussion than with all 14 of us, 15 of us, around the table.

So let's think about the advantages; let's think about the disadvantages. We'll come back and talk about that later.

I would just like to thank you, to start the day, I'd like to thank you for your participation yesterday. I thought everybody contributed and had good content for all of us to hear.

So we encourage and invite you to continue to participate in the same respect.

This is a personal thing that I am going to share with you, and it's a request of you. We know that we are coming from different backgrounds � geographically, vocationally, and many other ways as well. So there is a likelihood that we won't communicate as effectively as would be desirable.

And I'll be used to a certain kind of communications strategy and methodology of operation, and you'll be used to maybe a different one.

So here is my request of you: when I irritate you as the chair, and that's probably going to happen, not intentionally, but when it does or if it does, come and talk to me, okay? Don't hold it in.

Confront me. Really. I'm very serious about that.

I have found with others, including my kids, that when I hear their perspective it changes my mindset a little bit. So oftentimes we won't have a chance in all of these meetings to communicate as fully as might be desirable.

So I'm looking at Aaron, and I'm going to say, Aaron, if I irritate you, you come back and you confront me and share with me your perspective.

And Chris, the same thing.

MR. O'GRADY: But doesn't that leave us open, that you'll come to us and confront us?

CHAIRMAN JOHNSON: I will. I will. And that's not a threat, that's a promise.

VICE CHAIR McLAUGHLIN: In fact, Mike, there's something I've been wanting to tell you.

MR. O'GRADY: I'm getting the message loud and clear.


CHAIRMAN JOHNSON: Approach me in private. And most often I will at least understand the other person's perspective.

And I'd really like to just lay it out on the table, and set the record straight. How you work with others, I'm not suggesting how you do that,

although I would encourage your consideration of that approach as well.

I picked on Aaron not because we have a difference, because I think we have a good dialogue, but just because I was looking at him at the time.

DR. SHIRLEY: We've had a confrontation already.

CHAIRMAN JOHNSON: Okay. Before we proceed into the discussion, Ken, Caroline and Catherine spent some time last night while we were eating putting some consolidation slides. Was Andy eating or was he with you?

VICE CHAIR McLAUGHLIN: Andy? No, he just ate.


CHAIRMAN JOHNSON: Okay. Well, thank you, Caroline and Ken and Catherine.

What we're going to do is, we'll just review that and make sure that we have heard what you said. And maybe, Catherine, you can kind of guide some of our discussion.

VICE CHAIR McLAUGHLIN: Sure. Yes. Actually, Caroline and Ken did most of this, and what they were trying to do was group the issues. And partly it's because, as we went, as you can see up on the wall, there was some reoccurrence of some themes that kept coming up, just phrased slightly differently. And we decided we needed to have some better way to group them.

In addition we wanted to look at what the mandate was--

CHAIRMAN JOHNSON: Hang on. Let me interrupt. Some of you are starting to take some notes.

This will be available to you. So we're going to provide this to you so you don't need to take notes. But if you want to take notes you're welcome to. I'm sorry.

VICE CHAIR McLAUGHLIN: That's all right.

We also wanted to check the list that was raised yesterday with the lists that were in the mandate which we went over yesterday morning for both the hearings, the subjects that we're required to raise at the hearings, and the items that we're required to include in the report, and say, okay, is

there something missing? Is there a mismatch? In the statute itself there is a division between roughly cost, quality and access. So we thought, all right, let's see how that fits. And that's where Caroline and Ken went through all of the issues and put most of them within that category.

Now as you already know from my comment yesterday afternoon -- and I suspect many of you agree with me -- many of these issues and particularly the initiatives actually cross-cut all of those. So in some ways this is an artificial separation, but it was used to just get a first start on how to group it.

So what follows is their grouping of issues under cost, quality and access. And then there were the leftovers, sort of those overarching big ideas that people brought up that are going to be included.

So the first one is the cost issues. And it's a long list, there are a lot of problems, but these are the different issues that the group brought up under what we said was cost, that cost is a barrier to getting it as well as cost is a problem for the payer and state budgets, et cetera. So these were the different things about the cost issues and how money matters in the health care problem.

Were we going to go over individual ones, Randy?

CHAIRMAN JOHNSON: No, but just take a look at that. And I can see that we've missed a couple already, in my mind at least. Or I'm just not recognizing them.

One of the issues that we have is doctors not being paid sufficiently under Medicare, at least that's a perception, and they're leaving the system.

MR. O'GRADY: I don't think the data necessarily backs that up. MS. TAPLIN: We had that issue under “Access.”

VICE CHAIR McLAUGHLIN: That's a good example. We had that as “Access” because of physicians potentially not being there for a particular group. Why don't we go through those three slides?

CHAIRMAN JOHNSON: And my other point would be, as you look at this when you go home, if you see some things, or you think when you get home, we didn't include this, shoot that back to Ken. And he'll consolidate your input and share with Catherine and myself initially, and then we'll share with the rest of the group.

MR. O'GRADY: But, Catherine, when we think about these, it shouldn't be because it appears on one list, that means that it's -- it's just got to appear at least one.

VICE CHAIR McLAUGHLIN: Exactly. Because we have to start this mapping strategy. And so if you go to “Access” you'll see, that's a long list. It's crowded on that slide. That’s where you see, Randy, we said payment issues, for example, are inadequate. Or it's also the paperwork that was talked about yesterday, that different payers are having problems with their providers.

Were you going to say something?

CHAIRMAN JOHNSON: I was when you're done.

VICE CHAIR McLAUGHLIN: I was going to go to the quality side.

CHAIRMAN JOHNSON: We've added one line here that wasn't mentioned yesterday, and that's the very bottom one where it says availability of risk- bearing organizations. We can provide all sorts of preferential tax treatment, but if there is no place from which an individual or a small company can buy coverage, it doesn't make much difference.

And so maybe that was captured some place else, but in terms of access we added that one as well.

Just an example of something that came to mind following our meeting that we hadn't included yesterday.

MS. HUGHES: Randy, under “Availability of Providers” you have physicians and nurses. Well, what about mental health providers?

CHAIRMAN JOHNSON: Mental health providers?

MS. HUGHES: Yes, because they fall under a different category than nurses and physicians, and we all spoke about that lack of mental health access.

CHAIRMAN JOHNSON: Okay. Is that the availability of the providers themselves? We don't have enough of them, or we don't have access to them?

MS. HUGHES: Well, I know in Los Angeles--

CHAIRMAN JOHNSON: Or coverage for them?

MR. FRANK: Well, it's geography, too.

MS. HUGHES: I think that it's probably all of those. I know that there is a lack of mental health providers where my clinic is. It's 97,486 to one psychiatrist. So it is an access issue, but it also is an issue of language, culture. So there is also a lack of appropriate --

VICE CHAIR McLAUGHLIN: Oh, good, now we have the printouts. Now we don't have to toggle back and forth from slides, because we have the printouts.

CHAIRMAN JOHNSON: And, Ken, do you have that? Thank you.


DR. SHIRLEY: There is also the classifications of providers such as physician assistants and nurse practitioners. When you say "physician," you've missed another group of primary care providers.

MR. FRANK: Why don't you just say "other providers"?

VICE CHAIR McLAUGHLIN: Exactly. Remember, this was the list from things that were raised yesterday as opposed to what we know should be. So absolutely. Actually, in my mind it should be institutional as well as individual providers.

MS. STEHR: Yes. I was going to add the homecare workers. Because you can give you all the services you want, but if you can't find a provider you're totally out of it anyway.

VICE CHAIR McLAUGHLIN: You'll see later when we talk about the hearings and stuff, we say institutional, individual providers. And we say “paid and non-paid caregivers,” and you know, so absolutely.

And what this means is that the availability of providers has to also be broadly defined here.

MR. O'GRADY: Well, can any of us think of an area where there is an oversupply of providers?

VICE CHAIR McLAUGHLIN: Oh, yes, of course.

MR. O'GRADY: What, specialists in certain metro areas?


MR. O'GRADY: Psychoanalysts in Boston.


MR. O'GRADY: Or in Washington, actually.

Okay. Get that big bus, they're going to LA; right? I mean there certainly is a big question here about how much money is going into the system, how you do see this sort of lack of providers, across a spectrum of a number of different areas.

And there may not be an economic answer. I used to study the lack of nurses in rural areas. You know, somebody's husband gets transferred and all of a sudden that county has a lack of nurses.

I mean there are all kinds of other things going on. But I also think it's a very broad base -- institutional, individual across the base, physicians, other sorts of service workers. It's really across the base.


MR. HANSEN: I had a question for Mike, and it goes to this, whether doctors are leaving Medicare. My sense was that that's happening. You made reference yesterday to the data, and I was just kind of curious how current that data is.

MR. O'GRADY: It was the last time that we had a national cut in physician payment, which would have been '02 maybe, where it actually went down.

Congress at that point had MedPAC, the Medicare Payment Advisory Commission, do a fairly good systematic, scientific survey of providers. The basic question was: Given Medicare's payment rates, are you no longer taking Medicare patients?

What changed was that there was a number of physicians in the survey who said, I'm not going to just default to say I'll take them. I'm going to think about it a little bit. So it certainly will encourage me to take them more.

They had options like, definitely take them, no question; take them but after some consideration; neutral; and then less likely to take them; no I'm not taking any more.

So they found between those two top categories, is it just a slam dunk, definitely, if they walk in the door and I've got room I'll take them, versus I want to think about it a little bit. Are they the parents of some of my patients or some of those other things.

So more docs definitely wanted to think about it, but in terms of the bottom line of did people not get taken, they didn't really find anything significant, that I remember, out of that data.

CHAIRMAN JOHNSON: I don't think we have the time today to discuss whether or not there is a shortage of Medicare docs. But the fact that we have a question here just invites two things.

Number one, we should look at the data.

And also, look at this subject not only today but for the future. My understanding, based on what I've read, is that there are a lot of nurses who are in the 50 to 65 age range, and if those all are thinking about, or most of them are thinking about retirement over the next 5 to 10 years, that might have an impact on us as well.

So we need to look at probably current and future, if the data shows that for a variety of physicians.

And, Caroline, as you're listening to some of this, as you're beginning to think of data matters and so forth, if you would kind of join us all in thinking creatively about what we can get at and so forth.

Okay. Aaron and then Rosie.

DR. SHIRLEY: The question doesn't capture those providers who are no longer taking new Medicare.

The way the question is phrased doesn't capture those providers who say, all of my current Medicare patients I'll continue to serve, but I will serve no new ones.

Then that question doesn't capture that.

CHAIRMAN JOHNSON: Okay. That's a distinction. And, Ken, I'm sure you've captured that; right?

MR. O'GRADY: Actually, that was exactly the questioned they asked. It was new people. It wasn't anybody in their current list. It was all, will you take new ones.

CHAIRMAN JOHNSON: Okay. Rosie and then Joe and then Montye.

MS. PEREZ: Mine is just a little different as far as the availability of providers, linking them to the academic institutions' capacity to, you know, accept nurses. I know in Houston they're turning them away because the university systems don't have the capacity.

You know, there are a thousand people that want to be nurses but only a hundred slots because of a lack of faculty, maybe money. So I'm wondering, we didn't bring it up yesterday, so I'm wondering as far as access issues or cost, if that is a consideration.

If we're not training people to fill the gap as nurses are retiring, then our nursing shortage is going to get even worse.

CHAIRMAN JOHNSON: Okay. We've heard your comments. We're not going to answer your questions because of time constraints. But what you're doing is, you're telling us, we need to try to get at some of that.

Okay, Joe.

MR. HANSEN: Well, this just goes to the private sector. I think this is just so tiny, but doctors, some doctors are out of the insurance system too, and just doing an annual fee, and then they don't do any paperwork. But I assume that's just a very tiny piece right now. But it does limit access.

MS. CONLAN: For me in my county there are lots of providers. Many of them are not accessible to me because I have to have them accept both Medicare and Medicaid. And so while the majority of them, because they primarily serve seniors accept Medicare, they don't accept Medicaid, and then that 20 percent makes it difficult for me.

But then there is the issue, too, of providers now not accepting Medicare assignment. So they want the patient to pay out of pocket in advance for this additional fee.

Still it's set; there is a cap by Medicare. But, you know, it's just more cost for someone like me.

CHAIRMAN JOHNSON: What I'm hearing you say is that when we did the Medicare Modernization Act there was a lot of play on seamless coverage, of people covered by both programs. And what you're saying is it's not as seamless as it was intended to be.

MS. CONLAN: Exactly. There are very few Medicaid providers in my country. Those that are serving Medicaid patients supposedly do it out of the goodness of their heart.

And I was telling Dr. Shirley about the treatment that's received, and it makes it so it's, you know, given begrudgingly. And then Medicaid patients feel very uncomfortable in seeking that coverage.

CHAIRMAN JOHNSON: Okay. Do you want to move on?

VICE CHAIR McLAUGHLIN: The quality issues. This is what we talked about yesterday, although I know that there are a lot more. And I think it was reflective of how the conversation proceeded yesterday, and talking about personal reasons for being involved, that we didn't get into the quality issues beyond comments about the need for the patient to be better educated about choices, and the need for communication, and the fact that sometimes the system doesn't always work.


MR. FRANK: I think Randy made the point that we don't pay people for doing a good job. So it seems to me that at least we can say "absence of incentives to promote quality."

MR. O'GRADY: I assume that order doesn't imply -- because we talked a lot about prevention.

VICE CHAIR McLAUGHLIN: No. And it doesn't mean they're equal either. That tended to be the real focus yesterday.

MR. O'GRADY: There are some other things like personal responsibility and some of that stuff that we talked about. Okay, coming up.

VICE CHAIR McLAUGHLIN: You have your little handout there in case you want to have a preview.

MR. O'GRADY: Well, I like to stick with what you're --

VICE CHAIR McLAUGHLIN: You don't like to read the last page of a book?

MS. TAPLIN: One of the things embedded in holistic health care is the idea that mental health and physical health aren't separate, but they're one and the same thing.

VICE CHAIR McLAUGHLIN: Yes. We need to add something about the incentive structure.

And then the overarching data, all right, this whole issue of, it was brought up, not only for communities, if you're going to have a community level you can't get the data at that level. But also Randy brought this up about data on performance. So it's a very overarching theme that kept coming up about data needs.

And then there is personal responsibility, Mike, right there for you. And there were two sides of it. One was financial, but also was taking charge of personal health care, and Montye's comment about dieting and nutrition and exercising, and Pat's about her mother.

Caroline and Ken put both of those in there for personal responsibility.

And then the link between economic cycle and Medicaid spending was our focus, but it can go much beyond that. It's for any kind of spending.

In Michigan, we talked about the stress on the state budget. But Randy brought up too the auto industry as so dominant in Michigan.

So they're also having to back out on retiree health benefits and other kinds of costs because of the private economy problems.

So I think we may want to make it that broader. And then just the lack of an integrated health care system, that was brought up.

So this is what we did with the contributions that were made yesterday. And we're welcoming further. Richard and Dotty?

MR. FRANK: You want to go first?

MS. BAZOS: Sure. All right. Fine. would just expand the first one, "need data for decision-making with policymakers." But also providers. I mean I just don't want to limit it to policymakers. So if we could make that a little broader.

MR. O'GRADY: Can we add consumers, too? Because part of that is personal responsibility --

MS. BAZOS: Sure. So that's just a point. Thank you.

MR. FRANK: My comment is really about a way of starting to organize ourselves. I think the cost, quality and access certainly is a reasonable traditional way of doing it. What I was pondering as we left here yesterday was, in a sense, in order to make progress on solving the problem since you guys pushed us very quickly to start thinking that way, it seems to me there is coverage issues. There is the problem of how do we cover people who aren't covered no matter what the system looks like.

And then what do we want the system to look like? And those seem to be like two different directions. And I was just wondering whether we ought to perhaps start organizing our thinking, perhaps along those lines, perhaps along others.

But I was trying to figure out how we going to organize it. Cost, quality and access doesn't help us that much on starting to organize ourselves for a solution.

So the second comment is well, it's actually a suggestion is, it sounds like we could probably use sort of some reading as a group. Because there is just a lot of basic questions of fact that are on the table that keep coming out on the table that we could probably dispense with at home in the privacy of our own dens rather than here in public.

And I was thinking things like the MedPAC report, you know the annual reports.

MR. O'GRADY: You're that guy in class who always asks for homework; right?

MR. FRANK: If it would shorten class, absolutely. But a few of those. The CBO reports, some of the Kaiser Family Foundation fact sheets.

CHAIRMAN JOHNSON: We agree with you. And that's one of the things we contemplated sending out for this meeting even. In fact, we have sent a couple of things to you.

One is --

MR. FRANK: The GAO thing.

CHAIRMAN JOHNSON: -- the GAO thing. And that's got a lot of very important information in it.

These two reports that we've provided for you to take home today are two more.

But we will provide more information to you, and oftentimes, you're provided a big binder three days before the meeting. Come, and bring it with you and have read it all.

I don't know if the commissions do that, but I get a lot of that kind of stuff in my job. And maybe what we can do is help you by providing you information more sporadically, as opposed to everything at one time.

But I think your suggestion is a good one and we'll try to live with that and respond to it.

MS. CONLAN: I brought this. I don't know if it's appropriate to mention it now. I'm a member of a patient registry for MS patients. And quarterly we get these really long surveys that we're asked to fill out, all different kinds of data that we provide on an ongoing basis.

It kind of provides, like, a longitudinal study of our MS, but then other things can be included in the survey.

And then in return we get this quarterly publication. So the reason I brought this particular one is, they pulled out of that database information about coverage or I guess care for veterans using the VA system, veterans not using the VA system, and other MS patients.

And in terms of integrated health care, I was quite envious. I wanted to sign up and go off to Iraq or something so I could be a veteran. Because the array of services that are available according to this article if in fact it proves to be true, I was envious of it in terms of the range of health care providers.

So I don't know if you wanted to make a copy of this.

CHAIRMAN JOHNSON: Okay. Would you leave a copy with Ken?

MS. CONLAN: They are collecting information on MS patients and spinal cord injury patients. And it also includes the collaboration with the paralyzed veterans.

MR. O'GRADY: This brings up an interesting point, and Richard touched on it a little bit.

In terms of at least our first rounds of expanding our knowledge in this area, I would stay with very neutral. I wouldn't go to interest groups.

I wouldn't go to foundations that are particularly associated with one side or another. I'm thinking that we can ask collegially. I mean there are people who do this as their job. I mean this is what, having spent way too much of my career at the Congressional Research Service, that's really what they do. You get your primer on Medicaid, Medicare, and you get the nuts and bolts, how they pay, who's eligible.

And it doesn't waste your time and gets right to the point and gives you the stuff.

Now they only work for Congress. But we could gently ask, as colleague to colleague, could we get some access to some of that sort of stuff. That would be more than enough reading, I think, to keep people busy. But make sure you're dealing with people whose balance and fact checking and all that sort of stuff is their bread and butter.

CHAIRMAN JOHNSON: I have two additional thoughts I'd like to share with you on this slide. And then I'll get to the second one in just a second. I'm going to ask Joe to think about my comments and build on them if you would.

But the first one is related to how we might think for the future. And as I was thinking when I woke up about 2:30 this morning thinking about all of this stuff. And that's an hour earlier than normally I do. So I'm not sure what that says.

But I got to thinking. I think that when we look at this, and this isn't a statement, this is how we have to do it, but I'm just thinking about it, maybe what we need to do is look at these ideas that we have that will deal with the medical system in toto, such things as IT, and such things as information, and so forth, quality initiatives, what brings about improved quality.

And then we're going to have to maybe be a little bit more targeted to specific populations. And I'll just the population that just doesn't have enough money to buy health care insurance. That will be a targeted, I think, group of folks that we might have to think about in a different way than overall population.

And you might want to give some thought to how we might do that as well. That's not to say this is what we have to do, but just an idea for your consideration.

An issue that is not here -- and I'm going to start and if you'd build on my comments or disagree, I'd appreciate it. One of the issues I'm hearing among some of my colleagues is something that's called "legacy costs."

And what's meant by that is, we have some industries that have long-term workers, very significant numbers in the retirement community, compared with others their benefits are richer.

In many cases, there are negotiated benefits. And when those organizations are ones competing with others it's been a real challenge for them.

And, number two, there seems to be a desire by some of those industries to take their benefits obligations and shift those, to the extent they can, to the public.

And so the question is: How do we respond to that? And how will the United States respond to that?

And it's not my intent to answer that question now. It's just to throw that out as an issue that at least a number of us have been facing.

And, Joe, if you would comment on your perspective on that since you're working with represented people.

MR. HANSEN: I could go on for a long time, but I'll be very brief.

Randy absolutely raises a key issue here, and I think one of the main reasons I'm here is two concerns: concern about access and the quality, and keeping the health care system, which I agree with Frank has a lot of great strengths. And for the most part it does very well.

But the economic impact of what's going on in health care is, I also agree with Senator Hatch and Wyden. I think we're going to tip over the edge.

And the legacy costs are having a tremendous impact on companies like General Motors and smaller companies. And they're going to dump them, one way or the other, and that's going to add costs to us as taxpayers.

And what we do about that, and how we do it, and try to do it without having a lot of strife, is going to be a problem.

I don't have an answer. I agree, though, that it is a significant part of the problem. People are living longer, and they're getting more care, and everything that we all know.

So it's something that we have to talk about.

CHAIRMAN JOHNSON: Thank you. First, Therese, thank you, and then Mike.

MS. HUGHES: Two things.

One, I wanted to ask up front is, if you're giving us materials to read, to have them longer than three days ahead of time.

The second thing is I wanted to go back to something that Richard just said. All of the items that have just been raised fit under the umbrella of system design in my mind, as well as coverage.

And if we look those two overarching umbrellas with those ideas in it, then I think that the issues would flow a little easier than not.

Because what I see in the future -- and this is just my opinion -- is that we might get lost on IT, we might get lost on providers, we might get lost on access. And I don't think any of us here wants to do that.

And if we had the umbrella with the dots or the check marks down of ideas, then I think that we might be able to actually come up creating a new system, or changing parts of a system that aren't working, and I think they certainly, you know, support all of the issues raised.

CHAIRMAN JOHNSON: Can we talk with you offline and get some more of your thoughts on that?


CHAIRMAN JOHNSON: I don't want to cut short the conversation, but I think we have a time issue today.

VICE CHAIR McLAUGHLIN: I think Senator Wyden said it took them three months to come up with the title, Health Care that Works for All Americans.

And I know from conversations with him earlier that they very deliberately chose that title to reflect the fact that they want it for all Americans.

And that means this is not just about coverage, but it is also not just about costs of the people who already have coverage.

And so they very much want this focus to be this dual one that Richard has pointed out and now Theresa has followed up on.

And I think all of us have been thinking about it along those lines, and some of us come to the table with a primary interest in the coverage and the 45 million uninsured, and some come with a primary interest in the system that exists and making it more efficient and reducing costs and at the same time guaranteeing high quality.

So it is a tension that is going to occur, and there are different ways to cut this. And we'll come across this again when we talk about how to structure the hearings and how to structure the report.

So that's where we're moving for the rest of the day. Now in some degree we're limited in structure by how the statute is written, but we don't have to blindly follow that structure. We can group them in a different way.

And I think the system-wide changes versus coverage is certainly a logical grouping, and we'll work on that.

CHAIRMAN JOHNSON: One more comment to build on hers before we go to you, Pat, and that is, if we're able -- did we forget you, Mike?


CHAIRMAN JOHNSON: Okay, I apologize.

MR. O'GRADY: I'm so quiet.

CHAIRMAN JOHNSON: If in fact we do the measurement and disclosure and the consumerism and the pay-for- performance, at least some pretty bright people say that we can take 30 percent of our wasted health care dollars out of the system.

And therefore that would help us fund coverage for those who don't have coverage today. And I don't want to lose track of that, because that's where a lot of us are focused.

MS. HUGHES: I understand.

CHAIRMAN JOHNSON: Okay. Pat and then Mike.

MS. MARYLAND: Actually my comment dovetails into what you just stated, a not so subtle hint from Senator Wyden is that we should look at taking the current expenditures in health care, the $1.8 trillion, and figure out whether or not those dollars can be reapportioned in another column such that we can increase coverage and really improve quality.

Are we going to at some point in time really follow through with that? I think that's an excellent suggestion to take a look at.


MS. MARYLAND: I think it's very easy to get lost in some of the specific details associated with the cost, access, quality. And we really don't want to do that.

And I would like to see us take one item, significant in itself, and create a solution. It just makes a lot of sense. It's simple and easy to administer.

And this may be one way to come up with what that idea might be.

MR. O'GRADY: I just wanted to get back to the conversation about legacy and whatnot. I think there are a number of things that we've seen, kind of new developments in that whole area that I think highlight one of the dangers that we have on this group.

I mean to a certain degree the tradeoff that Randy talked about was very true and sort of came down. Now what we saw in the last couple of years was Bethlehem Steel go bankrupt. So all of a sudden now you have folks who had on paper beautiful benefits, and what was that worth to them when the company goes bankrupt, and that was about 10 cents on the dollar.

So you have this thing happening in terms of that area that may parallel what happened in pensions 10 to 15 years ago. Do you want to be really tied to that one company. Do you want more portable 401(k)s, some of that sort of stuff.

But it highlights for me in terms of, as we move through these problems, to a certain degree

there are other people that are working on the next six months or the next year. We need to be what's breaking, what's ahead 10, 15 years out, so that you look at this dynamic you've got.

These costs are going to be here. Whatever the economy is, the demographics, which is what we had on the Fed side, in terms of we look at the demographics of Medicare and Social Security and whatnot, it's coming, there is no doubt about it.

Let’s keep that other perspective on that issue as well as a number of others.

CHAIRMAN JOHNSON: We need to move on. One last comment, and then we'll go to the next slide.

MS. BAZOS: I'll just be quick. I just want to participate in the conversation about how we frame our work going forward. Looking in the long term, which I hope that we would do, I think we really have to at least look at the ideal system first, knowing we're not going to be able to change the whole system, knowing we're not going to throw the baby out with the bathwater.

But if we don't at least agree on a vision for a system, my concern is, we'll just be putting Band-Aids on what doesn't work very well now.

So I just want to have confidence that's not what we're going to do for two years.

CHAIRMAN JOHNSON: Thank you for your comments. We will certainly take that into consideration and listen more to your comments on it.

VICE CHAIR McLAUGHLIN: The next four slides really are, you can take home and have them. It was really just our organization of saying, all right, what is the mapping?

And we felt as though the list that was put into our mandate was worded in such a way that virtually every issue that was brought up yesterday Ken fit into something on there.

And so we didn't feel as though we were going to be left with, oh my gosh, the group is really interested in all these issues that we're not asked to talk about.

So how can we justify additional hearings, et cetera, et cetera? Most of them could fit in.

There were some issues that we were asked to address in the hearings and the report that we did not really talk about very much yesterday, and that's something that we have to be cognizant of as we prepare for the hearings and as we put together the report.

The order of the issues doesn't say anything in terms of how important we think they are, nor does the fact that the list created by either us by the mandate suggests that every item is of equal importance.

So neither the ordering nor relative weights should be inferred by this list. But we did just try to do this mapping for you so that you could see, and we could see, where the focus of the conversation was yesterday versus the focus today where we move forward of, okay, how shall we structure the hearings? Who should come to testify? How should we go about doing the report?

I don't see the purpose of spending a lot of time on this right now, but if anyone has questions, comments.

CHAIRMAN JOHNSON: That's a summary of what we discussed yesterday. So now do we have the slide for today in here, too?

What our intent for the rest of this morning is to go through the hearings first, and just have some initial dialogue on the hearing that we would be thinking of, and then to talk about the report, and some initial thoughts on that.

We'll be discussing some of the logistics that are related to hearings, and some of the topics that we might discuss within the hearings. But we won't get into all of our recommendations. And this is the data, and so forth.

It's more structure that we're going to focus on today, and the same thing for the report.

(Off record voices.)

VICE CHAIR McLAUGHLIN: While we're responding to our technical difficulties -- I guess Brent James hasn't called in yet -- I did want to just remind you a little bit, because this is something that Randy and I and Larry and Ken and Caroline and Andy now have been bouncing back and forth, is that we keep getting confused between the hearings and the community meetings.

And they are different, and they are set up to be different. The hearings really are set up to feed into the report, and the report is to educate the public and to start the dialogue for the community meetings.

So the first things we need to talk about are the hearings and the report. Richard, I know yesterday, last night at dinner, you started asking me a little bit about the community meetings.

Do you want to --

MR. FRANK: I was asking you about the hearings.

VICE CHAIR McLAUGHLIN: Oh, about the hearings.

MR. O'GRADY: So hearings are first?

VICE CHAIR McLAUGHLIN: Hearings are first.

MR. FRANK: My question was: What is the definition of the hearing?


MR. FRANK: And what do we mean by that?

Because the hearings that I've participated in have been ones where you have one congressman and 14 staff behind them --


MR. FRANK: -- and a lot of advocates in the room, and people presenting positions that anybody in the room could have written.

And then there are other things you could do in a hearing. And I was trying to figure out what we really were--

MR. O'GRADY: And is the hearing the one where there was this business about at least one person has to be --

VICE CHAIR McLAUGHLIN: No. That's the community meetings.

MR. O'GRADY: That's the community meetings, okay.

VICE CHAIR McLAUGHLIN: The hearings are supposed to give us information we need to develop the report, all right?

And we can have only one hearing and fulfill the statute. If we feel that one hearing gives us all the information we need to develop the report then the community meetings are the ones where at least one member of the working group has to be at the community meeting and be the leader of the community meeting.

And that is the one where we're supposed to do a lot of these community meetings for diverse populations in terms of urban/rural, West Coast/East Coast, minorities, cultural, rich people, poor people, old people, young people. You know, really have diverse populations at these community meetings all over the country.

And they have to start no later than February 28, 2006. But they could start earlier if we wanted to.

So they really are different.

Yes, Richard.

MR. FRANK: I still want to go back and --

VICE CHAIR McLAUGHLIN: Oh, it's not clearly defined about the hearings.

MR. FRANK: Hearings mean different things. I just want to get on the table what we think we want to try to accomplish in this hearing, and what structure would get us to that end.


MR. FRANK: That was what I was sort of raising.

VICE CHAIR McLAUGHLIN: Well, partly it's looking at the elements of the report is how I started

thinking about it since I was the person asked to take the lead on the reports.

I was thinking, well, given what has to be in the reports, what do I feel is already known out there?

You know the IOM reports, and the Kaiser reports, and the GAO reports, the CRS reports. We have lots of reports out there, and how much of it is just getting staffers to organize all this, synthesize it, record it, versus looking up the items that we're supposed to include that we really don't know very much about, either because it's not published, or what's published is old and hasn't been updated, or it was published but there are a lot of very talented people out there who are saying, you have to understand that the data they used were quite limited, or the methods that they used weren't very good.

In order for the staff to do that, do they need some help from people out in the field? And so that's how I was thinking about the hearings, what I thought we needed to get out of the hearings to facilitate doing the report.

All right? That's different, Richard,

than just trying to get on the record testimony from experts, which is what you're thinking about, the one senator with the staff, and coming and having 15 minutes for prepared remarks to get on the record.

MR. FRANK: I threw that out as an example.

VICE CHAIR McLAUGHLIN: As the classic case, right.

MR. FRANK: Well, as the classic case, as one that I think may not be very productive for our particular ends.

VICE CHAIR McLAUGHLIN: I think that, too.

MR. FRANK: So then the question is, once you're away from the tradition, where do you go?

VICE CHAIR McLAUGHLIN: Exactly. That's where we're headed now.

MR. O'GRADY: You've got a structure that says if the report is going to have five different items, at least as a starting point let's start talking about five different hearings, one on each of the items.

CHAIRMAN JOHNSON: I'm not sure. We've had some preliminary discussions on that.

MR. O'GRADY: You can go two per hearing.

Panel one, panel two.

CHAIRMAN JOHNSON: This is just a starting slide for today. We're going to use hearings, we're going to use our discussions, we're going to use staff summaries, analyses and so forth to develop the report, to go to the national public dialogue, and then to have some recommendations.

And what we're talking about today is the hearings in particular.

DR. BAUMEISTER: We'll have hard copies of this, too?

VICE CHAIR McLAUGHLIN: It's your book already.

CHAIRMAN JOHNSON: And so one of the things that we're going to be considering is: What is the scope of our recommendations? And we got into this a little bit yesterday with Senator Wyden, Senator Hatch.

And Mike asked the question of Senator Hatch or Senator Wyden, that I thought was a good one, and we've heard his thoughts. But we also have heard I think Dotty I think with some additional thoughts this morning that may or may not have concurred with Senator Wyden's input yesterday.

And that's not to say that Senator Wyden is right or that Dotty is right. It's just a little bit different approach.

Or maybe we've combined the two. But one of the questions that we'll want to consider is at what level are we going to approach this?

If we approach it at the 30,000 foot- level, of course some of the questions might be: Should we have good quality health care? And should health care be available for all? And we then end up with probably apple pie and motherhood kinds of statements.

On the other hand, if we look at things from the 500-foot level, we'll get bogged down in so many details that we may not have the impact we could otherwise have.

It was interesting to me when we did the press announcement on this, one of the reporters in the audience asked Senator Hatch, he said, What are your thoughts about herbal supplements as an item to be covered under health care?

Well, that wasn't the intent of that press announcement, and probably we're not going to be able to get into herbal supplements as a major feature of our health care delivery system.

So we'd like to contrast the 30,000 versus the 500-foot level, and figure out what are the big- picture items that we can really make a difference on?

And we mentioned yesterday the MedPAC commission recommendation. We mentioned the Clinton administration health care advisory commission’s recommendation to use the NQF, and hopefully we'll come up with some meaty recommendations that, whether it's impacted or implemented by legislation or by market forces, we'll be able to have a very positive impact.

Okay? So, and we need to be looking at both short term, what are some of the short-term fixes, and longer term. Mike's comment on looking to the future is very important. We've got to figure out how do we do this, and fix our system as effectively as we can.

And maybe we will have different timetables for those.

Another question is: What lessons can be learned from other commissions, and we touched on that a little bit yesterday, where we might look to some of the other commissions for some of their input, and read some of their reports, and take some nuggets from some of the other reports and bring into our own thinking for your review and consideration, and then recommendations later on.

The organization of our recommendations, we're going to talk a little bit about that to day. And some of the agents for action might be both the private system as well as the government.

We've heard Mark McClellan recently, who is the administrator of CMS. He's talked on a number of occasions about having collaboration between the public and the private sector, where it's not the public sector that leads, it's not the private sector that leads, but it's collaboration, together.

So on the hearings, what we'd like to talk about today is: who, what, where and when. Who, what -- why, what, who, where and when, okay?

VICE CHAIR McLAUGHLIN: We've been having fun with this slide.

CHAIRMAN JOHNSON: That's right. The “Why” is to provide input to the report. That's why we want to conduct these hearings, just to provide input to the report.

And the “what” is a subject we'll talk about.

“Who” is who are we going to hear from?

“Where”. As Catherine suggested already, we're not talking about town hall meetings here. We're talking about hearings, but one of the hallmarks of this group as opposed to others is that it's intended to be a group that gets information from a variety of settings.

So at least some of us believe that it might be helpful to go to practitioners in the field as well as those who typically traditionally testify in Washington, D.C., to get some of their input. And we'll talk about that as well.

And then we'll talk about the “when”.

Well, these are the “Whys”. And if you have any other suggestions as to why we want to do this, you know we'll hear that.

But I think what we'll do is we'll proceed as well to the next subject, which is what?

MR. O'GRADY: Can I just bring up one quick one on that one?


MR. O'GRADY: There's a notion, despite Richard's disparaging remarks, about traditional congressional hearings, that they serve in terms of kind of giving people their say.

And it's known that, especially if Congress is going to move in and start to legislate, even if they pretty much know the direction they want to go, there's been enough studies and whatnot, there is that notion of people having their day in court, their chance to stand up and even if they totally oppose it to say, I totally oppose it.

And that helps Congress in terms of back, in terms of, we heard you, we listened to you. We disagreed with you, but we decided to move forward.

And to a certain degree you're looking at the deadline and there is a parallel goal here that would say, no, we went out and we talked to people.

Because if there is something, we're going to come in and say, especially if we get back to Senator Wyden, sort of how do you move the money around?

And it's not like any of this money is just buying pools for people behind their houses. But we're going to say there's a disproportionate amount of money going to getting the last ounce of HIV- tainted blood out of the blood supply, and that's not really the priority anymore. We should put it towards rehabilitation services.

Boy, you better have talked to somebody from the HIV or blood communities. You know what I mean?

VICE CHAIR McLAUGHLIN: Two things. Remember, the community meetings -- the report is not the recommendations. The report is educational.

The report is to start the dialogue. I think that we were thinking the community meetings are when we really have to be very conscious of getting all these interest groups to participate.

Not only that, because that will feed into then the recommendations that we make; right?

The Congress then has hearings after our recommendations. So I'm just saying that these hearings. I'm sure that Congress will have the kinds of hearings that Richard talks about. We, I think, have to be very, very detailed in the list of interest groups, advocacy groups like you just mentioned, who participate in the community meetings.

It's not as clear that we need to do it for these hearings. I'm just making that distinction.

MR. O'GRADY: Right. And I'm also thinking about, as this group moves forward, how its recommendations and how the whole process is viewed.

Let’s take this example. Before, you asked about MedPAC’s survey about access, when Medicare payments were cut, physician payments dipped.

Now we could include that in this report. And we say, it looks like data, sample size was good, methods were fine, science was good. To a certain degree I would recommend that we have someone from the American Medical Association speak at one of these hearings, assert their side of the story if they have certain problems with that study, it's on the record that we've listened to everybody.

VICE CHAIR McLAUGHLIN: Right. And that's actually a perfect example of what I was saying that when I look at the report, what I think we need for the report is, in fact, some commentary from people in the field about the evidence.

CHAIRMAN JOHNSON: Let me add or build on or say in different words what we've been discussing.

Yesterday we talked about the issues, and we talked about initiatives that are existing. And one of the things that Catherine and I have had some discussions about is in addition to these two, talking about potential solutions, one of the advantages of this group is that we will have a chance to go out and hear from the American people. And there's a thought that if we talk about not only the issues and the initiatives, but we also talk about, here are the solutions, it will be perceived that we've already come up with our ideas, and our solutions to these issues.

Now when we conduct the hearings, we will potentially not only hear about this but we might have people who in our hearings will talk about this. But we will have moved down the road, so we'll have to figure out when we do a report then to what extent do we get into this area, in solutions, as opposed to just saying, here are the issues and here are the initiatives, and you, American people, come back to us with the solutions.

We might have to figure out, and we'll talk about this in a different meeting, how close do we get to potential solutions?

Not because they're necessarily ours as a group, but we've digested materials that will have come in from our reading and hearings and so forth, and then we'll have to figure out, okay, how much up front are we going to be in talking about these as solutions? Or are we just going to say, here are the facts, ma'am, and leave it there?

MR. FRANK: Two comments, one commenting on Mike's observations.

I think he's right. I think one of the things we want to do, and one of the good things about congressional hearings, I never thought I'd be saying this, is that I do think it's a way of showing respect to people who have big stakes in this. And I think that we do want to do that.

And I guess the way I'm thinking about it is, to say, all right, here are the tools that we have to accomplish, the information gathering, but also the respect-showing.

I think it ought to all be planned out from the front. I don't think we should plan the hearings without having fully thought out the community meetings, so that we kind of have a strategy laid out for how we want to accomplish these various goals.

Now having said that, what I heard both of the senators say yesterday was the first reports are really supposed to answer like three questions, which is, how do we spend money? What do we buy with it? And where are the opportunities that we might be able to do things with greater wisdom?

And that seems to be sort of what that first report asks us, is, where are the opportunities?

Which sort of gets us to those first two boxes. Actually, it gets us halfway through the second box or something.

And I think that if that's right then perhaps we should sort of have the hearings emphasize that, but then think about what groups could really bring good input to the table for answering those questions that you want to sort of make sure you're inclusive of in the process.

And then maybe you don't invite them later, because they've had their bite at the apple.

But I just think that trying to figure out the whole sequence of events up front is probably something that might keep us out of trouble later.

CHAIRMAN JOHNSON: Can you build on those comments a little more? Because I'm not sure I'm totally understanding yet.

First, the legislation says what we need to include in our report.

MR. FRANK: Right.

CHAIRMAN JOHNSON: So I don't know if it's broader or less than what the two senators talked about. But it also gives us room to include whatever else we'd like to include in the report.

So am I hearing you narrow the legislation, Richard?

MR. FRANK: Well, no. I was just -- from having read the legislation, from having heard the senators talk yesterday, if in fact we're supposed to, as I understand it, not offer solutions or recommendations in that report. So we're supposed to stop before we get there, because it's the first salvo.

And then both senators really emphasized this idea of educating the American people, and laying out in a transparent way the hydraulics of the health care system.

And then when Senator Wyden went through his chart, what he seemed to be saying is, lay it out transparently so people can see where the opportunities are, and then you go out in to the communities and find out what people are doing locally to try to fix things, what ideas people have, how the interest groups feel about this, et cetera.

And so it seems like a natural --

VICE CHAIR McLAUGHLIN: If you look at your slides you will see that these slides come later, although talking about them now is fine. We in the report are also supposed to list state initiatives, local initiatives.

So we are supposed to actually have in the report some accounting of what's going on out there. But, yes, it's supposed to stimulate people coming to community meetings to say, well, you didn't say anything about these initiatives, so that we are educated as well.

I mean this education effort is not just unidirectional.

MR. FRANK: Opportunities are defined by a combination of two things. One is where is there a problem? And, two, is there any possible solution; right?

If you have no solution, there is no point in pursuing that problem. So I thought that the initiatives are the way of saying, okay, here are some possibilities for addressing these problems that we've now laid transparent, et cetera.

Does that help?

CHAIRMAN JOHNSON: Well, it does. And I didn't hear all your comments earlier when you were talking about the value of hearings and so forth.

But one of the things that we've considered, at least to some degree, is the fact that oftentimes when we have hearings in Washington, we hear from folks who are big-picture thinkers. And they're researchers, and they might come from large associations.

But we don't often hear -- we hear less often from people who are in the trenches and conducting programs in their local settings. And I don't know if you'd call them state and local initiatives, but that's another focus, I think, that we can have and should have.

So that's a bias I have that I'm sharing with all of you about these hearings.

MR. O'GRADY: Just a factual thing. think you're wrong. Most congressional hearings -- a very traditional way of doing things is that you have the people, you know, either actual practitioners or actual patients or whatnot, and then you bring in the researchers.

I think you're right in terms of the media tends to then focus on the research. If you look at the actual lineup of those hearings, they almost always have somebody with a really heart-wrenching story there. Or someone who is, you know, here I am, I'm a nurse trying to help on the reservation working with type 2 diabetes. So the way it's laid out --

I'm just saying that if you go this direction, know that there is sort of a track record of what the media covers and what it doesn't. But you could certainly do that, and I kind of like that style, that you hear from the different groups that are affected by this.

But just know up front that some of that is not that those hearings don't have that, it's just that the media says, Bob Reischauer from the Urban Institute finds “boom” and that's the story, not the woman with diabetes.

VICE CHAIR McLAUGHLIN: That's a good point.

CHAIRMAN JOHNSON: And my comments aren't intended to talk about the woman with leukemia or the heart-wrenching story. It's to talk about local and state initiatives in those settings.

MS. CONLAN: I' m trying to clarify in my own mind this issue of what's appropriate to a hearing. And I know you're talking about the larger issues. I talked to an attorney before I came from Florida Legal Services. She looked at the matrix, and she was interested in participating to offer some input about Medicaid buy-in for people who are on Medicaid feeling trapped, wanting to work but realizing they would then lose their Medicaid benefits if they went back to work.

And she thought this would facilitate a Medicaid buy-in, facilitate articulation between the public and the private sectors.

Is that's something that's appropriate? But her perspective is from Florida and what she knows about Medicaid patients in Florida. Is that something that would be appropriate at a hearing?

CHAIRMAN JOHNSON: Without responding directly to your question, I think there are two things that we'll do in the hearings. Even if we were not to invite that person to testify, my understanding is that we're obligated, but beyond that we would probably want to make known a posting in a federal register or some place that we're going to have these hearings, and that in fact our website would take input in a written format in addition to those people who would physically present testimony.

So your colleague would have an opportunity to do that even if we were not to ask her or him to testify.

We haven't gotten into the details of the hearings. And by the way, what Catherine and I would like to do is, we're going to try to appoint some subcommittees, including a couple of other people to work with us in what we'll call a hearing subcommittee. And we'll have a report subcommittee, and we'll probably look at some other subcommittees that we will talk about later today.

So we're going to invite participation from some of you as we develop the hearings. But we're trying to get an overall view of them right now.

But that kind of detail is something that, if you have input, that kind of input, you'd like to share that, please do. And our reason for sending out the matrix to you is to get your ideas and your input.

Shall we move on?

MR. HANSEN: Just a question, not a comment.

At the hearings, I'm assuming, there will be people that the committee will invite. The community groups later on will be open to almost anyone who wants to come, and that's for more recommendations--

VICE CHAIR McLAUGHLIN: And, actually, Joe, what we have been thinking so far -- and part of this came also from advice from Larry Patton, who is familiar with the hearing structure, is that for the community meetings we make sure that we're pro-active as well, that we invite particular people. And let's say we do one in New Hampshire. And we'll say, Dotty, can you recommend somebody from this community, from that community and make sure we invite representation.

But they will be posted. And one of the things we want to do is, hook up with local media, try to get an interview in New Hampshire with Dotty to say, yeah, we're having a community meeting, and we're hoping to have it posted places. Senator Wyden told you we're meeting with the CEO of Starbucks. He may want to post community meetings in the local Starbucks store or whatever.

We really want to get out the word so that a lot of people show up. But we also have to be pro- active and invite local union reps, local practitioner people, and make sure that those people are heard from as well.

MS. HUGHES: Could I ask something? I have not had the privilege of ever attending a congressional hearing. But I have this image in my mind of what it could be like or it could not be like.

And I guess where I am, based on where the conversation has gone, is that there's a style for a hearing, how it's set up, and then there is content for the hearing, is that right? So we're sort of right now combining both of them, trying to figure out a style for the hearing and the content for the hearing, is that right?

So in the content for the hearing you have your experts. You invite them to come and address the board, whoever it is. You have your practitioners that you invite.

Are the only people who speak in a congressional hearing the people who are invited?


MS. HUGHES: Is that right?

CHAIRMAN JOHNSON: We would post in the Federal Register the fact that we're going to hold hearings. And you might say, hey, I'd like to testify. And so we might say, yes, we'd like to have you come and testify. As opposed to our figuring out

in advance who would testify.

MS. HUGHES: So I guess what I'm saying is, they're really not open hearings. I mean they're open to the public in terms of listening, of hearing, but they're not open to the public in terms of speaking.

MR. O'GRADY: You want me to take 30 seconds on how a congressional--

VICE CHAIR McLAUGHLIN: Well, this is not a congressional hearing.

MR. O'GRADY: Okay, just to give what the goals are and how you'd set them up. You're moving into a new area. Some of it may be just educational.

You're heading into a Medicare prescription drug benefit. You think the members of the committee should hear about drug benefits are designed in the private sector, and other programs and things like that, where you're trying to move into an area.

It can be two or three panels. Typically, and what I think would be more applicable for us to a certain degree, let's say we go to Utah, and they've done something that we feel is sort of interesting, and maybe innovative.

So you may have what I think of as a luminaries panel to start out, maybe the governor, maybe the head of the Medicaid program, something like that.

Are they experts? Yes. But they're sort of your headliners, however you want to think about that. So you have them first, so that they don't have to wait around basically.

Then you come in with the second. And it doesn't matter what order you do them in. But you then have what I think of as the right-side left-side of the brain. You have your lady with leukemia or whatever you think is really affected by this, whether they're practitioners in this area, whether they are patients, et cetera.

Then you have some people who are going to be your experts. Now you may also have, depending on how you want to do that, you may also have what you think of as stakeholders. So you're coming into Utah, you hear from the governor or the state Medicare director, and you probably at one point want to hear from the docs in Utah and the hospitals in Utah as well as from the patients.

So how do you make sure at the end of the day you've heard a wide range of the perspectives on this, from the very analytical to the very personal, and you've sort of gotten this range of where the stakeholders are, so you're not surprised later that if you say, this sounds like a good idea, and we move forward with it, all of a sudden to find out, it looked good but it costs ten times more than anybody told you in the hearing.

Do you know what I mean? So you're looking for that balance.

MS. HUGHES: So we come up with this, however we do it, are you going to let us know whether we're going to be blindsided later down the road. You said, so you wouldn't be surprised later down the road.

MR. O'GRADY: There’s a wide range in terms of good hearings to really bad ones. You certainly can see ones where people have only brought in people who agree with them. I mean, group-think is as common in Congress as it is anywhere else. So you can see that sort of stuff.

So what does that serve? It's a rally to get your troops together. But does that give you a notion that then when you go forward with a proposal, like hopefully when we're done those guys have something they can run with.

If you're in a situation, I can hear it, if it's not viewed as representative and broad-based to a certain degree, whoever is hurt by it is going to come in and go, they never listened to me. I never got a chance to say my side of the story. This isn't balanced.

CHAIRMAN JOHNSON: Let's go through the slides that we have on the subject of hearings. And maybe that combination of material will help some of our thinking, and then we can continue our discussions on hearings.

These are the subjects that we've contemplated covering: issues that are required right in the statute, and we've shared that with you yesterday; to cover issues raised by you, all of those, we talked about that yesterday; to cover initiatives identified by you. And we've had some discussions on that already, but we're going to have more likely. To cover initiatives, issues, and otential solutions identified by the experts or the practitioners, and those would be some of those that would be in hearings that we would have, okay?

Who are some of those who might testify? Potentially some citizens, consumers, patients. Providers, Catherine talked about the classification of these as individual and institutional, physicians, nurses, other paid and non-paid caregivers, potentially institutional like hospitals, long-term care facilities, managed care plans, clinics and so forth.

Now, would we do all of these? These are just some examples of who might fall into these categories of stakeholders and people who we might suggest to come. Purchasers, private purchasers such as consumers who are buying their own coverage, employers, unions, purchasing coalitions, and there might be others.

Public purchasers, Medicare, Medicaid, CHAMPUS, the VA. What are they doing that they're finding to be issues? What are they doing in some of their recent initiatives that direction.

And then maybe regulators, and we've talked about regulators not only being government, but some private accreditors, such as the Joint Commission on Accreditation of Healthcare Organizations, National Committee for Quality Assurance, and the National Quality Forum.

And there might be others that will hear from you all.

VICE CHAIR McLAUGHLIN: Randy, I just wanted to point out one thing while you were reading this. You may be looking at the slides that are in your book, and realizing they're not exactly the same as what are on Randy's computer.

For example, the slides now say, SCHIP and TriCare, not CHAMPUS. So in case you're confused between what's in your book and what's on the screen, it's because this was the previous edition.

CHAIRMAN JOHNSON: Who might testify, expert groups, policymakers from the public sector as well as from the private sector, health services and health policy researchers, some of the academic organizations, consulting firms, think tanks.

And then where to hold the hearings. We've contemplated Washington, D.C., and outside Washington, D.C. We've contemplated urban and potentially rural settings.

But one of the things we need to consider is, where are our stakeholders located that we would want to testify, and what are the logistical challenges of getting people there.

So then we get into the health report to the American people. So let's stop and continue our discussions on the hearings and subjects that you would like to raise or discuss, or suggestions, whatever.

Some of you have been quiet today so far, so don't want to call on your by name, but we would value your input.

VICE CHAIR McLAUGHLIN: Because Larry's not here, our taskmaster normally, but one of the things that he kept impressing upon is that by the time we walk away today, we have to have a very clear understanding of when the hearings are going to be, where they're going to be, what the subjects are, who we're going to invite. Because people are busy, and

in order to get these so-called experts, stakeholders, et cetera, that we want at these hearings, we should have invited them three months ago, but we certainly need to invite them soon.

So this is something that there is some urgency about in terms of making these preliminary decisions. And the discussion so far already makes it clear that this is complicated. It's not a traditional congressional hearing when we have a template, outlined so nicely by Mike for us, of how it's supposed to proceed.

And if we did that, we could have the template, and then we could just fill in the names and move on. But these are, first of all, they're not congressional hearings, they're commission hearings, which is slightly different. And also, it's just not clear to us anyway what's the best way to proceed.

I outlined to you what I thought, and Mike's comments certainly agree with that, that from my own selfish perspective some of you will be asked to be on a subcommittee with me to put together a report and I'm thinking well, what do I think I personally need to get from these hearings.

But Randy, who is coming at it from a different perspective is saying, well, what do I want to get from the hearings, and what do I think is the role they should serve.

So we already know that we are facing this kind of dilemma. One more comment, and then I hope I stimulated some comments from all of you.

Mike talked about the educational one, and we did talk about that in this first hearing in May in Washington, was what we were thinking about, having at least a couple of panels that are educational for the working group.

So then the question is, what issues, what areas, do we want to cover to bring experts in to talk to us so that we all feel more informed about a particular area.

CHAIRMAN JOHNSON: So with those comments in mind, what we would want to do is get as much information from you and comments and suggestions today. And then what our subcommittee will do is go and try to work out some of those details with the staff, so we can proceed as quickly as we can to conduct the hearings on a timely basis and provide the input for the report.

DR. SHIRLEY: In an early email, this was simply mentioning the potential sites, I think that would be an excellent and strategic move for several reasons. One, there is an opportunity to see some programs that are addressing some of these issues related to access, patient education, reduction of cost.

Also it's an opportunity to have it here on our home ground. And a facility that's named after Senator Cochran, which would also be a strategic move, I believe.

So we would welcome you to Mississippi, and we think we could accommodate the group and all of the logistic needs.

CHAIRMAN JOHNSON: Contrary to what we do here in Washington, D.C., and I'm calling this Washington, D.C., even though it's outside the beltway, it's almost inside the beltway. And we have rooms where we have people come in and so forth.

You're suggesting that just going to a facility that has implemented some of the initiatives striving to deal with some of the issues we've talked about today would be helpful?


MR. HANSEN: I need more education. There's no other way to say it. And you've got that kind of chicken and an egg thing, you've got the cost out here, and then the quality and the access over here.

I'm not sure which way you go first. If you do the cost part, I'm a little bit concerned that will be so dampening that we won't get to Dotty's point of how good can we make the system, which I think is what her comment was.

So I think we need to go all around the country. And I think Dr. Shirley's comment is good. But I would really need to get a broader overview from some experts for my own sake. I'm not as far along as some of the other members of this committee.

CHAIRMAN JOHNSON: Are you suggesting that you'd like a foundation of information --

MR. HANSEN: Exactly.

CHAIRMAN JOHNSON: -- from some of the thinkers, and then potentially some hearings outside of Washington.

MR. HANSEN: I think the hearings outside of Washington are absolutely necessary. Because I learned so much yesterday from the stories I heard around here, I realized how uneducated I am on some of these particular issues. Somehow we've got to do both.

MS. PEREZ: I think that would also take it out of the context of some of the conversations we had yesterday that, you know, we tried it once. For decades we've been trying to do something and it just hasn't happened. And maybe it's in Washington, the reason why it hasn't happened. So I think maybe that kind of already sets the context for what we're trying to accomplish. And especially as we go into the community meetings, and putting the report together, that this was a little bit different than what's been tried before, and that there was a real effort to get real input.

Maybe someone coming here to Washington is going to say, well, they're going to want to hear this. And that's the line, and that's what we're all going to have to stand behind. But if it said Mississippi or California or wherever, let's take them some real information and think outside the box.

MS. CONLAN: I guess I agree. You know, I think that there is a perspective that needs to come from a national perspective that maybe could come from Washington. For instance the people I work with are associated with the Center for Medicare Advocacy. And they can give information, national figures.

But then I think we have a particular story in Florida that we need to supplement that, so you know the particulars from our perspective. So I like the idea of having hearings in one setting for the overall, and then particular for specific.

MS. STEHR: I'll have to agree, that I think we do like the main meeting in Washington, D.C., and we get basically all the experts as an educational information-gathering for all of us, and then do the outside D.C. And I remember Iowa was listed too as a possible for the overall.

And I think that is a good idea because our governor just got a recent waiver, I don't know the details yet, but to do Medicaid expansion without cutting supposedly it's not going to cut any of the existing Medicaid recipients, but he's going to do an expansion and do a buy-in.

So I think they've got some good ideas on innovative things to try out there in rural areas. And I think that's a good idea to try and do one in Iowa.

MR. FRANK: So at the risk of going from the lofty to the commonplace, I have four questions that I'd like experts to come in and tell us about. Do you want to hear them?


MR. FRANK: The first one was to test the basic assumption that we heard yesterday, which is, is there enough money in the system? There are people out there who have studied this, and find out, is there enough money in the system.

CHAIRMAN JOHNSON: And how would that be answered, do you think?

MR. FRANK: I know at least one of my colleagues at Harvard believes that cost containment isn't a big issue. I don't happen to agree with him, but he is an extraordinarily smart guy, and he has a lot of evidence that he brings to that question.

There are other people on the other side

of that question, so I think that having them talk about it too. He believes that in general we could spend two or three or four percent more of GDP and there would be no problem except that people would be healthier.


MR. FRANK: So there's one.

Another one is I'd like people, maybe Weinberg, maybe others, to say, where are the high value and low value services? Which is sort of why he's sort of here's how we spend the money, here's what we get for it. Identify where --

VICE CHAIR McLAUGHLIN: Services, high and low value --

MR. FRANK: High value and low value expenditures.

VICE CHAIR McLAUGHLIN: Oh, expenditures.

CHAIRMAN JOHNSON: And can you just say a few more words about that so we're all clear?

MR. FRANK: All right, so for example, a lot of people would say that the way we spend money and the like is low value.


MR. FRANK: And high value might be the way we spend money in the first six weeks of life, right? Actually, prenatal.

The third thing is, what are the real uninsured numbers, and what are the things driving the uninsured?

And then the fourth one is a fairly detailed discussion of the financial crisis in Medicare, since it's all been eclipsed by Social Security, but everybody I think secretly knows that the real problem is Medicare, but it would be I think very useful for us to get the very basic facts on that. And then probably on Medicaid as well, but certainly Medicare.

MS. MARYLAND: Could you restate that fourth question again?

MR. FRANK: The fourth is, what are the details behind the crisis in Medicare and Medicaid?

CHAIRMAN JOHNSON: Okay. I've heard your comments and suggestions, and I think those are questions that really merit some discussion.

They highlight something that I'd like to address with us as a working group. That is, there are already folks who are assigned to study Medicare, folks assigned to study Medicaid. As a working group, is that a subject that we also want to take on? Or are we going to say, we'll let the other folks who are focused and specializing in Medicare or Medicaid take those on with their recommendations, and we'll look at the system more broadly or in total?

That's not to say that we won't touch Medicaid or Medicare, but is this group going to look at the reform of Medicare? The reform of Medicaid? And all of the other things we talked about as issues yesterday.

I'm not making a statement regarding what we should do as much as asking the question.

MS. BAZOS: I have a question with regard to your question. How could we address the issues that are here without having a really good grounding about whether or not there's the possibility to use Medicaid or Medicare as a tool for coming up with some of the solutions?

And I think that might be why we want to understand the programs more, and understand if they can be tools for our recommendations.

MS. CONLAN: And then I'm wondering, if we follow what you're proposing, why am I here? Because I represent Medicare and Medicaid beneficiaries.

CHAIRMAN JOHNSON: Well, I'm not proposing anything. I'm asking a question.

MS. CONLAN: Well, I know. But if we follow what you're saying, or if we took your suggestion, someone chose me for a reason, and I thought that was to bring the voice of the Medicare and Medicaid patients who are beneficiaries to this discussion.

So it has to be something for consideration.

DR. BAUMEISTER: But I think that if we're going to start one of the questions is, should there be a Medicare? Should there be a Medicaid?

MS. CONLAN: But we can't answer that if we're not educated.

DR. BAUMEISTER: Should there be employer- based health insurance? Should we start over?

I don't know any of these answers. I don't even know the questions. And I feel dwarfed really by some of the knowledge of some of the people here. I hear Mr. O'Grady, and wham, he's like a computer, you know.

And then I hear --

MR. O'GRADY: Too many damn hearings.

DR. BAUMEISTER: And then I hear Dr. Frank over here. And that's their life work, you know. And here I am really a country doctor.

MR. FRANK: You and Sam Ervin.


DR. BAUMEISTER: I've been in this stuff, delving in it, sort of. It's like the difference between a hobby and like drifting in a river with a guide, you know. And I can cast, and I can land a fish. But the guide is there. His knowledge is so infinitely greater than mine.

And I don't know any of these answers. But you talk about these hearings, are these hearings designed to be a dialogue? I guess I'm talking about David Cutler here who had a big piece in the New York Times a couple of weeks ago really about health care.

And that we're probably not spending enough. And good evidence based and pay for performance but pay more money. I don't remember all the details of the article.

But there are a lot of different opinions out there, and you come to Oregon you'll hear a lot of experts. We've got a lot of them out there who feel they know a lot about health care and stuff.

And I don't know, but we sort of softened up there. We talk about the economic cycle and how it influences health care. And we don't say, is employer-based health insurance the way to go here?

VICE CHAIR McLAUGHLIN: That was my invitation yesterday.

DR. BAUMEISTER: I don't know. I just throw it out. My brain is just sort of in chaos here.

VICE CHAIR McLAUGHLIN: Well, a couple of things. Yesterday when I made that, I said we just have to be aware that if we stick with employer-based health insurance system, so yes.

And I think Randy this morning was saying comprehensive versus incremental. I mean that is clearly something that this working group is going to have to talk about.

The expert thing though, I just want to say two things about that. One, to echo Montye, the composition of this working group was thought about very carefully by a lot of people. And when they called me for example for an interview, I said, well, you ought to know, I'm a researcher. That's what I do. I can't really talk about policy and this and that. And they said no, that's partly what your role would be on the working group.

So it was deliberately meant to be a simple country doctor.

CHAIRMAN JOHNSON: Which you are not.

VICE CHAIR McLAUGHLIN: And really, exactly, Sam Ervin definitely comes to mind. Sam Ervin, I'm just a simple country lawyer.

But I think that all of us have a different role to play. And that's the comment yesterday of, we're supposed to play that role, but also go beyond it and think as a group.

The second is that, I referred to this yesterday. I'm the director of this economic research initiative on the uninsured at Michigan, that's funded by the Robert Wood Johnson Foundation. And one of the reasons why they asked me to do this is because I said, you know, there are a lot of myths out there about the uninsured, and there are a lot of experts who say, and I'm not saying Mike does this, but they go, 41 million, and the reasons are. And was curious to say, how much of those are myths, and how much of those are actually what's happening.

So they gave me money to contract a lot of people to study this and say, what are they? And I'm saying the same thing to you now.

Mike and Richard and I are supposedly experts on different issues, and we're going to say blah blah blah. But that doesn't mean we're right. And it doesn't mean that we really do understand it.

And one of the reasons that I was excited about being part of this group is because I like to expose myths. That's sort of what I like to do. And that's what I think we're doing.

And Mike, some of the things you said yesterday, Richard and I looked at each other and went, that's a bunch of baloney, because we have a different view of the data. We have a different view of the evidence.

And similarly, we're going to say things that Mike is going to say, so it's not as though experts know the answers. And boy, don't think that at all.

CHAIRMAN JOHNSON: Mike, she told me the same thing. So don't feel bad. I made a statement of a few facts, and she said, the data doesn't show that.

Two comments, and then we'll come back to Mike. Your comment about the old country doctor reminds me of, I forget whether it was Adlai Stevenson or Ev Dirksen who was pictured with his hood up kind of like this and they showed a hole in the bottom of his sole, he got more mileage out of that hole in his shoe than anything else.

More to the fact here, hearings I have observed have been typically where a person has five or 10 minutes to testify, and then the panel responds to questions. But that doesn't mean that we have to have five to 10 minutes for each person to testify. We can construct these, and we might construct them differently depending on the setting, to accommodate the needs of the working group, as well as those who are sharing their input with us.

So that's something I think that the working group, or the subcommittee on hearings can think through. And if you have input on that Mike and then Montye.

MR. O'GRADY: I want to go back to Richard's point there, and the question you posed before.

I think that in terms of when we think about Medicare and Medicaid, they're about 50 percent of the health care spending in the country. So I guess I would go in the other direction and say, but you know what's the other next big chunk? It is employer.

I'd like to see a hearing like that in terms of laying it out so you can get an idea of how does this spending work? And then it gives us a grounding to then confront these other questions about, what do we think is going on.

And then not to be a one-note Johnny about this, but especially when you get to Medicaid. One of the real problems I think with Medicaid is that you look at these things like Social Security and Medicaid, they have these trustees report that sound a certain warning, whether it's effective or not. It's going to run out of money in X year, or Y. Medicaid has nothing like that. I mean I don't think you have to convince any governors that they've got a real problem, but there is all this other stuff going on with long term care, and the approach of the baby boomer, you know Medicaid may be in more trouble that Medicare when the baby boom comes.

And that's not as often highlighted in the press in different things. So it'd be a real advantage here.

But I think, you deal in a world, Randy, of employer. That's a massive player in this game, and therefore, I think it'd be real important to lay out some of those issues as well.

MS. CONLAN: I guess this might be a trite analogy, but in my personal life the question may be, do I change jobs or do I buy a house? And I develop a pro list and a con list.

I can only imagine what economists do to make societal recommendations. But I would think the hearings would be to help us develop this list of the benefits and the costs and then answer the question, should we have Medicare based on the evidence that we received on both sides.

So I don't think entertaining information or questions or testimony about Medicare necessarily puts a stamp of approval that we have to have it. But it helps us to reach a decision about it.

CHAIRMAN JOHNSON: And I want to make sure that you're not misunderstanding my comments. If you look at all of these that we discussed yesterday, a lot of them are touching on, if not related to, Medicaid and Medicare.

So it's not my intent to say that we should get into those subjects at all, for all the reasons we've all been discussing.

MS. HUGHES: First, I'd like to apologize, Frank, for interrupting you when you spoke. Your comments made me think that I feel awed by the expertise in this room. And I know that like Montye, when I was called to ask to be on the commission, I said, what do I bring that can meet the expertise in this room?

And so I listened to what's being said. And I think that just as a citizen, who's not an expert in this room, I'd like to ask that you consider several things.

First, I'd like to see if we could get rid of whether as a group we can have a meeting where we can have some experts, GAO, whoever you think is applicable for the menu, to come in and address us with the ideas of what the nuts and bolts are of the health care system today. That's the first thing I'd like to see.

The second thing I'd like to see is that when we discuss the hearings that we look at like you said earlier, Randy, the locale which it seems like that sort of has a consensus there. I don't know who these people are. I have to depend on you to tell me who they are, and I accept that, because I just don't know.

But I'm very uncomfortable saying, talking about experts coming to a hearing before you tell me whether you're going to educate me and bring me up to speed with the rest of you. And I won’t be up to speed with you, but at least I will have some grounding that can allow me to participate a little more in your dialogue.

So I would like to ask that if we could move that education piece off the table, I think we could move forward, or at least I could move forward more easily with the next point which is the hearing.

CHAIRMAN JOHNSON: Therese, there's only one person that Catherine and I and those who are working with us on staff had talked about personally coming to meet with us.

And his name is David Walker, who is the person who appointed you all, to be part of the working group. But he would approach this not only as a person who's got a passion for this subject and is knowledgeable about this subject, but he's approaching it from, the United States can't continue to do what we're doing, and we've got to find some ways to fix the system, just for the United States economic perspective.

Those are my words to describe some of his thinking, and he might not put it in those words. But we've got a conflict with him actually for the May date. So we're trying to work with him and others, his colleagues, to figure out when he might come and how he might come.

MS. HUGHES: And would be just be the whole kit and caboodle?

CHAIRMAN JOHNSON: No, but he would be one who would provide a foundation of information, but not the only one. And we have talked about dealing with some of the questions that you were just raising.

DR. SHIRLEY: Could I? I think some your comments are very interesting in that I don't have the slightest idea why I was selected. And I was surprised when I was.

And but I think that part of the decision was based on my experiences, my involvement, and what I had learned from that. And I suspect to a great degree that might apply to you.


MS. HUGHES: I think there are some dangers if we minimize internally that, to the degree where the experts can come and change my perception of what I have experienced, what is the impact it has on me and my community.

It's like, I know I have this pain in my shoulder. But some experts could come and talk me out of feeling that pain. That's the danger that I see in some potential danger that I see in the comments, that you internally minimize what you bring, you can educate the experts.


MS. HUGHES: I didn't mean to minimize what I bring. What I'm saying is, there is a disparity between knowledge, and I would like to at least feel that I'm on a more equal plane.

I have practical knowledge. It's knowledge. That's not my point. My point is that I would like some nuts and bolts on the system. That's all I'm asking.

VICE CHAIR McLAUGHLIN: Well, I think that's the precursor to the report. Right? That basic plumbing, where do the dollars come from and where do they go? I absolutely agree with you.

And I agree with what Dr. Shirley said. I mean years ago when I was studying small businesses and the health insurance, and I had all these great ideas, and then I went and was participating in focus groups, which economists almost never do. And if economists knew I did it they'd take away from union card.

And some of the comments from the small business owners, and all they knew was their experience and their own business, made me realize, my assumptions were way off on this.

Dr. Shirley is absolutely right that I think we're all here to learn from each other, but isn't that part of the whole point of this working group is to start a nationwide public dialogue. And we're a microcosm of that, and starting this dialogue, so that we all learn from each other.

But I also understand your point of let's just get the plumbing, and understand the dollars, where they come from, where they go, and these issues which are really the precursor to the report itself. That's what the report is supposed to do too.

CHAIRMAN JOHNSON: Any other comments on hearings?


CHAIRMAN JOHNSON: I think we have had good input and good dialogue this morning. And it's really been helpful.

And first to Joe and then to Richard.

MR. FRANK: I have a process question. I hope no one will take it the wrong way, but I've served on a lot of committees, and there's two types that I've noticed.

One is where everybody walks out having understood whether a decision has been made or not, and the other ones, you're never sure. And I just wanted to know which one we were going to be.

Because to some extent, and unfortunately I'm on another committee right now where I'm never ever sure that a decision has been made, and when the next meeting starts, it turns out they haven't. And so we're not getting anywhere, but at least we're spending a lot of time doing it.

So I was just wondering as a matter of process whether we were going to sort of stop at various points and illuminate what we have decided.

CHAIRMAN JOHNSON: Let see if we can bring some closure here.

First, what we've understood is, at least I'm going to share what I understood that we want to have some hearings or education which help our foundational education regarding the health system.

That's one thing I think we heard.

And the second thing I think we've heard is, we will want to do some hearings in Washington, D.C., or close by.

The third is, what I think we've heard some consensus on is, we would also do some hearings outside Washington, D.C.

Fourth, you've given us some questions, and others have.

MR. FRANK: Friendly amendments.

CHAIRMAN JOHNSON: We've had some subjects that we would cover. And we'll flesh out the input based on our notes and come back to you.

Fifth, what we will do is, we'll appoint a subcommittee, and we might be able to get it to you by the end of the day who will be on that subcommittee. Catherine and I will be for sure. But the subcommittee will work with staff to work out some of the details.

And then come back to you and let you know what we're talking about.

The sixth is we have set aside some dates in May, and it's the 11th through the 13th, and now we have a challenge, because not everybody can make all the dates.

And as we look between now and July 1 there is not one date on which our whole group can meet.

So what we tried to do is look at the dates where we had the least number of people who have said that they can't make it.

But we've looked at these dates, and we've thought, this is the Washington, D.C. meeting. This is what we've been kind of contemplating so far.

So let me just stop and see if you have any feedback regarding these at least preliminary decisions for you to say, yes, we buy into those.

MS. MARYLAND: So can I ask a question? The May 11th through the 13th is your foundational meeting, or the hearing in Washington, D.C.?

CHAIRMAN JOHNSON: What we've talked about, and you can give us guidance, what we've talked about is two days of information that we would receive. And we've talked about that in the form of hearings, two days of hearings. We've talked about one day could be in the form of a forum where there would be some point-counterpoint kinds of discussions.

And what we've talked about, though this is not a decision, talked about having a third day when we get together on the third day, and we work until maybe 3:00 o'clock.

That happens to be a Friday. But we'd work until 3:00 o'clock or so, and say, okay, we kind of have a brain dump, here's what we've heard so far, and these are some of the things that have been apparent to me, and that would help us figure out where to go from there.

Now, that wouldn't be the end of the hearings, because we would anticipate doing some more hearings. What we need to try to do is have at least one of the set of hearings on the legislative language as early as possible.

And then we can have other subjects, and we can build on those legislatively mandated subjects as well, after May. But what we're trying to do is get at least one set of hearings in.

VICE CHAIR McLAUGHLIN: About an hour ago I said that we have to walk out of here today with some kind of agreement about the hearings. And in particular the May hearings.

The subcommittee can in fact start talking about the broader hearings and what we want to do, and we as a working group can delegate to the staff, okay work out the details of precisely what panel on May 11th and May 12th.

But we as a working group, because of Sunshine, FACA, in this public meeting today, have to make the decision about whether we're going to have hearings over that three-day period, May 11 - 13, if they're going to be in D.C., and what the general issue is going to be.

Because if we don't, then we can't have the May meetings until we have another public meeting of the working group.

So just to stay on task, we do in fact need to come to closure about that, and make sure that everyone is in agreement that that's what we should be focused on in May, that's how we should spend the time.

MR. PATTON: Anything delegated to a subcommittee, the subcommittee does not need to have a public meeting. Its decisions or recommendations must come back to the full committee before you proceed.

So that's why if you delegate decisions about May to the subcommittee, you're having no meeting in May, so don't do it.

CHAIRMAN JOHNSON: Okay, well, let me test this. Larry, if we say that we're going to hold hearings on the meetings or on the subjects that are mandated by the legislation and related topics, have we met the obligation?

MR. PATTON: Yes, I think the framing out of this that's delegated to the staff to do is fine, so far as I know. I think we're fine. The issue is not to let the whole issue be sent to a subcommittee unless it's coming back to the meeting.

MR. FRANK: I just have a question, I just want to poll the group. I could imagine sitting through one day of hearings. I think that I would be totally burnt out after two days. I mean it's going to hard.

And we have a lot of work to do anyway. So I'm just wondering how we should time this, or whether we should have two half days. Or just something so that we can actually get the most useful things out of it, and then actually have enough time as a group to process what we heard.

Because I think that's sort of an important thing to do early on if we're going to learn from each other.

CHAIRMAN JOHNSON: That's kind of what we contemplated on the third day. But let me build on your question and ask a similar question, maybe.

Are you saying by your question that maybe we shouldn't have three days of meeting time including two days of hearings? That we might want to consolidate some of the hearings into a shorter period of time, and just have a two-day meeting for some of the reasons you're implying?

MR. FRANK: I was just sort of, as a personal matter, I find it very difficult to sit still for that period of consecutive hours. I can do it for a day. But I think if I did it for two days my brain would shut off after probably the second hour of the second day.

CHAIRMAN JOHNSON: There's another factor to be considered, and that is, for those of you who are traveling, especially from the West Coast, it's a four-day meeting if we have a three-day meeting. It's four days out of your offices, assuming that you're all participating.

MR. FRANK: Maybe what we could do is half a day, full day, and then two-thirds of a day, and that would get people enough time to travel.

MS. STEHR: That's what I was just going to suggest, that we do like on the 11th it's a start maybe 1:00 o'clock in the afternoon, go until 5:00, then do a full day, and maybe do like the really educational part, the government agency experts, maybe on the 11th if that's workable. Then do the opposite views on the 12th, and then the 13th is a working group. So we're getting a wide range, but we're also getting both views and not just one view.

Does that make sense?

CHAIRMAN JOHNSON: Let me test something with you. Would you be open to starting at 1:00 o'clock on day one, but giving the subcommittee some flexibility to figure out who all would come and what would be the agenda for the first half-day as well as day two?

MS. PEREZ: It would be the staff. We're going to take the subcommittee completely out of it.

MR. PATTON: For the May meeting, the subcommittee can take anything beyond that.

MR. O'GRADY: Although I don't know that I'd be comfortable taking the subject of the hearing and delegating that to staff.

MR. PATTON: That you should probably discuss.

VICE CHAIR McLAUGHLIN: Well, we do need some flexibility of the schedule, just because if there are three or four people that we've identified as the people, and one of them can come Friday morning and one can come Wednesday afternoon, do we want to go to a second best person? Or do we want the staff to be able to be flexible on the scheduling?

MS. STEHR: I think flexible.

VICE CHAIR McLAUGHLIN: Me, too, that's my issue.

MR. FRANK: My only plea was to, do we want to impose a constraint like no more than two half days or no more than three days.

MS. BAZOS: But Richard, can I ask a question about your statement? I thought what you were saying, you weren't questioning the three days -- personally I must be a glutton for punishment - -I think we need to really get up to speed fast. I'm willing to put in three days.

But I thought what you were saying is, if we could think about how the three days were laid out, so that if we had intense meetings in the morning, and we really heard a lot. The afternoon ones, okay, let's talk about it, what are your assumptions, or perhaps I think some homework ahead of time.

I want to have the right readings. I want to be able to say, if we're going to have a person come and talk to us, number one, I want to know what he's done his work in.

Number two, I want to be able to somehow tell someone what my assumptions are about that, so that right away this person can come and say, well, Dotty, that's a great idea, but you know what, you're really all wrong because of this. And I'm going to teach you why.

So I think that if we get all this information sort of in a vacuum we could just be sitting back at the table saying, well, I still don't get it. Like I personally have an assumption about how the VA could be much more efficient if in fact veterans could just get buy-outs from Medicare. I've

done some research in that area.

If we're going to think about opportunities, we need to quickly get some legs around those assumptions. Either they're just like way out in left field, let's never consider those things.

So I think we need to do our homework, but also we need to think about real efficiency at these meetings. So learn, do, build kind of thing.

MR. PATTON: Randy, if I could a bit in response to both comments.

One of the things, if you're sitting and thinking about the traditional hearing process where you're up on the dais, and people talk for 5 to 10 minutes, as Mike can tell you, this will drive you crazy very quickly. This is a long type of day.

But one of the things that Randy participated in something that the comptroller general, Dave Walker, had organized, which in fact was much more of an educational seminar approach, where in fact within an hour, or let's say an hour and 15 minutes, just to give an example, the presentation, you had the material ahead of time, as you're suggesting, and then you had 10 to 15 minutes of presentation, but the rest of the time you're engaged back and forth.

That's a very different thing than the kind of structured stilted format, and it seems to keep people's attention much easier, and you can get both the basic questions, and the more sophisticated questions for those who want to engage with the experts.

It may work for you.

MR. HANSEN: I agree with Dotty. I think we need the three days. But I like what Larry is saying, and starting at 1:00 o'clock doesn't help the people from the West Coast. They'll have to come the day before anyway.

So I'm fine with that. And I think Catherine, you kind of laid out how you wanted the subject matter to be. And maybe we could get to that.

MS. HUGHES: Speaking from the West Coast I'd just like to say that two days like yesterday and today is difficult for me. So having that third day is not a problem, and it's not a problem for me workwise. So I can just say that.

Not that I'm asking you all to just think, oh, West Coast, no sleep and the like. But I'm just saying that it would be easier. I do like the idea of an interactive hearing, because I feel I have a lot to learn. And I think the interactive hearing would be very helpful for me, whether I'm awake or asleep. (Laughter.)

CHAIRMAN JOHNSON: Okay, we've heard some counter-arguments for starting at 1:00 o'clock. Are we moving away from 1:00 to 8:00 o'clock or 8:30 to 9:00?

MS. CONLAN: I think I would have a problem, too, of traveling in the morning, and then just because of my disease may get tired sitting there listening, but I'm going to be tired from the travel.

So by 1:00 o'clock, that's my time of the day to be tired anyway, and after the traveling I'm not really going to be of much use anyway.

MS. STEHR: I'm thinking 1:00 o'clock too for those of us that are flying in the night before, but we're getting in so late that we're not started as early in the morning is kind of why I was thinking 1:00 o'clock.

MS. CONLAN: Well, I don't mind starting early in the morning, but I think compressing so much into one day like yesterday was difficult. And you can see what happens to my body as a result. So that's just my personal problem.

CHAIRMAN JOHNSON: Okay, other thoughts? Are we sitting at 1:00 o'clock or are we sitting at 9:00 o'clock.

MR. O'GRADY: Can I ask a question just in terms of this, and Larry, in terms of trying to think through FACA and how it applies, I'm hearing kind of different things from different people.

Would it make sense to have like on the morning of the first day to have some informational seminars, bring in whoever, ask Senator Wyden to put a request in to CRS or GAO, whoever.

Richard perhaps can fly down on the shuttle from Boston that morning, but it would allow some of these other things for folks who really feel they want just a little more background on these areas.

It wouldn't be a full hearing, and I don't know whether FACA allows that sort of thing. But it would be sort of resources made available to the working group to help people kind of prepare for the hearings.

MS. HUGHES: That's great.

VICE CHAIR McLAUGHLIN: And then the group would have a couple of hours in the afternoon to talk, and then Thursday we would have as outlined before some of these other experts coming in to talk about their perceptions.

And then Friday the subcommittee would potentially report to the full committee on Friday about the rest of the hearings, whether they're in Mississippi, in Iowa, wherever they are.

We could then hear from the subcommittee what their thoughts were. Is that --

DR. BAUMEISTER: I personally don't want to fly in the day before and have a free morning.

CHAIRMAN JOHNSON: You prefer to fly in the day before?

DR. BAUMEISTER: I would have to.

VICE CHAIR McLAUGHLIN: And fly in the day before and get going.

DR. BAUMEISTER: I don't want to have a free morning.

CHAIRMAN JOHNSON: So AM would be basically I'll call it education and foundations. I'm putting this down so I'm making sure I understand. PM might be a little bit of that plus the working group meeting. Day two would be more traditional hearings.

VICE CHAIR McLAUGHLIN: But still interactive.

MR. FRANK: The question is, if we follow up from Larry's suggestion.

CHAIRMAN JOHNSON: More traditional hearings but with a focus on interactive dialogue. And maybe not necessarily five minutes, five minutes, five minutes, but it would be maybe 10 minutes, or in some cases, we'll try to figure this out, maybe 30 minutes, and then some dialogue with more questions, depending on who specifically we would bring in.

Richard, are you cool with that?

MR. FRANK: Yeah.

CHAIRMAN JOHNSON: So more traditional hearings but with a focus on interaction. And day three would be the working group meeting. Are we cool

with that?

VICE CHAIR McLAUGHLIN: Sounds good to me.

CHAIRMAN JOHNSON: Now later on we'll talk about forming a couple of more subcommittees, and we might have some interaction from them. We might have some brain dumps or debriefing on day three from here.

VICE CHAIR McLAUGHLIN: Just keeping in mind what Larry said, but can we in fact give the staff the flexibility that if one of the people we really want to talk to can only come Friday, that that flexibility is fine, that we don't have to stay rigidly to this. This is the game plan, but we have to allow flexibility for availability. Have we met our stuff, Larry?

MR. PATTON: You're fine on that. I just wanted to come back to Mike's point to make sure that the general topics that you wanted to cover, I think Mike is right, it probably makes sense for you to at least make sure that you're in agreement what topics are going to be fleshed out.

VICE CHAIR McLAUGHLIN: Can we take a five-minute break before we do that?

CHAIRMAN JOHNSON: Hold on before we take a five-minute break. Is this a broad enough and narrow enough subject matter for the hearings?

MR. PATTON: Do you want to get the greatest level of specificity?

MR. O'GRADY: I think so. But I think you're in a good position here. Because as I read their legislative mandate, it's a whole bunch of it having to do with the uninsured. So I think if everybody is comfortable with it, you could move forward with some of that sort of work, and kill two birds with one stone.

CHAIRMAN JOHNSON: Okay, let's take a break from the dialogue. We'll reassess this and talk about hearings when we come back.

(Whereupon, the above-entitled proceedings recessed at 10:26 p.m. and recommenced at 10:49 a.m.)

CHAIRPERSON JOHNSON: Okay, Brent, we're going to welcome you in just a second and introduce you and ask you to introduce yourself, actually.

But before we do that, what I'd like to do is summarize what we discussed before the break, and see if this summary is solid enough for us to proceed

with the assistance of staff.

So here we go. When we've talked about hearings, what we've said is that we're going to have not only a series of hearings, but we'll intend that they be foundational, that there be a foundational education process for us in the days that we'll meet, and those days we're tentatively thinking of, or we have put down on paper as being May 11 - 13.

We will have an initial set of hearings and education and meeting in Washington, D.C. on those three days, May 11 - 13.

Subsequent to that, those three days, we will conduct some hearings outside of Washington, D.C. where we will focus on what I'll just for right now call practitioners and people who are really in the process of delivering care, or in the trenches in one way or another.

We will also be developing a subcommittee on hearings in which we will invite a couple of you to join Catherine and myself to be the subcommittee that will work with staff and provide information back to you and bring information back to you for your comments and thoughts on the whole subject of hearings.

The subjects about which we will conduct the hearings will be legislative mandates, cross- related subjects. So when we do the hearings we'll be considering the legislative mandates that of course are in the laws, plus the issues and the initiatives, the related subjects that we discussed yesterday.

We talked about doing a meeting that would start at 1:00 o'clock on May 11th, but what we've decided to do instead is start earlier in the day, and that might be 8:30 or 9:00 o'clock. Can we say 8:30 right now, just so everybody has got the starting time? At 8:30 in the morning we'll start with some what I'll call education forum types of focus, where we'll have some of the foundational education that will be provided by folks who have that kind of background, and there will be interaction with us and those who will be delivering the information.

We will meet in the afternoon to conduct kind of a debriefing, what we've heard and discuss some of that material further that we've had in the morning.

On May 12th we'll conduct more formal hearings that will look maybe a little more like traditional hearings in Washington, D.C., but the time allocated to the speakers might be a little different, and they're intended to be interactive as opposed to five minutes for a speaker, questions, next panel, five minutes for the speakers, ten minutes, whatever.

And then on the 13th we will meet as a working group to conduct working group business and to conduct a debriefing on what we've heard.

The focus on the hearings and the educational forum is interactive.

Okay, first have we captured what we've discussed so far and what we've decided? And are we comfortable with that approach and that that meets the legal requirements that are on the record so to speak?

Anyone have any comments to the contrary of what we've just discussed?

MR. O'GRADY: I just have one clarifying question. Larry indicated that if we sort of generally say we're going to talk about a more general topic, but that will meet our FACA, our kind of legal restraints.

At the same time in terms of just sort of our putting a Federal Register notice out, letting people know about this, do we want to try and drill down and be a little more specific at this point, just so that there's not any confusion, just � I mean not � we're kind of legally covered. But I mean beyond that, just properly communicating with the broader community.

CHAIRPERSON JOHNSON: Okay, by drill down, if we were to say, let me test this with you, I've stated on the sheets, we'll conduct hearings related to the subjects required by the mandate.

If we were to list those subjects in greater detail, more specifically, would that be helpful, do you think?

MR. O'GRADY: I was just, when the slides were presented before, the first says capacity of the public and private health care systems to expand coverage. And then the third says, efforts to enroll individuals currently eligible for public and private health care coverage. That seemed to dovetail into some of the things that Richard had brought up earlier, and that that would give people some sort of a feel for, and then depending on what our feeling was is that the time we want to start with things like Medicaid and SCHIP and some of the coverage expansion discussions, and that could be maybe some of the topics for the morning.

But that was just a thought.

VICE CHAIRPERSON McLAUGHLIN: I'm thinking though about Aaron's comments earlier, that if we chose, for example, to have one of the future hearings in Mississippi, it seemed as though some of the things being done in Mississippi would naturally lend themselves to talking about Medicaid, SCHIP, vulnerable populations, access, expanded coverage.

And that may be the better fit for the Washington hearing, especially coming after this foundation format, would be the next one, which is cost of health care and effectiveness of care provided at all stages of disease. Strategies to assist purchasers of health care to become more aware of the impact of costs. And then the role of evidence-based medical practices.

I'm just offering that as an alternative. That's still getting at the subjects we're supposed to cover in the hearing. But it might be a better use of the geographic issue that we talked about, the location of these so-called experts, where do they tend to reside, and how it would fit with our Wednesday educational format.

Just a thought.

Richard, you're looking pensive.

MR. FRANK: Well, I tend to agree with Mike. I think it's good discipline, partly for the outside world, but it's good discipline for us to decide what we really want to focus on and get educated about. And I think that helps the staff, because the last thing they want to do is do stuff that either we already know or we don't care about.

So I think for that reason it would probably be a useful exercise to drill down.

The other question is again a process one, which is, have we decided if we're going to do something like mimic the GAO conference that Larry referred to, how that happens and how that works?

CHAIRPERSON JOHNSON: Let's just take that for a second. Would we be able to consider that our format for that day one?

MR. FRANK: That was what I thought was day two, right?


MR. FRANK: No, I think day two, for the hearings.

CHAIRPERSON JOHNSON: So you're thinking that's how we would do the hearings.

MR. FRANK: Well, that's the way I heard Larry's suggestions.

MR. PATTON: I was actually referring to the educational portion, the foundational portion. But there are other ways to think about the hearings. And Mike may have some other examples he wants to put on the table.

But the traditional one is to ask a panel to come up, and they might present their 10-minute or five-minute spiel, what they're all about.

So for example if you wanted to bring in safety-net providers, they would all do their spiel, and then you would ask questions.

An alternative to that, Brandy, would be to have no set presentations, and organize the discussion around two or three questions. So that rather than hearing from them sequentially, it's more interactive from the very beginning, and you do it that way, and Mike may have other variations that might have worked on the Hill.

But there are different ways of thinking about this within the quote hearing format.

MR. O'GRADY: There is one other model just to put out there just for your consideration.

The way MedPAC tends to do it is that it's often just a staff member - -well, I shouldn't say "just", they're pretty expert guys - - they'll come out, and there is a topic for the day, how we pay hospitals for whatever.

Now they tend to drill down tremendously on some of the detail. But they are moving towards a report. This will be the outline of the chapter. And then a staffer or perhaps a consultant that's been brought in presents. And then there is very much the kind of discussion you were looking for, Randy, there.

It really is not so much a five-minute thump thump bringing the next group in. There is maybe a half hour or 45 minutes that the first 15 minutes is the presentation by the people sitting at the table, one or two of them. And then there really is this interaction between the commissioners then about what they really think, and what they think is the right thing to do.

CHAIRPERSON JOHNSON: A couple of comments. First, the GAO forum, here is the way it worked. There was a subject matter expert who came in and talked, and maybe for 30 minutes.

Then there were two or three responders who were also very smart people, but subject matter expert, and added or disagreed, or filled in to the subject matter expert's discussion. And that took at least an hour to an hour and a half of intensive discussion on a subject.

And there were three, I think three or four such sections, maybe three, and then there were some breakout groups, and then they came back to report on what they heard in their breakout groups.

Now what we could do if you wanted to build off of that would be to take the subject matter expert and a couple of responders, or you could have a panel of three experts, they go through their presentation, and then we have a half hour or so of dialogue with them where we ask questions, exchange information, and so forth.

If we do that kind of a forum it probably involves less people from the outside to share their perspective as opposed to doing more traditional hearings where we invite people to speak, and we have three or four panel members, and then we ask them questions.

Whatever we would feel comfortable with I personally am open to it. But I would like to pretty quickly come to a conclusion of what we'd like to do so we can move on to the report.

MS. HUGHES: I'm sorry --

CHAIRPERSON JOHNSON: Those of you who are speaking why don't you identify yourself now so--

MS. HUGHES: Hi, Brent, this is Therese Hughes.

I'm sorry, you're interchanging words and I'm getting confused.

Are we talking about the educational thing or are we talking about the hearings, or are they both called the same thing? I just need to have that clarification.

CHAIRPERSON JOHNSON: Can we call day one an education forum?

MS. HUGHES: That's fine.

CHAIRPERSON JOHNSON: And let's call day two, let's call that hearings to begin with. And if we want to have the same format for both, well fine, I'm open to that.

But let's just start with day one, I'll just share what I thought was the education forum, and building off Larry's comment was the GAO type of program that we conducted last year.

And day two hearings, we can come back and talk about that separately. But how do you feel about the education forum that GAO had last year? Is that something you would like to do, or would you like to structure it differently?

VICE CHAIRPERSON McLAUGHLIN: I have a slightly different question. Larry has left us, Mike you may know the answer. Do we post all of these though as hearings? Because the public is invited to all of these.

And so internally we may say one is the educational forum, and the other one is the hearings. But externally, I think these are all posted as hearings. But just serve different purposes for us.

MR. O'GRADY: But there may also be in terms of the way you want it handled, there is the notion of an executive session. There are certain rules. You take no votes. Keep in mind that the main purpose of the FACA law is sunshine, so that there is no backroom stuff going on.

But in terms of bringing in an expert, it's a briefing in effect on how Medicaid operates and you're not making any particular recommendation, et cetera, et cetera, that's probably fine.

And the question would be, if you really are having someone that is just trying to educate people, some people on a task force like this don't want that done in public because they want to ask what they think might be kind of a dumb simple question. And they don't want to do that in front of an audience. They're comfortable enough if there were 300 people out here, does that have a chilling effect on your willingness to just go, slow up, slow up, go back, I didn't get that.

So I think it's mostly in terms of the usefulness of the day. If you think it would be more useful to have it simply be sort of us, I think that's allowed because we're not taking any votes, and you just call it an executive session, and the public session starts at noon, or starts on day two, or whatever.

If you'd like to be more open, I think that's all allowed.

MS. BAZOS: Could I just follow-up on that point? We can express preferences now, but I think we have to wait until Larry comes back.

MR. O'GRADY: That's my understanding, but Larry is more the --

VICE CHAIRPERSON McLAUGHLIN: We can do it, but I think we have to make sure when Larry comes back that we did the right thing with full understanding.

CHAIRPERSON JOHNSON: Okay, having said that, how would we like to do this? Is the GAO forum the format that we'd like to do in day one or do you have a preference for something different?

MS. BAZOS: The GAO forum is the interactive forum?


MS. BAZOS: I think an interactive forum in executive session so that people are comfortable asking the dumbest questions, bantering around, sounds good to me. This is Dotty Bazos, Brent.

CHAIRPERSON JOHNSON: Okay. Other comments?

MS. HUGHES: Did the man above hear that?

DR. JAMES: I did hear that, and I'm perfectly willing to sound foolish in a public forum, so it's all the same to me. Do it often in fact.

CHAIRPERSON JOHNSON: Okay, I hear no objections to this. So let's move to day two, the hearings.

I'll start the conversation by calling them hearings, and ask you again the question, how would you like to proceed with them? Would you like to proceed with them in a similar style for day two? Or would it be your preference to conduct what appears to be more formal hearings that would look more traditional like hearings than this, and we'd have people coming on a variety of subjects that deal with all of the issues that are required by the law.

MS. CONLAN: This is Montye Conlan. just wanted to put out there, you mentioned, you might bring in one or two or possible three people. That seems to assume that there's only one or two or three positions, and are you skewing the results by doing that? Or if you have more voices coming to the table do you get a broader representation of the issue?

CHAIRPERSON JOHNSON: Well, one of the challenges we're going to have, Montye, is, we could, just on the subject of Medicare, we could host two weeks of hearings and not cover all of Medicare.

We could do the same thing for Medicaid. We could conduct a couple of days, maybe a week, of just access issues.

And so that's why we're not going to be able to cover all of the subjects in depth, like those groups that are really focused on, what are we going to do on Medicare reform? Or what are we going to do on Medicaid reform?

That doesn't mean we can't touch on those, and we are not going to become Solomon on Medicare, or Solomon on Medicaid. But we can certainly attempt to have education and hearings from people that we think would be helpful on those subjects, and these other subjects that are required by the legislation.


MS. MARYLAND: Have we defined the topics or the topic or two that we want covered the second day?

CHAIRPERSON JOHNSON: In response to that, we need to have hearings on those subjects that are legislatively mandated. Plus we've talked about the issues yesterday, and we talked about initiatives.

So we would try to incorporate the issues we discussed yesterday with the initiatives and either hold hearings on those, all of those subjects in Washington, D.C., or some of those subjects in Washington, D.C., and others in the subsequent hearings.

MS. McLAUGHLIN: So no, we have not nailed down whether we want to drill down, as Mike said, for, this is the list for the Washington group. We haven't done that yet. We've kept it very broad at this point. As Randy just said, the mandated ones, the issues, et cetera. But we have not in fact made a decision whether we want to keep it that broad at this point or make a decision.

Do we want the staff to work with the subcommittee to look at that whole big list and then see who's even available, see what panels make sense?

Or do we want to be more prescriptive and say, this is what we want the subcommittee and the staff to do the best job possible finding the best people to talk about the following?

I think from what Larry said to me at the break, we can do either way. It's okay for us to say okay, there's the list of the issues in the mandate. That's a pretty long list. And we are going to do either all of them at some level of specificity, or a subgroup of them in more detail. But we're not deciding now what that's going to be.

Mike is saying, maybe we do want to carve out some in order to have, as part of the publicity for this hearing, to give it more focus.

I can see the pros and cons of both, but we haven't yet made that decision.

MS. BAZOS: Can I ask a clarifying question, Catherine?

For the hearings, where we've talked about doing hearings inside Washington this day, and then other hearings. So should we decide that we want to have hearings around all the issues? I mean do we need to decide that ahead of time?

I mean you had said we could have in-depth hearings on some of the issues, shorter hearings on other of the issues. But the mandated, we need to have hearings on each one of the issues at some point, some time, some place, right?

CHAIRPERSON JOHNSON: Yes, we need to discuss those subjects.

MS. BAZOS: Okay, I just wanted to make sure.

CHAIRPERSON JOHNSON: Also, if you look at some of the subjects mandated by legislation, a good number of them do require researchers, like my esteemed colleague here or Richard or Brent James or others, who really understand the in depth, they've studied some of our systems on an in-depth basis.

And so initially going in, my personal thought would be, we would try to have as many of those subjects dealt with in our Washington, D.C., hearings as we can, and focus outside of Washington on some of the practical implementation of initiatives that have been done and so forth.

Now, that doesn't mean if you all agree or if you all would want, that doesn't mean we can't come back to Washington at a different time for another hearing. But we've really contemplated just as those of us who have been talking about this before this meeting, maybe three to four hearings total.

If you as a group say, no, we need to have 15 hearings between now and July 1st, if that's what your wish is, we'll try to accommodate that. But we haven't heard that either. So we're trying to balance what are the legal requirements, what are the timetables, and what are the subjects to be covered, and what's the best way to do that. Understanding that we'll have town hall meetings later on so the report can be put together and so forth.

DR. SHIRLEY: I'm looking at 20 mandated subjects. It might be helpful to get that number out there.

VICE CHAIRPERSON McLAUGHLIN: Actually for the hearings there are eight. Don't confuse the hearings with the report. There are eight.

CHAIRPERSON JOHNSON: However, I agree with my colleague, as I normally do, but we have to write on all of the subjects that were in the bullets yesterday. And therefore, we have to have some information from some place.

So we have the subjects of hearings. We have the subject of hearings that are mandated. We have the subjects that are to be in the report that are mandated.

So we've kind of put some of those together. Because somehow we've got to get information to include in the final report.

MR. O'GRADY: Just a footnote. In terms of some of this stuff, doing things in D.C. versus otherwise, much of that is tied just because it's congressional. That's where the members are, as they say, like that's where the money is.

Other things where we've gone trying to draw experts we tended to use some place in the middle of the country so you're not making it much harder for the West Coast people.

So you pick Chicago or you pick St. Louis, some place with a good airport, good hub, and everybody gets then a day trip. It's sort of a day trip for those of us on the East Coast, and you just sort of share the pain in terms of getting there. And the guys of course in the middle have the least pain.

But much of the stuff with D.C. is more driven by the institutional side of the Hill, and therefore we're not constrained by it.

CHAIRPERSON JOHNSON: Agreed, and yet there are many of the researchers and academicians who are on the East Coast. So not limited--

VICE CHAIRPERSON McLAUGHLIN: Don't tell the Berkeley guy.

MR. O'GRADY: Oh, yeah, the Stanford guys, the UC guys. There are some of them, yeah. I mean that's where the criticism came from. You guys in Washington only listen to a certain East Coast elite, and there is a whole big country out there.

CHAIRPERSON JOHNSON: Agreed, and that's why we're talking about going outside of Washington, D.C. Therese, you were going to comment? One more comment and then let's see if we can put closure to some of this.

MS. MARYLAND: My question is more of a philosophical question, point of view. Do we feel that with the combination of the hearings and the follow-up, town hall meetings or whatever you want to call it, that that will give us enough information to really understand the national opinion, if you will, of health care and the state of health care?

And I ask that question from the standpoint that we may want to consider the possibility of supplementing this with a survey of some type, a consumer survey in terms of their thoughts on questions and issues.

VICE CHAIRPERSON McLAUGHLIN: We certainly are going to use the Internet for interactive stuff. But the reality is, we don't have anywhere close to enough money for a survey. There's $3 million to pay for all of our travel to all of these other places. Surveys, a decent survey, would cost a million. And we just don't have that kind of funding.

But we are going to try to be very clever in our use of the internet to supplement what we get. The other thing is Richard, I know last night, and Therese and people were talking about the community meetings, and a way to try to make the community meetings bigger than just having 10 to 15 people in a city come to this America Speaks.

MR. FRANK: Actually, I emailed Randy --

DR. JAMES: Randy, could I ask people to talk into their microphones.

MR. FRANK: I emailed Randy about this, and he said, well, I volunteer to sort of hunt down some of this, so I just brought some stuff for you all to look at, so I'll past it around. And it's sort of a different way of kind of getting people to participate, where you can get both interest groups, but you also get regular people.

And they've been very successful in organizing forums around the country to do this. And there are a couple of these, these guys have done it in health. And they ran the GAO one, right, didn't they?

CHAIRPERSON JOHNSON: I don't recall that they did or not.

MR. O'GRADY: They've done a lot of work for the comptroller.

CHAIRPERSON JOHNSON: Okay, now, what we have anticipated doing, Pat, is getting input from citizens after the report. But we have not contemplated going to the broader range of citizens at the same time we're doing hearings.

Phase one is the hearings, phase two is doing the report, phase three is putting the report up on the website, letting people feed back into that, phase four is doing the town hall meetings and interactive website materials next year.

So what America Speaks is about is more the phase three/phase four kind of initiative.

Okay, to try and push us along, because we've got some other things we need to do, I'm going to test something with you. We've discussed day one.

I'm going to throw out day two as it sounds a little bit like a repeat, but see if we can say yes, let's move forward, and if not, what's the amendment to it.

Day two, let me propose to you, is a day of hearings with a structure that looks more like formal hearings, covering the subjects that are in the legislation for both the hearings and the report, and including the discussions that we had yesterday on issues and initiatives, that would allow interaction by us as a working group but the interaction would be after people present testimony, we would have opportunities to respond with questions or additional comments if we wanted to.

That would be May 12th. If after we conduct those hearings in Washington, D.C., with that kind of a format, and if we, after we go out to the other locations that we're contemplating for some folks other than academicians and researchers and so forth, we would potentially if you want conduct still another hearing in Washington, D.C., or maybe in Chicago, that would get at some of the same issues that we would be focusing on May 12th.

Let me test that and see if you are comfortable with that, or if you have amendments that you would want to propose to that.

VICE CHAIRPERSON McLAUGHLIN: Well, they applauded.

CHAIRPERSON JOHNSON: So you're comfortable.


MR. FRANK: I remain a drill-down guy. And I guess what that means is, I like the structure of what you say, the structure is fine. And what I would propose is that we keep the topics more focused, and have a more limited number of topics that are pretty broad, like Mike suggested like the uninsured.

And given, particularly given that we have an international expert on this on our panel, that should be an easy one to get the best people on, because she pays them.

CHAIRPERSON JOHNSON: Millions of dollars.

MR. FRANK: But I do think that if we have a leg up that way we might as well use it. Maybe choose the three or four issues that are most salient and perhaps we need the most education on and that are most controversial in a sense might be the --

CHAIRPERSON JOHNSON: And then you would imply on that, if we drill down on some subjects, that means we don't cover as broad a range of topics, and we have to find another day to do that.

MR. FRANK: Exactly.

CHAIRPERSON JOHNSON: Okay. I'm seeing some heads going up and down and nodding affirmation to the amendment.


MR. O'GRADY: Can I ask a clarifying question to the amendment? I've also heard this theme of folks saying, okay, I'm willing to put in the time at the same time, this can be wearing at points.

There are two different topics that have been brought up. One is the uninsured, and one is the overall question of costs and health care costs and where the money is. Would people be more comfortable given that other notion of how much. Because if you had day one where that's the briefing day or however you want to think about it, if like the morning was the uninsured, and the afternoon was health care costs and where is the money.

And then you go to the second day where you hear from witnesses in the morning is the uninsured, and the afternoon is you know what I mean?

Something like that. I don't know that we have to make the whole deal the uninsured, and then we're done.

Because what you said before about the idea of, once we get out into other parts of the country, we may want to deal with it. We don't want to limit ourselves I don't think necessarily in terms of those sorts of things.

VICE CHAIRPERSON McLAUGHLIN: Well, actually, Mike, there is this wonderful item, subject on the hearings, called, innovative state strategies to expand health care coverage and lower health care costs.

So that can actually be a topic for every single hearing no matter where it is so we get the best of both in that sense.

MR. FRANK: If we did spending and the uninsured, we'd probably cover half the eight anyway or maybe more than half the eight?



VICE CHAIRPERSON McLAUGHLIN: Half the eight. That's exactly right.

MR. FRANK: If we did the uninsured, and spending, then we would cover half of what we're mandated to cover anyway. Then we'd still have this other hearing we're going to do outside of Washington, right?

So it sounds like this is not going to be hard to accomplish, and we need to accomplish legislatively. And I wouldn't be surprised if we finished a couple of days like that, and then people will have a chance to think about it a little bit. And they may want to hear more witnesses and do something else, you know what I mean? Go beyond that.

But I'm just wondering if a full two days on either topic, whether people aren't just going to be coming out their ears by the end of the second day. That was my only thought.

VICE CHAIRPERSON McLAUGHLIN: Well, I think the education forum is going to be on the broad topics, I thought, for the first day, isn't it?

So we actually are going to cover the whole broad range of topics, sort of the plumbing system, as Richard put it.

MR. FRANK: Hydraulics.

VICE CHAIRPERSON McLAUGHLIN: Hydraulics, oh I'm sorry, I did plumbing, you did hydraulics. The hydraulics of a system-wide thing is what's going to be on the first day, that's the educational forum.

CHAIRPERSON JOHNSON: Would we also be doing Medicare and Medicaid on day one?

VICE CHAIRPERSON McLAUGHLIN: Yeah, that's part of the hydraulics. I said hydraulics, Richard.

CHAIRPERSON JOHNSON: I understand what plumbing is. I don't know what hydraulics are.

Okay, why don't you repeat what you've heard all of us say so we're on the same sheet of music.

VICE CHAIRPERSON McLAUGHLIN: So the first day in the morning, whether it's CRS or GAO, whoever it is, that we have run the educational forum, they are going to teach us about hydraulics, also known as plumbing, also known as, the system, what is the current health care system. And that is going to be in executive session where we we're not going to take any votes or any decisions. It's an educational forum. And we're going to be able to ask really dumb questions.

Brent, we're happy to know that you're happy to ask dumb questions in a large group. But there are some people here who prefer to be in executive session.

MR. O'GRADY: We needed to check with Larry.

VICE CHAIRPERSON McLAUGHLIN: Oh, that's right, we need to check with Larry.

MR. O'GRADY: Because essentially that's not administrative. You're talking about subjects that are a different subject --

MR. O'GRADY: Well, is that allowed, if there is no vote and there are no recommendations coming out of it, it's simply a briefing?

MR. PATTON: I'll check with the lawyers but I don't think you can. The exception is that you can close a meeting when you're doing things that either deal with commercial secrets, undue invasion of an individual's privacy, or proprietary information.

So you don't really have that choice on this, or administrative matters. So if you want to discuss kind of how you do your work unrelated to the subject matters. But you can't close for the subject.


CHAIRPERSON JOHNSON: Okay, but there is no reason why, unless someone is embarrassed about asking basic questions, there is no reason why you should have --


MR. O'GRADY: For everyone including all of us who work full time for the government, there is going to be topics we all know a lot about, and others we know nothing.

CHAIRPERSON JOHNSON: Okay, but what we can do, if there is an embarrassment with asking questions, what we can do is we can develop some mechanisms to help do that, including slipping papers to the chairperson --

VICE CHAIRPERSON McLAUGHLIN: To Brent, who is not embarrassed.

DR. JAMES: Send a note to me and I'll ask it.

VICE CHAIRPERSON McLAUGHLIN: You will be our questioner for sensitive questions.

The first day we'll do that afterwards. And we're not sure, it might be one or two panels in the morning, and then one right after lunch. But then the group will meet for a few hours to say, okay, what have we learned? How has this changed what we want to do next? Et cetera, et cetera, et cetera.

Then the second day we're going to have hearings, and in those hearings, they are going to be focused on the different coverage issues that are listed in the statute that have to be covered in the hearings, right?

And we will have panels structured around those topics with one, two or three. The subcommittee can make recommendations back to us later for future hearings.

But at this point we just want the staff to work on, how many people can we actually get, and I guess it means how many can Catherine call and get in May, to come and talk about these different issues about coverage.

And then Friday, the working group is going to meet to hear from the subcommittee on future hearings, to make decisions about future hearings, and other subjects that have come up.

CHAIRPERSON JOHNSON: Okay, thank you very much.

VICE CHAIRPERSON McLAUGHLIN: We have one hand and a lot of nods.

Richard, the hand?

MR. FRANK: My only question was, so your summary implies that we're going to do one topic alone all day.

VICE CHAIRPERSON McLAUGHLIN: On the second day. Coverage. I thought that's what the group decided to drill down on.

MR. FRANK: I thought it was coverage and spending.

VICE CHAIRPERSON McLAUGHLIN: Spending, though, is where the money goes and where it comes from.

MR. FRANK: Well, and also where are the sort of crises? What do the crises mean in Medicare, Medicaid, for the employer, retiree.


CHAIRMAN JOHNSON: Okay, thank you.

VICE CHAIRPERSON McLAUGHLIN: It's a correction, not an amendment. It's a helpful correction.

CHAIRPERSON JOHNSON: Yesterday we spent some time talking a bunch on searching subjects.

MR. O'GRADY: Can you hold one second? I've learned from enough of these that when the staff starts to get as nervous that those two look --

MR. PATTON: Just to clarify once again for the direction, in terms of, are you doing what Richard just said? Between Richard and Mike we heard, kind of, some parallel structure I thought between the two days using those two topics.

But I just wanted to be sure what you've restated, if you could restate it one more time.

CHAIRPERSON JOHNSON: Well, I have not heard or understood a parallel structure between the two days.

MR. PATTON: Okay, so that was when I heard that from Mike, I guess, and I didn't hear that.

So what the structure on day one is --

CHAIRPERSON JOHNSON: Education forum such as we had there.

MS. BAZOS: With all of the topics.

MR. PATTON: With all the topics. And day two --

CHAIRPERSON JOHNSON: Day two would be more traditional types of hearings with a focus on drill-down on the subjects that Catherine and Richard have been discussing.

VICE CHAIRPERSON McLAUGHLIN: Coverage and cost but not medical effectiveness and some of the other subjects we're supposed to cover in the hearings are strategies to assist purchasers of health care and clinic consumers to become more aware of impact of costs and to lower the costs of health care. That's costs, you guys.

Costs of health care and effectiveness of care provided at all stages of disease.

MR. FRANK: No, we won't do that.

VICE CHAIRPERSON McLAUGHLIN: Well, but costs of health care.

MR. FRANK: We identify I think on the employer's side there are sort of these retiree pressures on the employers, the Medicaid prices, Medicare prices, that's just sort of getting the facts and the clarity on those seems an important place for us to start.

VICE CHAIRPERSON McLAUGHLIN: Well, some of the facts we'll get the first day in the educational forum.

MR. FRANK: Right, the facts, but also the perspectives.

VICE CHAIRPERSON McLAUGHLIN: So give me better ideas of what that panel will look like for the hearing day, and what kind of people you're thinking of to testify on that.

CHAIRPERSON JOHNSON: I'd like to not get into that kind of detail actually right now, because we've got lots of other things we need to talk to.

Let me come back and ask, instead of getting into that kind of detail, if we can say, we'll do hearings on all of these subjects that we talked about. We will drill down on some of the subjects as well. But we are not going to exclude any of these subjects that we talked about.

Can we say that from a legal perspective and then give the staff some latitude to develop some recommendations and come back to us as a working group, legally?

MR. PATTON: If the staff is bringing recommendations back to the group, you need another public decision meeting. So I would not do that.


MR. PATTON: It can be fleshed out. The question I'm trying to get at is, to say we're going to do all of the topics in hearing, day two are you going 24 hours? This is not doable to do all of the topics on day two.

So all I want you to do is just try to come to a sense of, you're going to do as many as the staff can set up. That's a fine set of directions. See who's available and see how many of these you can do, and you'll do the remainder in subsequent hearings.

That would be sufficient directions to staff. But there's got to be a question. We can't do all eight topics and have panels. That is just not doable unless you're prepared to sit incredibly long period of time.

MS. BAZOS: I have a suggestion.

I think what we brought to the table was that if we focus the second day of our formal hearings on just one subject we'd be brain dead.

So I thought the suggestion was to have at least two topics. Someone through out, why don't we do the uninsured and something about cost.

So perhaps we could come to the agreement that we should be the uninsured. Because, Catherine, we have you with contacts for decent people to come, and then for the second topic, so that we have two topics, we just base it on the best experts that are available on a topic that's in that list of eight, and leave it up to who can come.

CHAIRPERSON JOHNSON: Are you comfortable with that?

MR. PATTON: Yes, that's absolutely fine.

CHAIRPERSON JOHNSON: Are the rest of you comfortable with that?

DR. JAMES: I'm comfortable with that.


Now let me just kind of share with you what we have tried to do. We'll have more committee interaction in the future, and we'll be more proactive in bringing recommendations to you as a full working group.

We've come into this session this morning with something of an absence of recommendations, because we've wanted everybody to have a feeling like you had input into the process and so forth, and to share your ideas. And we have a better understanding now I think of some of your thoughts and directions.

So we appreciate the dialogue.

Okay, are we ready to move on to this?

VICE CHAIRPERSON McLAUGHLIN: I'm ready. I think everyone is.

CHAIRPERSON JOHNSON: Okay, yesterday we talked about issues that all of us see, and we talked about some initiatives that we have seen implemented, or see about to be implemented, that we're aware of.

And Brent James, who is with us now, was not able to share his perspective with respect to that. So while we were on break I asked him if he would take a similar amount of time as we had individually yesterday to introduce himself, why he applied to be part of the working group, and then some of the issues that he has seen, experienced, observed, and any thoughts he has on initiatives that relate either to those or others that are working well.

DR. JAMES: Thanks, Randy.

Maybe I ought to give a little background first. I know many people on the committee but there are some I don't.

I'm a physician first of all, with a degree in statistics and a very heavy background in computer science. But I worked for the last almost 20 years at Inter-Mountain Health Care in Salt Lake City, Utah. In that role I run a training program on clinical quality improvement.

And really my areas of background are clinical quality and patient safety. That's where I've spent a good chunk of my life.

I guess two little things in association with that. We run a training program. The reason I'm not with you today is because our advanced training program is meeting. So I have a roomful of about 40 -- about 60 percent physicians and about another 30 percent nurses, 7 or 8 percent CEOs, CFOs, various academics, who are in services research for example.

But over the last 15 years we've trained about 1,400 health caregivers in quality improvement.

We actually have quite a number of knock off programs running. We call them mini-advanced training programs, mini-ATPs. But last count I came up with 10. Pretty strong ones, very strong one at the Alaska Medical Center in Anchorage that supplies services to the native Alaskan population.

A very strong one at Baylor Health Care Systems, Memphis, Tennessee. Well actually two very strong ones.

We're now on our 12th or 13th class in Sydney, Australia, where the public health services, New South Wales Health, started that kind of training.

We also have a very strong group, I think we're on our eighth Yarmshire County Council in Sweden.

One of my real reasons for doing that is, it just gave an opportunity to go and teach. All of the classes have projects. You're required to complete a successful improvement project to graduate.

And one of the things you very quickly discovered is that all of those countries suffer from fundamentally the same problems that we do in different ways.

One of my real interests in this is the different ways well, just comparing the U.S. to these other countries and what we can learn from that.

I guess the other major thing is this, there's a body of quality theory very well established outside of health care that holds that as you improve your clinical results, service quality and medical outcomes quality, it should cause the cost of health care to drop significantly.

The best current estimates are a little bit soft, 25 to 40% of all health care costs represent waste. Our work suggests that that's a low amount, that there is a massive gap in health performance within the system itself, performed kind of from the inside out, that there are opportunities to greatly expand access by appropriately controlling costs.

So the idea that better access coming from better outcomes that produce lower costs. I have a very intense interest in that, and I think that was the real trigger that got me interested in the citizens working group, just the idea that we very clearly need to reform health care.

And I guess what I'm suggesting is that the big part of that reform needs to come from the inside out, as opposed necessarily from the outside in. And I think the contrast that you can learn from looking at Canada, Sweden, Australia, Great Britain � I have a very heavy relationship to Singapore, too, to these other health care systems.

So with that, I'd be curious if anyone has any questions for me, about my background or my obvious prejudices.

CHAIRPERSON JOHNSON: Brent, did you say that you believed that the 25 to 40% might be low?

DR. JAMES: Yes, I do.

CHAIRPERSON JOHNSON: Could you build on that?

DR. JAMES: Oh, this really comes from Dr. W. Edwards Demming, who developed the main theory and demonstrated it very heavily in industries outside of health care.

The classic example in health care is patient safety. So for example the number one source of injury to patients in hospitals are adverse drug events, allergic reactions, drug-drug interactions, overdoses in their various forms.

Some of the research we've done suggests that well over 95 percent of all of those injuries result not from errors but from system failures in how the system is constructed.

There are some that result from errors, but it's under five percent, at least of classic errors. We researched the things that we would intuitively regard as errors. It turns out they're all technically errors.

Well, that's associated with literally billions of dollars in costs. If you have the adverse drug event you have to pay to fix it, pay to treat the patient.

And this has the potential of, to give a 15 to 1, 20 to 1, return on investment, as you take down adverse drug event rate by fixing the system.

Now the guy who published the main work on this in health care in the past was Craig Anderson at Chicago. 1991 was the date of a very rough estimate.

He said 25-40%. That corresponded to what people found in business outside of health care, when this movement really first started 20 to 30 years ago.

By the way, let's just put it this way, if you haven't already mastered this in a nationally competitive manufacturing industry, you don't exist any more.

You cannot fail to master this and compete successfully. And it's to the level of subconscious thought almost in most of industry.

We currently have a grant. We're trying to get some estimate of how broadly it spreads in health care. And based upon our initial findings, Randy, in that bit of research, yeah, I think that it's going to be, well, up around the 40 percent mark, let's say.

So for example, we've been observing people at the front lines, nurses caring for patients. You know we have this nursing crisis in the country with too few nurses. Our best guess is, somewhere around about 35 to 50 percent of nursing time is waste in how they do their work and how their system is structured in which they work.

And I don't know, I'd have to take some real time to show you the details, but I think it's very compelling.

CHAIRPERSON JOHNSON: Thank you very much.

We have a few people who are talking across the table here, and I'm wondering if they have comments that they would build on, or if this is new information, or if some of our experience as well.

I'm not trying to pick on anybody, but your data is compelling. So if we have questions or comments on that, I'd be interested.

DR. JAMES: I guess what I'm saying is that I agree that any health care reform has to somehow address this issue. And just in passing, the rates of quality waste in other countries are very similar to the United States.

So Sweden, for example, arguably the finest socialized medicine system in the world, at least by reputation, Great Britain, Australia, Canada, I've got a bunch of Canadians in the class downstairs right now.

But the reason is their health care costs are increasing at an unsustainable rate, despite their relatively low levels of cost compared to the United States.

And when you get down underneath it, you find these same issues.

So the reason I like teaching my classes in those countries is it means we work on projects down at a care delivery level, the level at which care actually happens. And you get to see all the dirty details.

CHAIRPERSON JOHNSON: What I'm hearing also is, you're suggesting that the issues that you are attacking are systemic as opposed to I'll just say personal neglect.

DR. JAMES: Yes, they are clearly system- based, no question about it. It's how you structure the system. One of the models I really like is one that Don Berwick cooked up for the IOM "Crossing the Quality Chasm" report. I think he may have sent it around, I really can't remember exactly.

The idea is that care happens at a front line level, so you have patients, then you have above them the local care, what we call the micro-system. Above that you have a health care system. So like IHC, the company who I work for, is health care system. And above that you have a policy level. And you start to think about what you do at every level of that little model, you know, up and down, to make things work right.

But the main point of contact, what the Australians have called the cold face, the sharp end, because patients interacting with care deliverers in various forms.

DR. SHIRLEY: This is Aaron Shirley. I'll just make a comment for the group. The kind of information that you have just shared with us is going to be very threatening to some folks.

DR. JAMES: Yes, it will. They need to be threatened by the way. And it turns out that with a little work they can respond quite positively.

MS. PEREZ: This is Rosie.

And as you were talking, I couldn't help but think about focus groups we've had in hospitals and just with associates, the nurses and staff having to do the work. And that's their main complaint is that they don't have enough time to spend with the patients, because it's trying to do all the paperwork because of the regulations or the accreditations or everything else.

And of course that's certainly not the reason why they came into health care was to do paperwork, but to do interactions with patients.

DR. JAMES: I hear you. It's interesting, last year, we have a clinical management team called Women's Newborn, where we're starting to generate the data systems. Frankly the data we have today are not the right data to manage care properly.

By manage care, I don't mean an insurance company. I mean a group of clinicians managing the way that they deliver care.

We're starting to create those data systems. And I think last year we took about $20 million for our system out of the cost of labor and delivery. It turns out that's the biggest single process we run, is pregnancy, labor and delivery. About 30,000 deliveries a year.

And we dropped the cost, the variable cost, not fixed, of the labor and delivery, by about $400 a case by appropriately managing elective inductions, you see what I mean?

And when you start to do that, it means that the staff gets to put their time where they're most effective. They came into care to deliver care.

And if you start to stress your systems, you get a whole series of efficiencies in terms of using their time wisely in terms of not being in recovery mode because you just screwed it up in different ways.

And it turns out it was pretty compelling. Somewhere along the line if people are interested I'd love to share those results. Because I personally believe that it will be critical to our long-term work. It just changes the way you look at the world.

CHAIRPERSON JOHNSON: Could we ask that you get the material to Ken Cohen. Do you have his email address?

DR. JAMES: I don't know, let me write it down. It's extensive enough, Randy. I don't know, I'll have to think what to send, and then I'll start to send some stuff.

But I'm looking forward to a long time to discuss this back and forth. And in honest truth, guys, I'll usually just listen. So I hope I won't be too much of a pedant.

CHAIRPERSON JOHNSON: We will connect with you so you know Ken's email.

DR. JAMES: Okay, sounds great, or he can just email me.


Other comments or questions? Yes.

MS. BAZOS: Well, this does bring up a question for me, this is Dotty Bazos. As we're having these discussions, and I'll ask you this, Brent, because you're not here. But some folks in this room have tremendous expertise. And if we wanted to get a paper or ask a question about whether they've applied their research to another question that might help us move forward, is it all right with everyone for us to just sort of email each other with those kinds of requests?

CHAIRPERSON JOHNSON: We talked about that yesterday actually. Not as a group, Catherine and myself. And there are some of you who have expertise that we could ask to participate in a hearing for example.

But rather than doing that in a formal hearing, we thought maybe we could identify some time where some of us could share the learnings that we have based on the experience that we have.

We just had a touch of that yesterday with Frank talking about the Oregon project. But there might be other similar kinds of experiences for which we would want to have longer periods of time.

And the response is, yes, I think Dotty, that we'd like to do that. And if any of you have similar kinds of experiences that you'd like to share, and you have written material you'd like us to review, we're open to reviewing that. And then share your requests for some time with Catherine or myself. We'd be happy to consider that as well.

DR. JAMES: Can I ask a procedural question about that?


DR. JAMES: Relative to the Sunshine laws, I guess that we should email things they become part of the public record so that makes it legal, right, when we email things around?

CHAIRPERSON JOHNSON: Well, I'll ask our esteemed colleague, Larry Patton, to discuss that.

My understanding has been that what we use as materials in our meeting is public, but not necessarily what we email, as long as we're not emailing decision matters back and forth.

Is that a correct understanding?

MR. PATTON: I think what Brent is going to is the question of whether it's best to keep the most comprehensive record possible. That's probably advisable.

The tapes for the emails with the staff will be backed up and maintained. Individual emails between a member and another member obviously are on their email systems, they are not on the email system of the working group.

But it's a question of what you choose to do. There is nothing that prevents a working group member from sharing an idea with another one. The biggest question, where you start to get into a clearer area is where there's actually if all of the working group is on an email, it should be copied so that it goes to Ken or one of the staff so that it will be part of the backup system.

Because you shouldn't be doing any offline decision-making or even too much, that type of information sharing at that level. But I don't think you need to copy email. But as Brent says, it would in fact be a nice thing to do. But not a required thing.

DR. JAMES: The main thing is, Larry, it sounds like it's a legal thing. I was hesitant to start to blast things out because, first of all, it's burdensome, but more important, I just wanted to make sure we can make it part of the public record pretty easily, can't we?

MR. PATTON: Yes. So if you want to blast

things out to the entire group I would recommend copying the staff. And we'll get those emails to you. That way it will be part of the backup tapes.

DR. JAMES: Okay, wonderful.

CHAIRPERSON JOHNSON: And could we just send it to Ken Cohen? Any information we want broadcast would go to Ken. And he would send it out to us.

MR. O'GRADY: Randy, can I? Given that there's been a number of questions about sort of how we educate ourselves and how we continue to do this, is it possible for the working group to have a web page where there'd be sort of a reading file along these lines, it would be part of the public record as well as real easily accessible to all the members as well as anyone else.

MR. PATTON: We're going right there this afternoon.

VICE CHAIRPERSON McLAUGHLIN: At lunch, just like I worked at dinner, I'm working at lunch to talk to staffers here who are drafting the prototype for our website in the short run.

In the long run we're going to have to add a lot of interactive stuff. In the short run for information, we're close to having something ready to be put up.

CHAIRPERSON JOHNSON: Chris, you had a question a few minutes ago.

MS. WRIGHT: Brent, this is Chris Wright, and it's really not a question, just a comment, hearing what you have been doing, and what I see in some other areas of the country also, in that you're actually looking at maybe not so much time of root cause analysis of problems, but actually hardwiring systems into place.

And I guess my question to you is, do you see that can be done at a national or federal level?

DR. JAMES: I don't know whether this is going to cause a real heart murmur for some people, but it is a major cultural change, and change is hard.

But what we're seeing now is that these sorts of things are happening on a fairly wide scale. And the pace is accelerated.

This is just me being perhaps a little bit naïve, but I personally find that very, very encouraging of this kind of reform from the inside out. It ties heavily into electronic medical records, too, very heavily into electronic medical records and how they're used, and the techniques we use to make them effective.

So it all kind of fits together as a piece. But yeah, it's clearly passed the tipping point. But on the other hand, it's darn hard work. There's a fair bit of resistance, you know, just general training strategy that is working its way through the system.

But I think it gives us at least part of a foundation from which to make recommendations that could really have some teeth. I would think of it as, what do you do in the short term, and what do you hope for in the long term, or what vision do you have for the long term?

Now, just a little bit of background, again, a little bit of prejudice, I was a member of the IOM committee that produced "Crossing the Quality Chasm,” which was of a similar nature. That was our 30,000 foot level, not too prescriptive, recommendations for health care reform for the country.

And frankly, I regard it as probably the finest piece of work with which I've been associated today. Of course our work as a working group is going to surpass that, I'm confident.

If you haven't had a chance to see it, I strongly recommend it to you. But it was built around the same sorts of ideas and principles. And I think they're starting to really play out.

CHAIRPERSON JOHNSON: Well, Brent, your comments today go to some of the initiatives we discussed yesterday regarding also disclosure to doctors and hospitals and patients of performance, paying for performance, and having patients have an increased sense and opportunity of consumerism � not just cost shifting for the sake of cost shifting, but actually financial discretion.

And it sounds like what you're talking about goes hand in hand with that.

DR. JAMES: Yes, it really does. So again, truth in advertising, I'm currently serving on the IOM performance measures subcommittee. We're just wrapping up, hopefully getting our report ready to go. So I'm very heavily involved at that level.

CHAIRPERSON JOHNSON: Well, Brent, thank you very much for your input. We're sorry you weren't able to be here yesterday but glad you're able to be with us today for the time that you are.

For everybody's information, Ken has provided his email. I will give it to you in case you'd like to write it down, but you're going to receive emails from him in the future.

Ken Cohen is So it's one word before the @, kcohen, k-c-o-h-e-n @ a-h-r-q dot gov. Okay?

Okay, well, it's closing on 12:00 o'clock. Is lunch here? Lunch is not here.

The other agenda item for this morning is to get in and talk about reports. And Catherine is the one who is going to facilitate this discussion. I'm going to find a power source to turn my computer on.

VICE CHAIRPERSON McLAUGHLIN: As we said, you guys have a copy of the slide so you can look at them. They're in your book, maybe under a color tab. So it's just all part of tab four, page three, tab four.

The hearings are to feed into the report, and we debated for quite some time about how to start, whether we start talking about the report and then talk about the content of the hearings, or vice versa.

And arbitrarily we picked this way, but it could have been either.

The report has, again, a list of things that we are required to put in, remembering that the focus is to start this dialogue and be educational.

A lot of it is summaries. There is a long list, if you look at the list yesterday, a long list of summaries. And this is Senator Wyden's, where the dollars come from, where do the dollars go.

And that's something that we will have staff who hopefully have access to a lot of good data as well as use summaries and tables that have already been calculated by other people.

So that's the analysis of the cost utilization data, and coverage and payment data. And those I don't think will be very controversial, with the exception of what we choose to present. And that will be something I'm hopeful the group can at future meetings, the staff can present us with suggestions of how to present different data, but also discussions of what the focus of the data should be.

So we're going to start fairly inclusive and then whittle it down so that we don't have a 2,000-page document, but have something that is digestible.

We also will want to talk in a little bit about dissemination. But at this point I was just talking about the development, this is really stuff the staff is going to do using information that is already available, and in some cases, and Caroline Clancy talked about this a little bit yesterday, using the MEP data and the hospital discharge data, other data that HHS has, that are confidential, and that researchers outside are not allowed to because of confidentiality reasons.

So you can't get city-level data or MSA level data if you're a researcher, but they have it. So there will be some new aggregations that are not available that will be calculated just for our report using those data.

The next step is the critical syntheses of extant literature. And that's where I was saying this morning earlier that I personally would like to see some people come to the hearings and tell us, Brent I'll use your example of "Crossing the Quality Chasm", have some people from the field come in and say, yes, that report was wonderful and it laid out this and laid out that, but here are some problems that I have raised with that report that I think the staff and the working group should be familiar with when putting together their report.

The same with the IOM report on the uninsured, again, truth in advertising, I was one of the reviewers of that final report which is on record, it's in the report, so therefore have a lot of information about what was in that report, and personally have some problems with how some of the data were generated.

So we can go along that list of saying, all right, let's look at the literature that is out there and do the best of our ability to be critical in our synthesis of it, and I'm using "critical" not as the word is negative, but have critical thinking of, all right, do we think that doing due diligence that we could say to the American public here is what we

know about the hydraulics. Here's what we know versus here's what we really don't know. Evidence suggests that, but experts will tell us that the evidence is spotty, or it's based on a very small sample size or only one experiment, or it's too early to tell.

Yesterday, Brent, several people were talking about the Clinton reform in the early '90s, and one of the comments that came out was, make sure we're secure about our data and our facts in our report.

So that is where I would like some help in the hearings, and also, just from talking to other people.

And then finally for the development of the report, insight and information provided at the hearings. What kind of innovations, what kind of initiatives are taking place that, either because of where they're taking place, aren't in the popular press or the published literature, or are so new that we wouldn't know about them because no one has evaluated them, no one has really put them out there.

And that's the other thing I would like to get from the hearings to help us fulfill the mandate of what we're supposed to include in the report.

We're not live yet on the computer here, so Brent, you're not missing anything. You're seeing paper copies like everyone else. Actually we just did this on purpose, Brent, so that you would not feel left out in anyway. You're not missing anything.

Dissemination, we're going to make this available through multiple venues. And this is where we are starting to work with the website, trying to get it up, but also from every member of the working group. Already yesterday and today you mentioned newsletters you get, you mentioned email networks that you're on, you mentioned websites that you go to. Boy oh boy oh boy, do we want to hear more and more about that over the next few months so that we can develop a really nice list of places to put information about the report.

The report will be posted on our website, but we want to make sure that the word gets out to as many groups as possible all over the country so that they know to go to our site and look at the report.

We also want to use the media, and when we decide as a group where we're going to have community meetings, I propose that we get in contact with local newspaper reporters and radio interviewers and have our PR person or Randy or I or if one of you in that local area preps to give the information about, gee, the report is up on this website. So that people really know about the report.

And similarly, in press, professional and trade journals. And we really want to make sure that the report is disseminated as broadly as possible so that people do in fact look at it and have some sense of what we're doing and then can contribute back to us saying, well, you missed this example, or you missed that example, or I'm concerned about these particular issues. So we get a lot of feedback.

In order to do that, the next slide says that we really need to present this information at various levels of complexity. So we are going to have a complete report on the website, which as I have on the slide, will be a full consideration of the materials presented that we've developed with multiple tables and complete sets of data.

But we also have to have shorter summaries, shorter summaries that are going to be available on the website as well, at community meetings, and in print and radio venues.

What I would like to see is a pie chart or a histogram, or I'd like to have that presented a different way for it to make sense to me.

And that's where we're going get feedback on the report so that we then can develop our recommendations.

Now the next slide actually calls this the revised report, and I have since been told by the wonderful staff members that I used the wrong word. It's the recommendation, develop the recommendations.

So we're not just going to revise the report. We are going to make recommendations based on revisions that we get, input that we get, from the public on the report.

And so those are some of the issues I've listed that we need to consider from all those community meetings as well as working on an Internet.

I talked to somebody at dinner last night, we've been thinking about putting a Jeopardy-type game up on the Internet for example, where we present some of the information in the report in the form of Jeopardy, where you have the columns, you know the squares, and you have a lot of facts, or you have some of the hydraulics information of where the dollars come from, where do the dollars go. And people do it interactively in a Jeopardy format.

There are a lot of different ways we can try to make this user friendly to reach a lot of people, and we also, a year or so from now, are going to have to have an interactive component on the Internet so that people can give us feedback.

And this goes to your comment, Pat, rather then paying somebody to do a polling, a household survey or whatever, which I really just don't see us having the resources to do. This will not be a random selection, because it's people who go to websites. But at least it will give us some feedback.

And what Richard was talking about last night, with America Speaks but didn't get around to me, but I'm hoping that that material is getting around, it sounded to me that one or two of the community meetings could in fact be random draws from the population.

So it's not going to be a national survey of taking people from all over. But you could go to several larger communities. What was the largest you said they got - 5,000 people in one of these?

MR. PATTON: 5,000 at one site.

VICE CHAIRPERSON McLAUGHLIN: 5,000 at one site. I mean I don't know what we can afford. But part of it is, if they've done this before where they say, all right, we need to have a random draw of women of child-bearing age, of elderly women, of younger adults, of this, in the different groups, and then they pluck someone, well, that's how a survey works too.

So it would not be nationally representative, but it at least will be representative across the different groupings.

So we're going to try I think some combination of those two methods to substitute for yet another survey of responses to our report.

MS. MARYLAND: Question. I know that the National Research Corporation, for example, does consumer preference surveys in terms of hospitals across the country. I don't know anything about the cost associated with that, but it seems to be doable.

Now I don't know whether or not we'd want to go in that, where they would pick randomly selected by state or city a number of individuals that would participate in the survey as their preference hospitals and answer specific questions as to why that is their preferred choice.

And I was thinking when I talked about survey more that type of methodology, not a national, every household type survey.

VICE CHAIRPERSON McLAUGHLIN: Well, some of the information like that we'll be able to get from existing surveys that are already out there.

MR. FRANK: Yeah, I was just going to say that CMS and others are now putting CAPS and NTQA into their assessments. And they have those types of things.

And there's the net website, the CMS website, which has the hospital quality ranking, quality ratings. Have you tried it? You type in your zip code, and you ask, they give you a choice of hospitals, and you can see what the cardiac mortality rate is and all that.

MS. MARYLAND: I'm talking about more of a survey asking opinions from the public regarding what they consider the major factors impacting their lives and how health care ranks in terms of that, and, specific to health care, what are the problems that they see particularly in terms of the payment of health care.

That's the type of survey that I'm talking about.

MS. WRIGHT: Are you familiar with the BRFS survey? The behavioral risk factors, I think they're just coming out with a new one. And it asks those type of series of questions, and it gets to, the last time you saw a doctor, who did you go to, and so on. And most of them are dated within the past three or four years, and I know they're being updated this year.

VICE CHAIRPERSON McLAUGHLIN: And of course Richard Frank’s colleague, Bob London, at Harvard, does these kind of surveys with Harris and other people all the time of what do you think your problems are. And absolutely we'll incorporate those data.

I thought earlier, perhaps I misinterpreted, I thought you were suggesting a survey to get the consumers response to our report.



MS. MARYLAND: Understanding their issues with health care so that as we start to shape our recommendations, that we have more than just a town hall response.


MR. FRANK: I'm sure Bob would be willing to come down and talk to us.

VICE CHAIRPERSON McLAUGHLIN: About the results of the surveys he's done?

VICE CHAIRPERSON McLAUGHLIN: Okay, so there are some comments on the report that again we're going to try a form, a subcommittee of people, and we're trying to hire staff.

And I talked to Carolyn Clancy about access to those data so that we can get going on this. Because there is a list of descriptive things that really at this point don't take a working group decision, but we need to get going so that when the

working group meets sometime this summer the staff are prepared to give us what they've done so far, and we can then make the decision of, well, I really think you need to include these data. Or this is the kind of question Pat raised: Why don't you have information about those surveys?

And so at this point it's really just to inform you of the overall strategy that we're taking about development and dissemination, and to let you know that I'm going to be calling on some of you for help and input as we move along, but that the overall goal is to have the staff start as soon as possible getting to work on gathering the data and getting organized, so that when we have a working group meeting, not too far away, because we were supposed to have the report ready by the end of August.

CHAIRPERSON JOHNSON: We're trying to buy some time on that.

VICE CHAIRPERSON McLAUGHLIN: Yes, and as Senator Wyden said yesterday, on conversations with us about the reality of this, I mean we didn't have any staff at all until a week ago yesterday. And so we really can't meet that deadline, but could we have a working draft by the end of August that would then be circulated to all members of the working group and get some feedback, and then to have the report ready by October, is that a more realistic goal?

I don't know whether it is. It depends on how quickly we can hire staff again, and get access to things. But that is our goal for now, which means that sometime probably in July, we haven't really looked at calendars, we need a working group meeting or in August to say, okay, this is where we are.

But in the meantime we have to have some meetings of the subcommittee with the staff to really get cooking on this.

CHAIRPERSON JOHNSON: My question is probably a preliminary question, and we haven't talked about this at all, and if you want to postpone the response, that's fine, but would you envision an outline to the working group in an initial stage of getting input from the working group, and then a first draft to the working group after you had feedback? And what would be the first draft? Would it be a complete report or would it be some of the key points that you've indicated here earlier that would be not a full detailed report.

What are some of the process concepts that you're contemplating?

VICE CHAIRPERSON McLAUGHLIN: Well, the outline as it exists right now is the list in the statute. I mean that's how I'm starting, is to look at the items that we're required to put in, and then say, all right, how do we respond to each of that.

And so that's not really something at this stage that I want input from the group on, but rather, as we make those decisions about what data we're looking at, what we're including, then send out information to all of you and say, all right, this is what the subcommittee and staff have recommended. What do you think as a working group? Point out things that we've obviously forgotten, give us some feedback on your opinion about certain things.

But right now the outline is the list. just have to see if PowerPoint will give me an hydraulic system picture.

MR. FRANK: I can do that for you in my introductory lecture.

VICE CHAIRPERSON McLAUGHLIN: There you go. I used the bucket brigade, but it's the same idea.



MR. PATTON: Oh, no, the only thing I was going to say is, you've got one heck of a challenge. Because most commissions, separate from your charge, most commissions have about three to six months of set up time in which you can very systematically pursue an executive director, and systematically hire staff or seek detailees, so that when you start you are fully equipped.

You are doing it on the run, so you're trying to get dressed as you're running out the door. So it's a very tough challenge.

VICE CHAIRPERSON McLAUGHLIN: And we don't want any indecent exposure.

MR. PATTON: Absolutely.

CHAIRPERSON JOHNSON: Well, it seems like we have some moments of silence here. So maybe that indicates it's time to take a break for lunch. And the lunch is over here. Why don't we reconvene in half an hour.

(Whereupon, a lunch recess was taken.)


DR. JAMES: Hi, this is Dr. Brent James trying to get into the system so I can meet with you.

CHAIRMAN JOHNSON: This is the old country farmer or doctor, and 13 or 14 others. Actually, we're here, Brent.

DR. JAMES: Sounds like I found the right place.


As we look at our agenda for the next period of time that we're here, Larry Patton is going to bring us up to date as to some of the legal and logistical matters that we need to be considerate of as we proceed as task force members.

So there are some slides in your book on this. We invite your attention and notes as he shares.

By the way, just another word: Larry has been working with us since the day we were appointed. Came up, introduced himself, and basically has been very very thoughtful.

And sometimes he has been, as we say in the Midwest, in my face, and it's all been very helpful kinds of feedback.

So I was thinking earlier, Larry, and I'll just say this aloud, that I really do appreciate personally, and the working group does as well, the input that you've provided to us. Even though we are not going to like what you're going to say, we appreciate it very much.

So thank you very much.

MR. PATTON: Thank you. The slides are in tab five, and I'm not going to say every single word.

But what I just wanted to be absolutely clear about, I'm not a lawyer, although I do play one at work. And so as a result there may be things related to FACA with the government and the Sunshine Act and other things that from time to time we'll need to seek guidance from the attorneys here at the department just to be sure.

But what I wanted to do is walk through a couple of things that you need to know about existing law that governs your activities, and also raise some questions about ethical rules and guidelines you may want to adopt by looking at what other commissions have done to govern your conduct.

And then beyond that, to talk just basics about reimbursement, and take it from there.

So let me start with FACA, which is government in the sunshine. Essentially FACA was designed to cure some ills. There used to be tons of advisory committees that were around that lingered forever.

So believe it or not, this was partly designed to make sure these commissions sunset after two years or needed to be specifically extended.

The second was that many operated in secret and led to what people thought were biased proposals coming out of them. And so the notion was that if you do it in the sunshine, then everyone can hear your deliberations along the way, recognize whether you've considered all alternatives. And it provides that in fact you must accept public input along the way, and I'll talk about that specifically as we go along.

The other thing that the people at the General Services Administration asked me to mention is that there are currently 62,000 of you serving across the government on advisory panels, some like yours for the president, others to departments or to agencies.

And without the relatively low cost input that you provide, compared to what it would cost to hire consultants to do this work, the government is getting a phenomenal deal and is incredibly grateful for your service.

The basic requirements are pretty simple. One is that all meetings need to be open and accessible. This means that we need to have a Federal Register notice published, as you'll talk about after this session. You'll also have a website, and it should be listed there. And we should in fact try to reach out to the trade press to make sure as many people know about your meetings as possible. So that requires 15 days advance notice.

Another issue is accessibility. And you have to take into account limitations for those who are handicapped or have other issues. So holding your meeting in either a non-handicapped-accessible building or in a remote location where it would be very difficult for anyone to come and observe, that's a problem.

Richard is pointing to the fact that this place is definitely not as closely accessible as others. And we were limited to some extent, because as I mentioned this morning, you are on the fast track. And given the fact that by the time the you were all surveyed for schedules, there was very little time to schedule the meeting so we used the agency.

But in the future, we’ll have greater lead time. I'll talk about the additional ways that will affect how we organize and do the logistics for meetings in a moment. You also need to, at a minimum, allow public input in written form, so that at every meeting people can submit written documents to you.

I would encourage that it be done electronically, because you need to make everything that's submitted to you available for public review at the Commission offices. And so I think the most logical thing to do is to try to have as many submissions in electronically as possible, that they're available on the website.

You also need to make sure that all documents that are prepared for the working group are made available. So when we were talking this morning, and Brent was talking about something that would be blasted out, I was thinking of something that would be actually in an email but not necessarily a document.

A document that is prepared for the working group, if Brent wrote up anything about this and sent a document along - that should be posted on the website. So anything, if you have consultant reports, any of that needs to be up there and maintained.

We will eventually need to have a designated federal official who needs to go through a series of steps just to make sure that the interests of the government are maintained. But that should provide no real issue for you. We'll probably make it one of the detailees to the working group.

I'd thought I’d just mention in passing the fact that we have a transcript that can be made out of this since we are recording the meeting and you are required to maintain detailed minutes of every meeting.

Our national advisory council meetings tend to average one day and 30 pages of detailed notes. Those are required, within 90 days, to be certified by the chairman of the working group.

Now the trend for most commissions, rather than having the chairman being forced to certify, and if you get into controversial issues, it's an interesting thing, because on the one hand you may retrench a bit from having a transcript available word by word. On the other hand it does pose an issue and a burden on the chairman to ensure that the summary is in fact absolutely accurate and captures all points of view.

So many commissions, rather than putting that burden on the chairman, are increasingly moving to posting a transcript. So that's an issue that you'll need to discuss. An interesting thing that I would urge you to watch is verbiage here.

You have basically public meetings, which is, I think, when it comes to the word, meetings, the only type of meeting you really can have is public. In the notes here on the second page of the slides, you'll see a statement about closed meetings. The criteria for a closed meeting is not met by this group, because you will not be getting into any of those issues. So whenever you refer to a meeting, it's this one, and it's open.

However, you can have working sessions and administrative working sessions. And working sessions could be the subcommittee type of meetings. And those do not require public notice, are not open to others, so that you do not have the 15 members. For a public meeting, as I said, you need to give 15-day notice.

If you were closing a meeting, if you qualified to do commercial trade secrets for example, a group that did that would still need to give 15-day notice before they could do this.

You have no advance notice requirements for the next two types of sessions here. So a subcommittee can meet as long as the issue they are being asked to address comes back into a public session.

You obviously do not have to come back to the public session and say, Joe said this and Mary said that. What you need to do is come back to the overall recommendation.


MR. ROCK: Larry, just a question, and I'm reading the text. It says under working session, our morning conversation here, it sounds like day one, our education forum, could actually be a working session, and what we're calling day two would actually be the public hearing.

Is that accurate?

MR. PATTON: I wouldn't advise that, only because you're not sure it's not really a designated subcommittee to come back with something to the group. I think you're best off always to err on the side of having meetings open. It will raise more questions than it would otherwise, particularly if it's just foundational, and it will be on the subjects you're addressing.

If you want I can ask the lawyers for a ruling on it. But I'm not sure what you gain in terms of public appearance. I think you lose by appearing to be doing stuff --

MR. ROCK: Be right technically and wrong in public appearance.

MR. PATTON: Right. The other is administrative working sessions. And those, if you're discussing personnel matters or other types of things regarding your internal operations that don't affect the substance of the recommendations that will be in the interim or final reports, I think you're fine to do privately, and you don't need to announce them in advance.

Never make a decision as a working group by private telephone call, by private email exchange, or in a private meeting.

Now the tricky part here, or the reason why I emphasize private in all three parts, is that you could make a decision in a chat room that was announced and available to the public to participate using the Internet. So you could have a call-in 1-800 number where you had sufficient lines for anyone who wanted to call in, and to make a decision on a telephone call in that way.

What you cannot do is make a decision in an email chat that's just among you to which the public cannot participate. You cannot do a conference call that just involves the members of the commission.

So that you can go and use electronics later if this proves to be useful to you.

CHAIRMAN JOHNSON: And you're talking about content here of --

MR. PATTON: Right, these would be the content ones.

CHAIRMAN JOHNSON: -- the working group, not necessarily decisions of, we'll meet at a specific date or something like that?

MR. PATTON: Yes. Now you always have to have copies of meeting materials available on the website no later than, and the lawyers advise me, it would be useful several days before so that people can be knowledgeable observers.

But as long as they are up and available on the day and they are available here as we've made copies of the materials for the meeting these two days, that needs to be met.

I have the recommendation also about the transcript, but that's a matter for you to weigh because obviously there are pros and cons to doing it that way.

I think you do want to encourage the written submissions electronically as I said. It'll be much easier to keep them posted.

And I think it's useful along the way to also show, since you are a citizens' working group, to try to have public comment sessions where appropriate.

If you've just completed a review of something you may want to see if anyone wants to add to it.

In terms of maintaining records, all the records of the working group must be available for review by anyone who wants to come to the office, which is in Bethesda, to take a look at them at any time.

A lot of you have probably heard of FOIA, which is the Freedom of Information Act, under which people can send a FOIA request to a federal agency or a department and say, we want to look at X, and then the agency charges them, I don't know, 10 cents a page to copy it, something like that.

As a FACA committee, as a government in the Sunshine committee, no one has to go through FOIA to look at your stuff. Everything is available all the time, so 24-7. So in that sense at least - I'm exaggerating a bit on 24-7 - but it needs to be available when the offices are open.

As part of the process, because you are connected to the department server for email for the staff, all of that will be backed up and maintained. We need to maintain records - I'm blanking on the number of years. After the duration, then the records must be processed in accordance with the requirements of the National Archives and Records Administration. But I believe it's somewhere in the neighborhood of three years that they need to be maintained afterwards.

Are there general questions about FACA before I move on, or government in the Sunshine? Or does anyone feel that this is too onerous or too much of a problem? Are people comfortable with the general requirements you need to meet?

DR. JAMES: Sounds pretty reasonable to me.

MR. PATTON: And Brent, you've been operating under them for a long time.

DR. JAMES: I have, and they work out just fine.

MR. PATTON: Okay, let me turn to ethics and conflict of interest and financial disclosure.

There'll be a number of issues here which are ones that are discretionary for how you want to proceed.

The commission will hire two types of people: folks who are employees and will in fact be federal employees, and they're subject to all of the rules that govern employees of the Senate.

In the statute as you know both those of you who are members of the working group and the staff are to be treated as if you're employees of the Senate. So as a result it's the Senate ethics rules that will apply for the staff.

You're in a different position because you're not a full-time employee. So as a result you face fewer restrictions in terms of things, and more of them are actually a question of whether you wish to establish rules governing your conduct.

The other types of people that the commission would hire would be consultants no matter what mechanism is used. And for consultants only those rules that you as a group establish for employees or consultants would apply.

So now examples of what commissions have done to try to avoid conflicts of interest. Now Brent serves on our national advisory council. And because that's a commission that advises the agency, the executive branch rules apply.

So as a result when Brent comes to Washington to meet with our national advisory council for the Agency for Health Care Research and Quality, he is not permitted to go to the Hill to lobby.

Now several of you do have jobs that might in fact have you going to the Hill. And the way that most commissions resolve it is, they simply say that on the days of meetings - so for example like today and yesterday - that you would voluntarily refrain from going to the Hill. Because if you're initiating a lobbying visit, it might confuse people as to whether you're going as a working group member to lobby the Hill, or whether you're going as in your personal capacity or professional capacity.

But that's an issue for you to think about.

In setting salaries of employees, the working group has great discretion. In general I would advise that you follow the guidelines that agencies would use. For example in hiring interns, what does the department use as a guideline. So that

you don't get any questions about whether you are in fact showing favoritism or paying people inappropriately.

And in a lot of cases the more high priced people probably will be coming on as consultants. But if there is an employee at any pay level it's usually useful to look at the executive branch standards or GAO for that matter. Whoever you use as a model, it will keep you on the straight and narrow.

The other question is whether you decide, and you may choose to do so or not, but you may decide to go to different firms to contract for background papers to feed into any part of this process. I'm not sure what you'll end up doing. If you do, some commissions ask that whenever there is a firm under consideration, that they, in fact, see if anyone has any conflicts so that they need to recuse themselves from the decision, because their wife works there, their immediate children work there, they have a financial interest in the stock.

This, therefore, eliminates the potential that people think that you went to them because you've got some personal tie. So it's very useful to make sure that that's done.

I have in the notebook an example of that type of disclosure form to think about, as I also have background on the FACA requirements.

Public financial disclosure, there's - the disclosure of individual assets by individuals will not pertain to most of you. The criteria that kick in are two: one is, and these are the legislative branch rules, not the executive branch rules, is that if you have a rate of pay that is in excess of 120 percent of the GS-15 level, which the rate of pay you're receiving is in fact at that, above that level, you're paid at level four of the executive branch scale, which is $140,300. So as a result, that pay qualifies, it fits the first criterion.

The other aspect of the pay is not total pay received. It's that you're eligible at the rate. So therefore you don't have to receive $140,300. You have to be eligible to receive it for each day worked.

The second is, whether you spend 60 days on commission business per year. For purposes of ethics, that's triggered by whether you are reporting any time for a given day.

So for example, if you were seeking reimbursement for half a day of work because you were doing something for the commission, and the rules that you establish for how you will pay yourselves would justify reimbursement, then that time counts for counting the days.

So even if the commission didn't meet, but you were delegated to do subcommittee work, and you spent half a day doing it, and you decided that the subcommittee work was reimbursable, that counts.

I think the odds are that only the chair and the vice chair and the executive director will hit that. But if you do hit that, you hit the disclosure of assets rule.

Now for the executive branch we have both confidential disclosure, which I have to do, and then for people who are at a different level, they need to do public financial disclosure.

In the legislative branch there is only public financial disclosure. And so I have shared with the chair the forms that are used by other commissions that hit that level. But I think that that's only potentially viable for three people, the

chair, vice chair, and the executive director. So I don't think that will hit any of you, but I wanted to lay it out in front just in case you start to think it through. Because one of the issues you do need to figure out is, other commissions, and certainly with our national advisory council, we tend to pay people for the days that they are here, and we pay them for one day of preparation, to prepare for the meeting.

And that also comes back to all the comments we heard earlier that people would like materials ahead of time so they can be prepared and ready. So that if the chair chooses to adopt that approach and in discussion with you about payment for the days you're in meetings here, whether they're hearings or meetings, and the day of preparation, the other question that you face as a group is how do you want to pay for any other time?

Is subcommittee time free? Or is subcommittee time that you're on the phone and conference calls, do you want to pay for those and account for those? So that's another issue you face. But do know that that will begin counting against the 60 days, so there is a pro and a con to it.

If anyone chooses that they would prefer not to receive reimbursement for the salary, not for travel but for salary, if any of you have any work issues or any issues where you would just prefer to decline, that is a possibility. I still have not gotten the form from GSA to indicate what has to be signed. But there is just a need for a signature to indicate that at some future point you're not going to turn around and change your mind. There can't be a future lien against the government. If you decide not to accept salary, you decide not to accept salary.

Let me stop there on the ethical things. I was not proposing in my presentation that you actually debate these now. I think that this is a matter where you may want to reflect and come back, either later today or come back at another meeting to do this. I think you need time to think this through. Are there any clarifying questions?

MS. STEHR: Are you paid for your travel time?

MR. PATTON: That's a decision for the commission to make.

MS. STEHR: At least for some of us it takes at least a day to get here.

MR. PATTON: So those are part of the rules that you can establish for how you will determine that. I don't know of any restrictions on that. I will double-check with GSA to be absolutely sure. But I think you're free on that.

Other types of things?

Let me turn to, if you could pass these up, while I had slides in the book on travel and reimbursement, I thought that perhaps the most logical thing to do was to walk through the basics of what you're going to need to do when you walk out of here.

And so what this page basically says is, remember that your airline travel is being covered centrally so that is not being charged to you. Everything else has been charged to your credit cards.

And so what you need is to have a receipt for lodging, no matter what the lodging costs, small or large, you always need a receipt. They need the original receipt, so you cannot fax this in or send an Adobe Acrobat file. That doesn't meet the test. So you need to have the original receipt. So I hope everyone kept their receipt checking out of the hotel, and just make sure that you always maintain those.

The only other receipt that you actually need is if you have for example, if someone is taking a taxi from here to BWI and the cost is over $75, then that is a requirement that you need to have a receipt. It used to be $50 a few years ago as the cutoff point.

A large part of that is that over time, while the government used to require every single receipt for every single ten cents you spent, it became such a burden that it just didn't prove worth it for trying to catch the few people who actually did try to cheat on this. As a result those are the only two areas where you need receipts.

You will be paid a flat amount for food. In this area it's $51 a day. So as a result when we're at a hotel, though, we probably will be having the meal incorporated within the overall contractor support and won't be charging you as we did for a lunch here today.

But whenever we have to orchestrate a meal outside of a hotel setting, you will need to pay it as you go and get reimbursed for it.

If we orchestrate a meal, let's say at a hotel, there is a formula which I don't know off the top of my head, but the $51 is composed of an amount for breakfast and an amount for lunch and an amount for dinner, that would automatically be deducted so that it would come down.

So there are specifics in some of the other statistics material that folks put together for you. But I think that is the basic overview.

The only other thing is that for your hotel rate, when I first came into government, if the federal rate was let's say $149 and the hotel was at $149, I had to pay out of pocket the tax. It started a few years ago that that's separate. But any additional charges beyond one phone call for $5 home, if you have a home phone call that meets that criteria, just circle it on the bill and let them know, and that will be covered.

But the other thing is to avoid other things, cost of the Internet or any of those things are at your expense. I've talked to the chair, and we are looking at for the hotel next time, looking at Crystal City or downtown Washington, and I've asked

for the contractor to look for hotels that have free Internet service if that's possible at all, because most of you will want to be staying in touch. So if we can do that, we will always try to look for hotels that do that.

In terms of writing up your expenses, there is no form. But the basic thing is to make sure that whoever is handling reimbursement - and we will handle it temporarily until we have someone on board who can do travel at the working group offices - that you just make sure that you walk it through in the logical way so that the person handling it knows that you've covered every leg of the trip.

So just basically if you got a ride with family to the local airport or pickup there, just indicate that, because that will make sure that the person doing travel doesn't try to waste your time reaching you and saying, did you forget to add this?

And for everyone, you want to get paid fast. So if you can walk that through, that will be fine.

CHAIRMAN JOHNSON: What's the rate for mileage?

MR. PATTON: Does anyone know? I don't know the --

CHAIRMAN JOHNSON: What we should do for this first submission is just submit the number of miles, and it will be calculated.

MR. PATTON: Right, so if you drove to the airport and you left your car, put the miles in there and back, put the parking lot fee - you don't need a receipt, again, unless you're over $75 - and we'll take it from there. And we'll make sure that you get accurate feedback regarding how much you get per mile.

CHAIRMAN JOHNSON: How are tips handled and miscellaneous expenses like that?

MR. PATTON: For the most part, if it's within like a taxi fee that's generally just covered in whatever amount you're putting in for the taxi. Obviously if you're putting in an exorbitant amount for a tip it may get flagged, because it will seem like an unusually expensive trip.

But I honestly, I have never submitted anything for tips at hotels. I have just paid them.

MS. TAPLIN: And the same goes for meals? It would be sort of rolled in?

MR. PATTON: It's rolled into the $51. So the thing is - if you're paying tips separately - the other thing is that when you're out on commission business, if we in fact don't have a scheduled meal and you are doing anything separately, while it may be very gracious to pay for someone else's meal, it's probably best, since people can only get reimbursed for their own meals, pay for your own meals because obviously why should someone absorb it if in fact it's covered by your per diem.

So if you pay for someone else, that's not going to get covered. And we encourage people to pay their own share of taxi fees. It just starts to become complicated, because then they have to cross- check to make sure that there's been no double counting for taxis. Even if you share a taxi, just divide it up. It'll be much easier in the long run.

Someone raised the question with me, and I know it's an issue for several people, whether it's possible to get advanced reimbursement. I know it is as a federal employee. I don't know the question, and I will check it before you leave, whether that's possible if anyone needs to do that. So I'll get the answer for you before you leave here today.

I'm trying to think if there are other things. Yes?

MS. STEHR: Approximately how long does it take to get reimbursed?

MR. PATTON: I'm trying to think. Oh, actually, there is an issue that plays out. One is that they will prepare the voucher, as the submission is called. Then they will fax the top copy to you that you need to sign. Probably they'll fax you the whole thing. But you need to sign the top copy and you need to mail that back, which is your certification that what you've put on there is true. And that triggers the process for getting reimbursement.

After that, it's relatively expeditious. I would say no longer than 10 days. And the sooner you get your stuff back, and you don't have to type this up, so if you wanted to write this on the plane or however you're going back, just do it, and then complete it once you count your expenses back to the home or office, wherever your final destination is, and get that out in the mail tomorrow so start that process. Catherine?

VICE CHAIRPERSON McLAUGHLIN: They'll automatically do the $51 a day or whatever. We don't put that on our --

MR. PATTON: No, you don't. They will calculate that based on the rules. On something that Ken prepared for you earlier, and I'm not sure where that went, but it talked about the fact, and this is something as an employee who seldom travels, I don't pay that much attention to it, but apparently on travel days you get 75 percent of the amount. Why that rule exists, I don't know.

In the old days we used to calculate quarters of the day. So if you arrived back home at 11:59 you only got half a day, and if you arrived home at 12:02 you got three-quarters of a day. I think they've now just done 75 percent to simplify the computation. So everything used to depend on when you left your house to catch the plane, and when you came back. And it seems to me that they've just gone to a greater simplification of that.

MS. CONLAN: I'm finding that I have a need for a lot of tips for all this wheelchair assistance each leg of the way. So all of that is covered?

MR. PATTON: Let me talk to Tina, and we'll get you an answer before you leave.

Anyone else?

DR. JAMES: Larry?


DR. JAMES: This is Brent. I just assume that my HHS and AHRQ stuff are, I ought to treat them as completely separate accounts?

MR. PATTON: Correct, because they're reimbursed separately.

DR. JAMES: And it sounds like I'm under different rules. I'm under executive rules when I'm with AHRQ, and I'm under legislative rules when I'm with the citizens working group.

MR. PATTON: And actually it just means that most of the rules you're under are just in fact less onerous. I mean they're basically more ones that you decide as a group to establish for yourselves.

So let me go back to the example I used earlier, Brent, it was that on the lobbying. On the lobbying you've got an absolute prohibition from lobbying the Hill while you're on a trip for us. But the working group can make a decision about how they want to cover it or not cover it.

I think it would be unwise not to have a rule governing it, but it's your choice here. So it's just one of those things that, the rule may not be identical, may or may not be identical to what's imposed on you by the executive branch.

CHAIRMAN JOHNSON: We'll talk about some of the issues that Larry has raised when we're done with the questions and answers. We'll talk through some of the questions that he has put. But let's make sure that we have answers to your questions right now.

MR. PATTON: Other things that either I know or can find out?

Okay. I'll turn it back to the chair.

CHAIRMAN JOHNSON: Okay, thank you. Thank you, Larry.

Let me go through at least some of the questions that I thought I heard raised. And if there are others that you have, we can address those as well.

The first one that I thought I heard raised was, would we like to put a summary of the meeting online, or would we like to post a transcript online?

You can understand some of the implications of both, I think. It would seem that if we put a summary online, it would take some time to review that and make sure it's correct, and it's subject to some potential argumentation as to whether or not the summary captured everything that was essential to be captured.

If you put a transcript online, you have all the details there. Anybody can review what it actually says, although it's longer, and there may not be the kind of review that the average lay person might do.

DR. SHIRLEY: We'll have to watch our language.

CHAIRMAN JOHNSON: I've been meaning to talk to you about that, Aaron.

By the way that's just come over the transcript, Aaron, so. So that's true.

MR. HANSEN: A summary would be helpful to me instead of reading through the whole thing just to look at it. But is a summary treated like minutes where they have to be approved by the committee or by you?

CHAIRMAN JOHNSON: I would assume that if we do a summary for ourselves, it has to be posted.

MR. PATTON: Right, anything you would produce. But on the other hand, and actually I should have raised this, so I'm glad you raised the question Joe, is that if you do a transcript and post a transcript, then probably before you leave today, we should talk with the writer, who is here, about what type of summary would be helpful for all of you.

It obviously doesn't need to be that 30- page detailed summary. It could in fact be a much more terse and directed summary that would be useful for what decisions were made, or what other things you want to capture, and we can give him direction today, and this could be by the chair, it doesn't have to be a group decision unless you want it to be, in terms of what would be actually useful to you.

So it doesn't mean you wouldn't have one or the other, but again, both would have to be posted, but this could be framed in a way that's much more direct and useful to your next meeting so you can capture everything quickly.

CHAIRMAN JOHNSON: You may end up with a transcript a lot quicker than a summary. Because whoever is going to review the summary, if they're going to try to make sure it captures all of the essential elements, that's a review process in itself.

MR. PATTON: So your summary doesn't hit the same legal issues if the transcript is posted.


MR. PATTON: So once that's posted, it doesn't have to be comprehensive in any way. It just has to be a useful working document.

CHAIRMAN JOHNSON: Let me ask the question in a different way. Maybe this is helpful.

If we are to do a transcript, that completes our requirements for posting a summary of this meeting.

MR. PATTON: That's correct.

CHAIRMAN JOHNSON: So if we were to be able to say to the person who has done the transcribing or whatever, give us a summary of the action points, action items, we would not need to post that, or we would need to post that?

MR. PATTON: My understanding is that anything produced for the group should be posted, but on the other hand it could be much more terse. It doesn't need to meet the requirements of completeness or even balance because the transcript is available for people to review directly. This is just a document that's designed to help you.

So it could be one or two pages if you wanted. It doesn't need to be a long document in any way, shape, or form. But since it's a summary of what the specific public actions are - it's not going to be what Joe said, or what anyone said - my guess is that you would have very little trouble posting it, because anyone who sat through the meeting would have heard the same things.

CHAIRMAN JOHNSON: Okay. Do we have a proposal on transcript or summary, or transcript and summary of action points, something like that?

MS. WRIGHT: Would there be any difference if we got a summary, and then as in the public or Freedom of Information Act, then someone reading the summary is referred to a full transcript?

MR. PATTON: If we do the transcripts, the transcripts have to be available.

CHAIRMAN JOHNSON: Brent, what is your practice in the other commissions and working groups that you've been on? And can you share a little bit of what you think has worked well, and the advantages and disadvantages?

DR. JAMES: I think the philosophy of being generally open is a very very strong philosophy, and we should think of generally open and only if we have a sensitive issue should we go into - I can't remember the exact name for it. That's worked pretty well for us.

And we tend to use transcripts. We tend to read through them as we come in to prepare for the next meeting and then actually make corrections.

So when we have it just right - my guess is this is a long transcript for a NAC meeting, a full day national advisory committee meeting.

MR. PATTON: Absolutely.

DR. JAMES: On the airplane I usually you read through it, and then one of the first orders of business is, approve the transcript.

Now it's not at all uncommon to have people do summaries, brief working summaries as working documents. Frankly I can't think of a time when it would have been sensitive enough that we wouldn't have been willing to share those as well. At least in the past it's just not turned out to be a big issue.


MR. HANSEN: Are we making the rules for all the meetings, not just yesterday and today?

CHAIRMAN JOHNSON: I think we are probably trying to set a precedent.

MR. HANSEN: I'm comfortable with just a transcript, and leave the summary for our own.


MS. MARYLAND: I'm comfortable with the transcripts also if we have a chance to review them before having them made available.

CHAIRMAN JOHNSON: Okay, thank you. Okay any comments to the contrary of those two?

MS. HUGHES: Can I just ask something? This is Therese. Pat, do you mean before it's made available to the public or before it's made available to us for the next working group?

MS. MARYLAND: To the public.

MR. PATTON: You have, just as a guideline, you have 90 days from the meeting to post either the summary or the transcript. So that would give plenty of time to meet Pat's suggestion that we make it available electronically to you, or in fact, potentially, if the website permits, there may be a section of the website where things could be reviewed before they go public.

So either way it could be made available.

VICE CHAIR McLAUGHLIN: I would skim through for when I was the person to make sure that it captured the words I used, and not different words.

MR. PATTON: You couldn't make substantive changes.

VICE CHAIRPERSON McLAUGHLIN: I would rely on everybody to do the same for when they're talking, and I would just look for my name and then what it says I said. And you can't change what you said, right, Larry?

MR. PATTON: Correct, you can't make substantive changes.

VICE CHAIRPERSON McLAUGHLIN: But if they wrote down the wrong word because you didn't articulate well --

MR. PATTON: Which is a problem for all of us.

VICE CHAIRPERSON McLAUGHLIN: -- which is a problem for all of us, that you can in fact make those kind of corrections. But that is really the only correction you can make.

So for our approval, Pat, just means you look for mistakes in a transcript, not your desire to sound more articulate or smarter.

MR. PATTON: And you certainly can't change the substance. So that if you said something and you regret you said it in public, you've said it in public.

VICE CHAIRPERSON McLAUGHLIN: So if you have a dangling participle, it's still there.

DR. JAMES: We nearly always have a few small changes, but they are of a nature of, the word was actually this not that. And sometimes they can be, they can recapture transmissions pretty well, and it just means that on the transcription it wasn't clear, and they didn't get it quite right.

But it comes up, one or two of them, almost every time.

CHAIRMAN JOHNSON: And you are recording this meeting so the tape is the foundation or the basis for the transcript.

MR. PATTON: Foundation for the transcript.

CHAIRMAN JOHNSON: Okay, can we move to another subject? Are we comfortable with that?

DR. SHIRLEY: I can see some academic type reading through the transcript and wondering how this group wasted the taxpayers' money.


CHAIRMAN JOHNSON: Okay, another question that Larry raised was the subject of lobbying. Is there a statement that we might make regarding lobbying by this group. And he suggested that some other groups have come to a conclusion and agreement that they would not lobby on the dates of meetings. They would not go to Capitol Hill or the White House to lobby on days of meetings.

Let me ask you for your thoughts on that. Is there anyone who would feel heart burn with that? Otherwise if you don't, we'll kind of take that as an accepted recommendation for our consideration.

DR. SHIRLEY: I recommend that.

MS. BAZOS: I don't have a problem with that - this is Rosie. I just think we need to be clear, because I think at some point yesterday we discussed about building consensus as we moved forward with the recommendations and the community meetings as we went forward to keep people abreast of what was coming out with the senators, Orin Hatch and - I'm blanking on the name. So I just think we need to be clear once we get to that point.


MR. PATTON: And that does not count as lobbying.

CHAIRMAN JOHNSON: Okay, thank you very much. We'll take that as a recommended action.

Then Larry, you had a comment on salaries and conflict of interest.

MR. PATTON: Primarily on salaries, just in setting salaries, because the working group has no history in terms of hiring folks. And probably one of your first hires will be some interns as well as then starting to think about staff, that we just use guidelines either from GAO what they would pay, because they are a legislative branch organization, or the executive branch, just so you have some guidelines for a comparable level job, so that it eliminates the potential of anyone coming back later and saying, oh, you just gave them money because you like them.

Other groups have tended to go in this direction for setting salaries when I talk to other commissions, and most thought it was a prudent move.

CHAIRMAN JOHNSON: So what you're suggesting, as I understand it to put it into practice, if people from HHS or Department of Labor would be employed by this working group --

MR. PATTON: No, this would be people you hire directly. If they are people from HHS, they will be on detail to you and remain paid at their current salary.

CHAIRMAN JOHNSON: Okay, thank you, that's a good clarification. So that people we would hire directly would, we'd look for equal or a comparable job at comparable pay?

MR. PATTON: Right, and I'm not applying this to consultants. Consultants, a lot depends on the overhead or what have you. That's a separate issue.
This is just direct hires who become federal employees under your supervision.

CHAIRMAN JOHNSON: So let me now ask you again in a different way than the first, but similar is the second question: Do any of you have heart burn regarding that recommendation? Seems fair?


CHAIRMAN JOHNSON: Okay, I think we have an agreement there.

The next item that I have that Larry mentioned was, should we be paid for the following things: reading of information; subcommittee work; and travel work?

And I'm wondering if you would like to reflect on that and come to a conclusion next time, or if you'd like to discuss it right now?

First, would you like to discuss it right now? Is that your preference?

MS. STEHR: I'd like to discuss it now.


VICE CHAIRPERSON McLAUGHLIN: Well, I have a question about the time, travel time, for example. If it takes some people two hours, do you submit two hours? It wasn't clear to me how we submit our time.

Say it's based on some Senate salary, grade, level, blah blah blah, that's an annual salary. But does that boil down to an hourly rate?

MR. PATTON: I want to separate this discussion from the one about staff. Staff would be paid at different levels. You are statutorily paid at level four of the executive scale, which is $140,300 a year, and that's then pro rated.

VICE CHAIRPERSON McLAUGHLIN: That's what I'm asking if it's pro rated on an hourly basis or a daily basis?

MR. PATTON: Well, those numbers can be determined. And that would be a matter for the rules you wish to adopt.



MR. FRANK: I guess my pleasure would be to say, we pay you for one day of preparation, and whether you prepare on a plane or whether you prepare sitting at home, it's up to you.

CHAIRMAN JOHNSON: Let me ask a question of those of you who are in the academic community, and then I'll share what the experience is in the business world.

For those of you who are in the academic community if you work extra hours in your salary - I don't know what your salaries are - but if a person at a $140,000 level would be working extra hours, would they be paid? Or if a peson would be traveling would they be paid for travel?



CHAIRMAN JOHNSON: You would not be? In the business world the person at that level is considered an exempt employee, and they are not paid for travel.

If they are a non-exempt person they would be paid for travel.

Is it the same thing in the hospital situation?


CHAIRMAN JOHNSON: Is there any compatibility of those rules with what we would be doing here? That's question number one.

And then we can address Richard's potential recommendation regarding preparation being allocated for maybe a day or something like that.

But your thoughts - and before we get response from others here, Brent, can you share what your experience has been on other commissions with which you are affiliated?

DR. JAMES: I have a bit of a unique circumstance, Randy. I prefer to not be paid. And the reason is, for the amount of money that it brings in it's just too much hassle, and I'd just rather be clean.

CHAIRMAN JOHNSON: But I'm not talking about you personally, I'm asking about other commissions on which you serve. And I'll ask Larry the same thing in just a second.

DR. JAMES: For most of us, the way it works is, they pay for an extra day's preparation time and the preparation time includes all travel. So I would get paid, say this Friday at the NAC meeting if I were accepting a salary, I'd get paid for Thursday and Friday. I'd get two days' pay, and that two days would include all of my travel, if you see what I mean.

MR. PATTON: That's our policy, is the day of meetings or hearings you get a full day's pay, and then one day of prep time as Brent says that covers travel and prep, so it's kind of a combination extra day.

CHAIRMAN JOHNSON: And when you have been in subcommittees in the past, Brent, first the question for you, and then Larry, question for you and anybody else who has also been on similar types of committees.

DR. JAMES: With some of the organizations, for example for IOM we tend to pay a flat rate and say, okay, we're going to ask you to do this paper and here's what you'll get. For IOM we always contribute time anyhow, so we don't get paid at all.

I was trying to think of our subcontractors, how we handle them. I think that is contributed time.

I think for the other committees where we've commissioned work it's always on a subcontract basis, and I've seen it done, it's usually an agreed amount based on an estimate of the total amount of services which will be provided, with a follow-up to show that the services or the time was spent, you see what I mean?

MR. PATTON: And Brent, correct me if I'm wrong, but I don't think we have experience with actual meetings of subcommittees separate from the full NAC, although they may be speaking by conference call, correct?

DR. JAMES: That is correct. We've had quite a bit of activity that happens offline, but we're not reimbursed for that.

MR. PATTON: Right.

CHAIRMAN JOHNSON: So if we were to have telephone meetings of subcommittees that would be comparable to some of the experience in the past which have not been reimbursed?

DR. JAMES: That is correct.


Richard, you have been on some other subcommittees? Comments?

MR. FRANK: Well, I mean the IOM is definitely, you don't get paid for. Let me make a point about what I think might be different here, which is that I think because we don't have the usual sort of cast of characters, that is, academics, feds and things like that, we have people whose circumstances are different. And therefore you're taking people away from a different set of circumstances.

For example Harvard thinks it's wonderful that I do these things, and they encourage it. I get brownie points.

MS. HUGHES: Where do you cash them in?

MR. FRANK: Right. But there are other people who have day jobs where it's really a loss, that they're gone from whatever it is, whether it's a formal labor market or informal activities. And I think that perhaps we need to recognize that, or at least poll the people who are not in these sort of typical circumstances to find out this affects them.

VICE CHAIRPERSON McLAUGHLIN: I absolutely agree, Richard. I'm glad you said it. That's where I was headed that for somebody like Richard or for me, this is a service to your state government, to the federal government, that's expected. It's a part of your job. You're supposed to do it.

And also serving on some of these IOM committees or an NIH review committee, it's not like it's part of your job, but while you're there you're networking, you're finding out new information that enhances your job.

Richard is absolutely right. That's not true for many of us around the table, neither of those things are true. And so therefore, although it's informative to find out how other commissions work, I don't think it should dictate the decision that we make.

And I feel that way particularly for the subcommittees. I'm not going to feel comfortable asking some of these people to take a lot of time to work with me on a subcommittee unless I think that that falls under the same rules as prep time for the working group meetings.

In other words, I would recommend that if we have a two-hour conference call where we discuss different things, that again there's a day of prep time. You're just not traveling.

And in fact we may travel. We may want to meet somewhere. But I think that we need to keep this in mind that in order for certain people to really take away time, even for a conference call, we have to recognize and value that time. And I'm not sure how to do it. I'm just saying, I do think we have to think about this more carefully.

DR. JAMES: I think that's a very good argument.

MR. PATTON: What I would suggest at this point is that you resolve the issue of how you're going to deal with meetings at this meeting, because people need to be paid right after this meeting. And think about the issue of how you want to do the subcommittees and come back.

And if you tell us what you want to do, we will have it done, unless you expect that there'll be extensive meetings. I forgot that you're planning to have subcommittee meetings before the next meeting. Withdraw the comment.

I was just trying to think through the prep time for a subcommittee two-hour conference call versus prep time for a two or three day meeting. I'm not sure one day would be the right amount.

VICE CHAIRPERSON McLAUGHLIN: The Reports Subcommittee may be unique, because that is just going to involve a lot more work, because we're going to be sending a lot of data, a lot of information, and saying, give us feedback - us being the staff - feedback on what you think et cetera. I could easily see each request bundled into a day's worth of work.

That may not be the case for every subcommittee, Larry. But I guess I would feel more comfortable asking people to give that amount of time if I knew that there was going to be some kind of compensation and recognition.

MR. HANSEN: My union background will show through in this, and I'm going to decline pay for myself in this. But we have the concept for lost time you get paid for it.

And I think that what Richard said and what you're saying I agree with completely, and to figure out a fair way of doing this, the work that

they're doing, the preparation time or the travel time if it's more than a day.

CHAIRMAN JOHNSON: Other questions or comments?

VICE CHAIRPERSON McLAUGHLIN: So Larry's first thing, full working group meetings, right? He's asking if we can come to closure on that one.

CHAIRMAN JOHNSON: We're now talking about subcommittees, so let's stick to subcommittees.

MS. HUGHES: This is Therese. I guess I'd like to say that I think I agree with Catherine and Joe's and Richard's remarks. I don't think we need to go around the table and ask what is each individual's situation. But I would just like to suggest that we pay for the day. We get the day preparation which can be travel and/or preparation.

And then where the subcommittee goes, I would like to suggest rather than looking at it as a full day value, it may add up to a day value, look at it at an hourly value. So if we're two hours on the phone call and then we have two hours preparation, then that is what we need to --

MR. PATTON: Submit.

MS. HUGHES: Submit, thank you, that's what we need to submit as something that would be workable for people.

So that's what I'm proposing.

CHAIRMAN JOHNSON: Let me see if I understand your comment. You're saying that just like we assume a day's preparation for a full day meeting, for every hour that a subcommittee meets they would assume an hour preparation?

MS. HUGHES: No, no. So I'm on your subcommittee, and we're going to discuss whether we're buying apples or oranges next time, and it takes us an hour. We've allocated an hour.

I may need an hour. If I need any time, I take an hour. I may need an hour.

MR. PATTON: She's suggesting submitting actual time, actual time that a person spends, they submit that.

MS. HUGHES: Thank you. Fee for service.

MR. PATTON: So it's an hourly rate. So for example one person who's chairing the subcommittee may in fact spend three hours preparing. The members of the subcommittee may only spend two hours preparing.

And whoever spends three hours, submit three hours. Whoever spends two hours submits two hours. So it's just actual time spent as opposed to saying it's always going to be eight hours.

MS. HUGHES: And the reason that I'm suggesting that is because we have a limited budget, and we don't know where the budget is going to go. And it seems to me that by doing it on an hourly basis for subcommittee work that we are able to control some of the costs somewhere.

CHAIRMAN JOHNSON: I think you're correct, and that's in the back of my mind. We do have a limited budget.

And by the way the budget this year probably will be a little more plush comparatively speaking to next year when we have the town hall meetings and lots of travel time.

So I think we have some serious questions that we're going to have to look at. And here's what I'm hearing, and then I'd like to propose something.

What I'm hearing is that for travel time and reading time, we combine one day of meeting or we combine travel time and preparation time together and give credit for one day of travel time for each meeting.

Is it for each meeting?

MR. PATTON: It's for each meeting. It's not for each day of meeting.

CHAIRMAN JOHNSON: Thank you, for each meeting.

For subcommittee time what I'm hearing is, we have a self report of the number of hours worked for each subcommittee meeting. And that that will be until we address it again, if we do. And that we try that and see how it works. But for the foreseeable future we try to do that.

But we take a look at the budget as we go along to see if in fact we can continue to do that. We're going to have to live within a budget, and we're providing more open-ended opportunities to payment for us than what I see for exempt people for most organizations.

And in this particular focus we are exempt people. So I'm open to trying it for the foreseeable future. But if we find that it's running our budget up, if we perceive that, and we'll come back � we won't change it without bringing it back to you. So we won't make any changes until we bring it back to you.

But I want to just make sure that we understand. We have to follow a budget, and we don't know what our expenditures are going to be yet.

MS. HUGHES: Randy, I would even say that in terms of maybe for the travel day to a meeting, 75 percent of the stipend or the per diem. I understand the restraints of budgets, and I'm just trying to look at it in a way that would be amenable.

I support the comments that were said earlier by Richard. I can't think of what I'm saying.

VICE CHAIRPERSON McLAUGHLIN: Because there is a difference between salary level, full year, full time, being exempt, versus salary level 12 days a year being exempt.

And I think that's the confusion, that the salary level that we're talking about, $140,000, is normally considered exempt, and people who earn that amount of money do not get this kinds of payment.

But we're not talking about full year - the executive director will be full year, full time - but the members of this working group I hope are not going to be full time, although it's beginning to sound like we may be.

And therefore the level on which the compensation is based is not really relevant in the decision-making of this in my opinion.

CHAIRMAN JOHNSON: Okay, well, that's a point of difference between those of us around the table here.

Richard, you were going to comment?

MR. FRANK: I had something similar to Catherine, which is, one analogy is the exempt employee; the other one is the consultant. And even people who are exempt employees by day, they do consulting on weekends and stuff, and they charge you for every hour they work.


VICE CHAIRPERSON McLAUGHLIN: And this is more of a consultant.

MR. FRANK: This might be more like that than the other.

CHAIRMAN JOHNSON: Okay, thank you.

MS. CONLAN: I just wanted to mention that when I worked on a contract basis as a teacher I was paid for the actual time that I was working with students, and all the other preparation, whether it be gathering materials or developing lesson plans or whatever, that was I guess figured into what I was paid, but I wasn't paid extra for that

So I'm familiar with that, and on my part, I'm comfortable with that.

And also, unless we make a recommendation that there is a Medicaid buy-in and it's accepted, I don't want to earn too much money, because I'm working against myself.

CHAIRMAN JOHNSON: Okay, another comment and then we'll summarize.

MS. STEHR: I'd like to have the one day, full day travel time, because of my circumstances. It's an entire day of travel. Plus I'm missing my work of caring for my son, and I'm paying out of pocket a considerable amount of money to hire a nurse to care for my son. So I need that full day.

So because of budget restraints, those of you that don't feel you need that full day, then don't take it, is what I'm proposing.

CHAIRMAN JOHNSON: Let me summarize what I think we've heard.

Number one, full travel day, preparation time is included. We'll pay for subcommittee work on an hours-spent allocated basis, okay?

VICE CHAIRPERSON McLAUGHLIN: As submitted, if the person wants it.

CHAIRMAN JOHNSON: As submitted. Any further comments regarding this?
One day of travel for each meeting.

MR. PATTON: And that includes prep as the chairman said.

I think that is a perfectly justifiable decision. The only thing I would just say, and this is just for people to keep in mind as they put their time in, is remember you've got the 60 days hanging out there.

So if you put two hours in on a given day, because we said if you choose to submit it, that two hours for that one day is going to start ticking against the 60. So just note that for each day that we start adding up it might trigger for someone who gets very active in subcommittee business the 60-day financial disclosure requirement.

That's just making sure you remember it, that's all.

CHAIRMAN JOHNSON: Okay, we're ready to move to a different subject unless you would like to stay on this one for a while longer.

Okay, we have 15 minutes left before we conclude our meeting. Here are the subjects that we'd like to run through.

Number one, we'd like to just briefly talk about some subcommittees.

Number two, a comment about future meetings.

Number three, attendance at our meetings.

And number four, the use of electronic technology in attending our meetings.

So those are some subjects that we need to discuss. Are there any other subjects that you'd like to get on the table before we proceed into that discussion?

DR. BAUMEISTER: I have a cab coming at 2:30 because I've got to catch a plane over at BWI.

CHAIRMAN JOHNSON: Are there others of you who are leaving at what time?

MR. FRANK: 2:30 also.

CHAIRMAN JOHNSON: 2:30. So talk fast, Randy, don't use your southern drawl. We'll try to end by 2:30 then, okay?

First subject is on subcommittees. Catherine and I are pleased to let you know that Dotty Bazos and Pat Maryland will serve with us on a hearing subcommittee. Dotty Bazos and Pat Maryland will serve with Catherine and myself on the hearings subcommittee. And we're going to of course consult with folks from HHS and so forth as we proceed forward.

Catherine is working to develop a subcommittee on reports, and she'll approach some of you to participate in that.

Would you like to talk about your discussion at lunchtime on some of the website?

VICE CHAIRPERSON McLAUGHLIN: Yes, I will, I'll try to do that. Because one of the potential subcommittees was electronic communication.

In the short run we are trying to get a website up and running quickly where we can post the bio sketches and the comptroller general's announcement, where we can put the announcement of the hearings in May, we can put a description of our charge, what we did today. Just to get something up the next few months to use as a communication tool to the public.

We don't expect a lot of Joe and Jane Public to come on, but we hope that this will make it easier for some interest groups and people interested in what we're doing to see.

As such we have not hired a web development team. We don't have time to do that. But as I pointed out earlier, we just had our first meeting last Monday. Ken and Caroline and Andy's first day on the job was last Monday. And in fact it wasn't a full day on the job, because they're still detailees, they're still closing up stuff from their previous jobs here at HHS. Friday was your first full day, and Caroline still hasn't had her first full day I guess.

Actually we were on the phone at 7:00 o'clock Friday night, all of us, still trying to get things ready for the meeting today.

But there also have been a couple of wonderful people here at AHRQ who have been working with us to try to get up a website in the short run. And as I said in that slide earlier, it's to be considered an interim website.

And several of you sent back some feedback that totally echoed ours, which was wonderful, which was, we don't want this to look like the AHRQ website. We want it to look different. We want it to be the citizens, and have it be friendly.

So we have been working with them to try to make a different design. And one of the things that is going to guide us is actually more this style of the lines on the left, a triangle, a very clean easy-to-read style.

And they have in a very short amount of time laid out a template, but it's still in development, so we don't have it to show to you. But it's going to be more similar to this.

There are certain regulations. They have to have the HHS seal up there. They have to have -- you know, there are certain government regulations that have to be up there. But to the degree possible we're going to make it fairly simple to navigate. We're going to make it look different, have sort of our signature that will fit across, and try to make sure that just simple things like the colors are different, the logo is different, so that it's not confused as being just another part of ARRQ.

So those of you who haven't sent feedback to email, I guess last week from Randy, we're still open. But we really want to get this up in the next seven to 10 days so that we can put information up.

But I just wanted you to know that there are two people here at AHRQ web design who have been in communication with Larry and now all of us, now that we're on board, and trying to get something that is fairly simple at this point, knowing that some time over the summer we're going to have to change it to make it more interactive, et cetera, ready for the October hard launch, as they say in the business of the website, where we really do publicize it heavily and get citizens to come on board.

So it's a two-stage process.

MS. STEHR: Will it be accessible for people with disabilities?

VICE CHAIRPERSON McLAUGHLIN: Absolutely, and different languages - that's what has to come down the pike.

What it's going to be now, it's going to be fairly simple, fairly straightforward. But what we're going to start doing is start working now on putting up the more permanent site, which will be accessible and much more sophisticated.

CHAIRMAN JOHNSON: Other comments or questions?

Okay. In addition to that, one of the other subcommittees that we've considered establishing is a general communications subcommittee. And we haven't proceeded with that, but it's just one that we've talked about the potential of, and we will come back to you with more information on that as we proceed.

We've already talked with you about scheduling for May 11th, 12th, and 13th and we've received blackout calendars for you, and we've even, I think, shared some dates with you for June.

What we're experiencing is a very difficult time getting everybody together. In fact as I mentioned earlier I think there is no date between now and July 1st where everybody is available.

In fact in almost every case we have two people at least who are not able to make it based on what you've told us.

So we're going to try our best to schedule around your schedules as a first priority, and then around other schedules as we meet, such as speakers and so forth.

But the scheduling is going to be a real challenge, and let's just try to do our best to meet your needs and our needs as a group.

MS. BAZOS: One thing we did talk about at dinner last night for the future, perhaps maybe you have to wait until next year to start that, but thinking about structuring committee meetings so that they're on a specific day of a specific week of the month, you know, so that they're standardized.

CHAIRMAN JOHNSON: Well, hopefully we'll be able to get a calendar of events out earlier than what we are right now, but if we look at the dates, Dotty, we're really jammed until July, and then there's more openness, but we have, even in July, some of us, July through the rest of the year, have quite a significant schedule, and so that's our reason for wanting to schedule in advance. Maybe a certain day of the month would be helpful if it fits with everybody's schedule.

VICE CHAIRPERSON McLAUGHLIN: That's what Dotty last night was saying, and several people echoed this, that on committees that they, working groups that � other working groups that they're on, the third Friday of every month. And so, when we now get requests for giving talks or whatever we can say, "Oh, I can't come that Friday in August 2006 because there's predictability, and I agree with Randy, I don't think we can do that for at least the next four or five months if, even starting in October, but certainly 2006 we might be able to, in the next month, figure out, you know, a day that basically works so that it doesn't conflict with your regularly scheduled meetings, Brent, or Richard's or Pat's or whatever, other committees that we're on, and then we can get in the book.

CHAIRMAN JOHNSON We’d like to ask all of you to attend all of the meetings, and we'd like it to be you who is here, so if, I'll pick on you, Chris, if you have someone that you think would be a good substitute for you, well, first, they're not able to sit at the table, but we'll miss your input, even if you were to have them come and take notes.

So we would urge you to make it to the extent that you can, and, again, just picking on you because you're closest.

Now, one of the things that we've done today because we wanted to introduce him to you over the phone is Brent James, and, Brent, we're glad you're here. One of the things we need to discuss is the extent to which we're going to have attendance by, I'll just call it electronic communication, whether it be telephone, conference call, or where there's a camera in the room taking pictures of us and so forth.

How do you feel about that, pluses and minuses? Let's just have a few minutes of discussion regarding that.

DR. JAMES: I've done a ton of that. Number one, face-to-face is always better. The number two thing to be said is there's a two-way interactive video. While a step down, it's the closest, and I know that the main AHRQ building is wired for it, but many people won't have it.

In that regard there's another technology that we've been playing with a little bit out here. If you have high-speed Internet connections, you can actually communicate in multi-way interactive video over the Web, but you have to have high-speed connections. But you get a picture of everybody and then can share documents, and then you have sound through the telephone or through web-based telephony.

And then the third level is teleconferencing. Teleconferencing is the weakest usually, although I think it's a really good way for subcommittees to meet. Now it's interesting if you've already met each and know each other the teleconferencing and the TWIV work better, substantially better.


DR. JAMES: Two-way interactive video.

CHAIRMAN JOHNSON: Thank you. Okay, comments?

MS. HUGHES: This is Therese. I'd like to say I'm restricted to being here in person or on the phone.

CHAIRMAN JOHNSON: You can only be here on the phone or in person, you don't have the other technology?

MS. HUGHES: I don't have access to the other technology.

UNIDENTIFIED SPEAKER: Same thing with me.

CHAIRMAN JOHNSON: Okay, another person, same thing.

MR. HANSEN: Well, I've done all three. This is Joe. I've done all three things, and I agree with Randy, the teleconferencing, especially with large groups, really is not very productive for that. I find when it goes on for a long period of time, and if we're going to do it, you almost have to have a land line because if you start using cell phones you get static and all types of other things

And so, face-to-face is the best, if we manage it, the best.

CHAIRMAN JOHNSON: Other comments?

I think what we want to really ask you to consider is, do we want to say we will only do in person meetings? Or do we want to say we'll encourage doing in person meetings and use alternative technology whichever would seem to work best at the time?


MR. FRANK: I guess the way that I would proceed is, I think we need to get to know each other. I think a lot of things we need to hash out. And I think, I agree with Joe, that for that there is basically no you can't do better than face-to-face.

Maybe a year from now when we're going to spend a lot of time together, maybe after we've spent a bunch of time together, after awhile you sort of get to know how everybody's speech and thought processes work, then maybe some of these other technologies become more feasible.

Until I felt that everybody certainly started to understand at least the bizarre way that I think, and I get to return the favor.

CHAIRMAN JOHNSON: Okay. More input?

MS. BAZOS: Can I just ask what drives the question? Were you thinking that you'd like to have the meetings or does it have budget implications?

CHAIRMAN JOHNSON: Well, there certainly are budget implications. If we for example were to do the TWIV, that has certain cost implications if we do multiple sites.

Let's just say that half of us decided that we weren't going to attend in person, we were going to do the TWIV instead. Well, what does that do to the content of our meeting? What is the impact on the expense of our meeting if we were to do something like that?

And we're just trying to get your input on that right now. We'll go back and look at expenses, but just have some preliminary comments on that.

VICE CHAIR McLAUGHLIN: I think it also may change, Dotty, though, the availability of dates in the near future. You know, maybe people can't take the whole day of travel, the whole day of the hearing to get back, but they could in fact participate for four hours, five hours, over the phone. And I think that's basically what your situation was, Brent.

DR. JAMES: Yeah.

VICE CHAIRPERSON McLAUGHLIN: The amount of time it would have taken to get here, you just couldn't � you would have been here for an hour and have to turn around and go back.

So I think that is what precipitated our thinking to some degree was in fact Brent's example, because originally he was going to be here. But because of things that changed he realized there was no way he could get here.

So do we want to allow that possibility if we really need to have another meeting to decide this and that, blah blah blah, but only eight people can come on any given day, do we want to explore this as an alternative for flexibility in scheduling?

DR. JAMES: I've attended NAC meetings by TWIV, and frankly it's not as good as being there in person, no question about it. But it's better than teleconferencing for example. And just in passing it's substantially cheaper than flying, at least from out in the West.

MS. BAZOS: I think using alternative means to help people attending parts of meetings if they can't get there in person is an excellent idea. And the cost seems like it would be flat or less. So for that I think it would be worthwhile certainly to pursue those options.


VICE CHAIRPERSON McLAUGHLIN: But I tend to agree with Richard's comment that this first year, and Brent, I'm sorry you're not here, because it has been wonderful getting to know each other, just in these two days, and see facial expressions.

DR. JAMES: Yeah.

VICE CHAIRPERSON McLAUGHLIN: It really makes it so much better.

DR. JAMES: Yeah, it really does.

CHAIRMAN JOHNSON: And by the way, I think it’s a loss because you're not here, actually.

DR. JAMES: You may be further ahead than you think, guys.

CHAIRMAN JOHNSON: Okay, do we have any further thoughts on that?

What I'm hearing, and let me just articulate so we can see if we have it. What we're going to do is do our best to be here in person. Full court effort to do that.

But if it's absolutely necessary we will look at alternative methods of communication.

Okay, we have five minutes left. Is there anything else that any of you would like to bring up before we adjourn?

DR. JAMES: Could I ask just one question, Randy? CHAIRMAN JOHNSON: Yes, and then we have two others when you're done, Brent.

DR. JAMES: Okay, you may have already discussed this, if so just instruct me on the policy, I've so far been contacted by three individuals out of the clear blue sky because they have heard that I've been appointed to this committee. And they want to just sit and chat and talk. How should we handle those sorts of things?

Just so you know, the way I've been thinking about it is to learn all I can from them about their viewpoints, the things they want to do. Maybe down the road if we start to pull things together, to test ideas on them, maybe. But how should we think about those things?

CHAIRMAN JOHNSON: What Catherine and I have been doing so far is saying something like this. We're in the process of getting organized. We will

be developing a website, and there will be information on the website that you'll be able to access.

And also there will be an opportunity for you to submit your thoughts and ideas to the website.

So that's the media that we've contemplated. Now if you feel, anybody here, feels like you'd like to sit down and hear their perspective, I'm not aware of anything that would preclude you from doing that, except that could be time-consuming for all of you, especially as we move forward and the working group becomes more well known.

So that's an initial response to your question, Brent.

DR. JAMES: Okay, great.

VICE CHAIRPERSON McLAUGHLIN: Three people are getting ready to leave.

CHAIRMAN JOHNSON: Therese looks like she has some thoughts on her mind.

MS. HUGHES: Well, I thought that yesterday, and I could be wrong, Larry suggested that everything should come to the website, or this morning, it should just be submitted electronically.

DR. JAMES: Just so we have a record of it.

MS. HUGHES: Right, and so I don't know if he's not here, I don't know where he went but I don't know if this is the same measure of conversational openness.

CHAIRMAN JOHNSON: So what you're suggesting is that maybe that even amplifies the need to send something to the website?

MS. HUGHES: Right.

DR. JAMES: Yeah, that's a good clarification.

CHAIRMAN JOHNSON: Okay, Pat, were you the one who had a question?

MS. MARYLAND: My question was exactly Brent's.

CHAIRMAN JOHNSON: Okay, thank you. And Aaron.

DR. SHIRLEY: I've noticed here outside of Washington in June, when and if a decision is made about the possibility of having a hearing in Mississippi, it would be good if we knew that as soon as possible.

CHAIRMAN JOHNSON: You're singing to my friend here on my right, and to the staff as well. And one of the things that we're going to do is kind of sit down and think through after you all leave some of our scheduling challenges and issues and begin to look at that.

So not only in your location but our other locations where we're going to do hearings.

Anything else? Well, thank you very much for your participation in the last two days. You've been great to work with. We look forward to seeing you on May 11th.

Have a good day. And thanks, Brent, for joining us.

(Whereupon, the meeting was adjourned at 2:30 p.m.)

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