Meeting Minutes, July 22, 2011
Call to Order; Approval of April 8, 2011, Summary Report
Collaboration, Including Partnership for Patients
Public Reporting on Quality
Chairman's Wrap-Up and Final NAC Member Comments
NAC Members Present
Bruce Siegel, M.D., M.P.H., National Association of Public Hospitals and Health Systems (Chair)
Mitra Behroozi, J.D., 1199SEIU Benefit and Pension Funds
Paul N. Casale, M.D., The Heart Group, Lancaster General Hospital
Keely Cofrin Allen, Ph.D., Director, Office of Health Care Statistics, Utah Department of Health, and Executive Secretary, Utah Health Data Committee (by telephone)
Helen Darling, M.A., National Business Group on Health
Louise-Marie Dembry, M.D., M.S., M.B.A., Yale-New Haven Hospital
Nancy E. Donaldson, D.N.Sc., R.N., Center for Nursing Research & Innovation, University of California, San Francisco
Silvia M. Ferretti, D.O., Lake Erie College of Osteopathic Medicine (by telephone)
Arthur Garson, Jr., M.D., M.P.H., University of Virginia (by telephone)
Helen W. Haskell, Mothers Against Medical Error
Lisa M. Latts, M.D., M.B.A., M.S.P.H., WellPoint, Inc.
Andrea H. McGuire, M.D., M.B.A., American Enterprise Group, Inc.
Keith J. Mueller, Ph.D., The University of Iowa College of Public Health
Welton O'Neal, Jr., Pharm.D., Takeda Pharmaceuticals North America, Inc.
Christopher Queram, M.A., Wisconsin Collaborative for Healthcare Quality
Katherine A. Schneider, M.D., M.Phil., AtlantiCare Health System
Xavier Sevilla, M.D., Manatee County Rural Health Services, Inc.
Alan R. Spitzer, M.D., Pediatrix Medical Group
Jeffery Thompson, M.D., M.P.H., Washington State Medicaid Purchasing Administration
Janet S. Wyatt, Ph.D., R.N., Institute of Pediatric Nursing
Patrick Conway, M.D., Centers for Medicare & Medicaid Services
Pauline Sieverding, M.P.A., Ph.D., J.D., Veterans Health Administration (for David Atkins)
Jane Sisk, Ph.D., Centers for Disease Control and Prevention
AHRQ Staff Members Presents
Carolyn M. Clancy, M.D., Director
Irene Fraser, Ph.D., Director, Center for Delivery, Organization, and Markets
Boyce Ginieczki, Ph.D., Acting Deputy Director
William B. Munier, M.D., M.B.A., Director, Center for Quality Improvement and Patient Safety
Carol Sniegoski, M.S., M.P.H., Computer Scientist, Center for Delivery, Organization, and Markets
Jaime Zimmerman, M.P.H., NAC Coordinator
Karen Brooks, C.M.P., NAC Coordinator
Call to Order and Approval of April 8, 2011, Summary Report
Bruce Siegel, M.D., M.P.H., NAC Chair, called the group to order at 8:30 a.m., welcoming the NAC members, other participants, and visitors. He noted that the following new NAC members were present: Mitra Behroozi, J.D., Paul N. Casale, M.D., Andrea H. McGuire, M.D., M.B.A., Christopher Queram, M.A., Alan R. Spitzer, M.D., Jeffery Thompson, M.D., M.P.H., and Janet S. Wyatt, Ph.D., R.N., He asked the NAC members to introduce themselves.
Dr. Siegel referred to the draft minutes of the previous NAC meeting (April 8, 2011) and asked for changes and approval. The NAC members approved the April 8, 2011, meeting minutes with no changes.
Carolyn M. Clancy, M.D., AHRQ Director, welcomed the NAC members, in particular, the seven new members, and other speakers and guests.
The Big Picture
Dr. Clancy stated that President Obama's proposed Fiscal Year 2012 budget for AHRQ includes $65 million for patient safety research, including $34 million to reduce and prevent healthcare-associated infections. It features $46 million for patient-centered outcomes research ($24 million of which would come from the Patient-Centered Outcomes Research Trust Fund) and $28 million for health information technology (IT).
Dr. Clancy reviewed the following AHRQ news and Case Studies:
- As part of the Keystone Project, use of the Comprehensive Unit-based Safety Program (CUSP) in the State of Michigan's intensive care units reduced central line-associated bloodstream infections to zero, with 60 percent of hospitals remaining at zero for 1 year and 26 percent remaining at zero for 2 years. Smaller hospitals were more successful than larger hospitals.
- AHRQ, in association with the Ad Council, developed and distributed a multimedia, Spanish-language public service campaign that encourages Latinos to ask questions of and generally converse with their physicians.
- AHRQ's State Snapshots, an interactive Web-based tool, features information from the 2010 national reports on health care quality and disparities. The site has a new feature—a directory of State-based improvement resources.
- AHRQ's Project ECHO (Extension for Community Healthcare Outcomes) features the use of technology, especially telemedicine, for physicians in underserved communities. One project resulted in hepatitis C patients in underserved communities doing as well as patients cared for by specialists at a university-affiliated hospital.
- A new AHRQ/Ad Council multimedia campaign for the Effective Health Care Program, "Explore Your Treatment Options," ran on television and radio and in print, Web, and outdoor placements. The campaign seeks to help patients make better treatment choices.
- In an Impact Case Study, an on-time quality improvement effort at the Gurwin Jewish Nursing & Rehabilitation Center led to a reduced incidence of pressure ulcers by 70 percent. The effort featured integrated on-time reports and the targeting of residents at risk for unintended weight loss.
- In an Impact Case Study, a nonprofit collaborative, the OpenMRS Consortium, was developed with the aid of AHRQ-funded research on electronic order writing and computer reminders.
- In a Knowledge Transfer Case Study, the University of Medicine and Dentistry of New Jersey incorporated U.S. Preventive Services Task Force (USPSTF) recommendations into its medical student curriculum. The students learned to use the electronic Preventive Services Selector tool on mobile devices.
- A Knowledge Transfer Case Study found references to five AHRQ Effective Health Care reviews in clinical reference summaries posted online by DynaMed. Hospitals in more than 175 countries use DynaMed's online tool. Clinicians can access Effective Health Care Reviews using their mobile device.
AHRQ Program Updates
Dr. Clancy provided the following Program updates:
The Affordable Care Act authorizes the USPSTF/AHRQ to report high-priority research gaps to Congress. It also links some insurance coverage (and required payment by payers) to recommendations from the USPSTF and similar bodies.
Efforts to enhance the USPSTF's transparency include the online posting of draft recommendation statements for public comment and the USPSTF Procedure Manual (available at http://www.uspreventiveservicestaskforce.org). The USPSTF has been revising its review and grading language to increase transparency. It has been using Web-based solicitation of new members and conducting teleconference briefings for stakeholders and partners prior to the release of draft recommendations. The USPSTF recently released a recommendation about screening for testicular cancer, recommending against screening in adolescent and adult males (grade D).
- A Healthcare Cost and Utilization Project (HCUP) study of emergency department (ED) visits in rural hospitals found that low-income adults ages 18 to 64 years accounted for 56 percent of visits in 2008. About 44 percent of adult visits to rural EDs were paid by Medicaid, uncompensated, or billed to uninsured patients. About 31 percent were covered by private health plans, and 25 percent were covered by Medicare. HCUP recently released its new Kids Inpatient Database (an all-payer hospital discharge data set).
- AHRQ supported a study of geographic or regional variations in hospitalizations by age groups, using HCUP national all-payer data. One finding was that variation patterns using Medicare data and all-payer data differ. The patterns for the two types of data were similar for some subsets.
- AHRQ made available a series of new health IT funding opportunities. A new Evidence-based Practice Center report on medication management through health IT pointed to a promise of improved processes, although the evidence is not uniform across phases of medication management, groups, and types of management.
- AHRQ made available a new toolkit for workflow assessment for health IT. The toolkit is available at http://healthit.ahrq.gov/workflow.
- AHRQ's Medical Expenditure Panel Survey (MEPS) is being used to inform provisions of the Affordable Care Act. For example, it is being used to determine the amount of the small-business employer health insurance tax credit and to determine the health insurance status of young adults and their health care use and costs. The MEPS data will help gauge the impact of the planned excise tax on the most expensive employer-sponsored plans.
- AHRQ released MEPS data on 2010 premiums from its insurance component, including annual estimates of offer rates, takeup rates, premiums, employee contributions, plan types, deductibles, and co-pays. The Affordable Care Act authorizes a tax credit for small-business employers who provide health insurance to their employees. The MEPS data support this action.
- A number of Comparative Effectiveness Reviews developed within AHRQ's Effective Health Care Program have been released. One such review was an update of the report "Health Literacy Interventions and Outcomes: An Updated Systematic Review." Recent Methods Reports include the topics of addressing challenges in genetic test evaluation, a framework for best-evidence approaches in systematic reviews, and signals for updating systematic reviews.
- New AHRQ-supported consumer products (such as brochures and slides) focusing on diabetes were released, representing successful evidence translation. Products focusing on autism were also released.
- AHRQ's collaboration with the National Business Group on Health produced a translation of the Effective Health Care Guides for use by large-business employers. Helen Darling, its NAC representative, noted that she disseminated a message about this release on Twitter, encouraging comments and use by employers of AHRQ's Centers of Excellence to help select coverage.
- Various initiatives in advancing care coordination are moving forward. The "Care Coordination Measures Atlas" is now available at http://www.ahrq.gov/qual/careatlas. It provides a framework for understanding care-coordination measurement and provides information on more than 60 measures of care coordination in primary care.
- There are now 79 Patient Safety Organizations (PSOs) operating in 20 States. The Program held its third annual meeting in April 2011. One benefit of PSOs is that they submit deidentified patient data to AHRQ, which is using the data to develop common formats.
- The National Quality Forum endorsed AHRQ's Consumer Assessment of Healthcare Providers and Systems (CAHPS®) nursing home surveys. A survey for patient-centered medical homes is being developed.
- An interim report indicated that the use of CUSP to reduce central line-associated bloodstream infections has expanded to 350 hospitals, with recruitment ongoing. This early report indicated number of deaths prevented and financial costs saved.
- AHRQ is working with the Centers for Medicare & Medicaid Services (CMS) to implement the Children's Health Insurance Program Reauthorization Act of 2009. The collaboration features a focus on measurement and will lead to a set of core measures. A first-round effort produced a list of cross-cutting topics, a list of preventive services, and lists for acute care and chronic care. The effort includes input from a NAC subcommittee.
- The AHRQ Fifth Annual Conference will take place September 18-21, 2011, at the Bethesda North Marriott Hotel & Conference Center. The theme is "AHRQ: Leading Through Innovation and Collaboration."
Dr. Siegel stressed that much of AHRQ's work is used to inform policy. The use of MEPS data in particular will be very important, as they relate to trends in employer-based insurance as a result of the Affordable Care Act. It appears that many employers will cease to offer private coverage.
Dr. Clancy noted that the study of geographic or regional variations based on HCUP data produced additional findings. She suggested that the NAC place this topic on the agenda of a future meeting.
Ms. Darling applauded AHRQ for disseminating data rapidly. She emphasized the issue of rapid-response teams, which have an ability to educate other health care workers in general, thereby extending their value. Dr. Clancy noted that a key aspect of rapid-response teams is their focus on knowing what to do. Ms. Darling stated that she was astonished by some of the results of the study of geographic variations in hospitalizations.
Dr. Welton O'Neal raised the issue of academic detailing, asking whether there were any new grants or awards in this area. Dr. Clancy suggested that this issue be another topic on the agenda of the November 2011 NAC meeting. Academic detailing is the idea of distributing customized, targeted information for the purpose of introducing improvements into practice.
Dr. Patrick Conway noted that CMS recently released two new national prevention coverage decisions aligned with USPSTF recommendations. One decision focused on alcohol misuse and treatment, the other focused on depression screening.
Dr. Katherine A. Schneider wondered how AHRQ decides to initiate certain consumer education campaigns. Dr. Clancy responded that AHRQ responds to topics and priorities presented based on the comparative effectiveness or effectiveness of a health care program.
Dr. Lisa M. Latts reported that WellPoint developed an online course for teaching Latino patients how to ask questions about their health/conditions. She expressed an interest in linking to AHRQ's project with the Ad Council. The linkage was made.
Dr. Xavier Sevilla noted that his patient board expressed concern about the length of the CAHPS survey forms and whether the number of questions could be reduced or an abbreviated version developed. Otherwise, the size of the form could reduce the response rate.
Dr. Alan R. Spitzer raised the issue of the range of attitudes about safety and quality. Some institutions become very involved, and some do not. He asked whether there were ways to stimulate interest in safety and quality earlier in health careers. Dr. Clancy noted that the Affordable Care Act contains a section about curricula where such issues could be addressed. One difficulty is the number of people needed to reinforce safety/quality ideas throughout training. Dr. Siegel noted that many physicians endure, rather than embrace, safety and quality efforts.
Dr. Jeffery Thompson reported that Medicaid in Washington State made a decision to cover autism care. He asked for help from AHRQ for real-time data collection.
Dr. Janet S. Wyatt encouraged AHRQ and the Ad Council to consider the full spectrum of health care providers in its campaign encouraging patients to ask questions.
Collaboration, Including Partnership for Patients
William B. Munier, M.D., M.B.A., Director, Center for Quality Improvement and Patient Safety, AHRQ
Dr. Munier began a session on collaboration and the U.S. Department of Health and Human Services' (HHS) Partnership for Patients by noting that partnerships have been part of AHRQ's mission from the beginning, for both research and implementation projects. An example is the CAHPS Program, which features collaboration with Federal partners, purchasers, patients, stakeholders, and gatekeepers.
The Patient Safety and Quality Improvement Act of 2005 contains a provision authorizing the HHS Secretary to promulgate common definitions and reporting formats to support uniform reporting of quality and safety performance. Such common formats allow PSOs and others to collect information on all adverse events that is interoperable and can be aggregated. Dr. Munier cited the collaborative efforts of a multiagency workgroup created by AHRQ that has been overseeing the development of common formats. AHRQ has been publishing and continually updating versions of the formats.
Dr. Munier described in detail the Partnership for Patients project, which grew out of a tragedy—the avoidable death of a hospitalized young girl—and provisions of the new Affordable Care Act that target patient safety. The goals of the Partnership are to prevent patients from becoming sicker or injured, help patients heal without complications, and reduce costs, especially by reducing rehospitalizations.
Dr. Munier reviewed the organizational structure of the Partnership and highlighted the following areas:
- Leadership. Partnership for Patients is led by Dr. Clancy and Donald M. Berwick, M.D., M.P.P., the Administrator of CMS. Dr. Munier chairs two workgroups, and Howard Holland, Director of AHRQ's Office of Communications and Knowledge Transfer, leads consumer engagement activities.
- Science. The science workgroup features representatives from several Federal agencies. It recently found that there are no agreed-upon ways of measuring hospital-acquired conditions (HACs). The workgroup developed estimates for HACs, recommended goals for the Partnership, and identified evidence-based intervention tools.
- Data and measurement. The data and measurement workgroup comprises representatives from several Federal agencies. It is charged with developing methodologies for measuring national incidence rates of both HACs and hospital readmissions.
- Operations. Partnership operations, including infrastructure development, are directed from the CMS Center for Medicare and Medicaid Innovation. AHRQ is heavily involved.
AHRQ's role in the Partnership for Patients focuses on the need for national measures to improve hospital performance. AHRQ's development of common formats to be embedded in electronic health records will allow analysis of trends over time and comparisons across hospitals nationally. Dr. Munier stressed that the collaboration across Federal agencies, working with providers and consumers, will reduce injuries, save lives, change culture, and reduce costs.
Dr. Siegel noted that his organization, the National Association of Public Hospitals and Health Systems, is applying to be a contractor for hospital engagement in the Partnership for Patients effort. He has encouraged his organization to seek a culture and leadership that embraces change. Dr. Conway noted that Quality Improvement Organizations can offer broad assistance. Ms. Darling suggested that the salaries and bonuses of chief executive officers be linked to patient safety results. Previous large efforts in patient safety have led to pushback and the watering down of goals. It was suggested that perhaps the Partnership should focus on only a couple of main goals—reduced HACs and readmissions. Dr. Siegel suggested that boards of directors of health systems be made responsible for results in patient safety.
Dr. Latts stated a need to produce clear definitions of the many terms relating to patient safety. Helen W. Haskell reminded the group that AHRQ can play a role in public awareness and patient education, and that conversations between patients, insurance companies, and employers are needed. NAC members noted that the Partnership for Patients is mainly hospital based, and encouraged AHRQ to consider expanding it to the ambulatory care setting. Dr. Clancy wondered whether interim measures were needed. Dr. Conway added that measures would be improved steadily over time. Dr. Nancy E. Donaldson cautioned that the program approaches safety on a macrolevel, yet the microlevel may be the key to improvement (e.g., staff characteristics). One key to success will be getting people to use the data.
Dr. Louise-Marie Dembry stated that measurement must be transparent and reasonable and should not be used in a punitive manner. Dr. Clancy noted that she and Dr. Berwick have been discussing the issue of reasonableness and psychology in measurement. Dr. Paul N. Casale raised the issues of standards in a community, the critical need for timely data, and tools needed to bring data to health care workers. Ms. Mitra Behroozi added the need to address all levels of the health care workforce.
Public Reporting on Quality
Dr. Clancy introduced a session on public reporting, stressing the important link between increases in quality of care and decreases in health care disparities.
Quality Reporting and Disparities
Bruce Siegel, M.D., M.P.H., NAC Chair
Dr. Siegel noted that representatives of national hospital associations met in San Diego recently and produced a call to action on health care disparities, highlighting the link between disparities and health care quality. The call stressed the following goals for hospitals:
- To collect ethnicity, race, and language data that are patient reported.
- To improve cultural competency in practices.
- To make governing boards and management teams more representative of their communities.
Dr. Siegel referred to the article he coauthored and published recently in the Milbank Quarterly, "How Health Care Organizations Are Using Data on Patients' Race and Ethnicity to Improve Quality of Care." The article discusses a long list of issues relating to race, ethnicity, data, and quality of care. These include the following:
- How organizations can address race/ethnicity/quality of care.
- Difficulties with race and ethnicity categories.
- Possible differences in populations or socioeconomic results.
- Deciding on a benchmark population.
- Sample sizes of groups and when disparity exists.
- How data can be displayed to make them actionable.
- Where the causes and accountability lie.
Dr. Siegel posed a final question: should we move toward public reporting of disparities/quality of care data?
AHRQ and the Science of Public Reporting
Irene Fraser, Ph.D., Director, and Carol Sniegoski, M.S., M.P.H., Computer Scientist, Center for Delivery, Organization, and Markets, AHRQ
Dr. Irene Fraser stated that the issue of public reporting, which can be a factor in achieving better quality, has been gathering interest. A consumer pathway (in theory) features the use of information to choose providers, leading to shifts in market shares and responses by providers. However, we have little evidence for these events and this theory. We have more evidence for a provider pathway, in which providers value their reputations and market shares and strive to improve scores.
AHRQ traditionally does not play a role in provider-level reporting. However, the Agency develops measures, creates reports of national and State data, provides tools for CMS and others to use, provides clearinghouses, seeks to improve data for reporting, conducts research on reporting, and provides technical assistance and learning networks for users of reports (e.g., chartered value exchanges). Dr. Fraser described AHRQ's role in measures reporting, including standardizing data, developing benchmarks, funding data improvements, developing measures and software tools, and developing a Web site builder (MONAHRQ or "My Own Network, Powered by AHRQ").
Ms. Carol Sniegoski described MONAHRQ, a software tool that can be used to create an individual Web site for reporting data on health care quality and costs. When constructed using the software, the site will operate in an automatic fashion, using local data and publicly available measures. Built into the software are AHRQ tools such as quality indicators. Ms. Sniegoski described, with screen shots, the steps for downloading the MONAHRQ software and making it operational. Local hospital discharge data and CMS's Medicare Hospital Compare measures will load into the program, and the Web site produced has interfaces for users seeking hospital quality ratings, hospital utilization, and much more. Features include search functions, classification tables, bar charts, and detailed statistics tables. The program can drill down to the county and hospital levels but not to the ZIP Code level. A demonstration is available at http://www.monahrq.ahrq.gov/demo/index.html.
MONAHRQ project goals include the following:
- Encourage local reporting.
- Disseminate best practices in reporting.
- Encourage use of endorsed measures.
- Help harmonize local reporting.
- Provide options for tailoring local reports to local needs.
Future plans for MONAHRQ include adding new content (e.g., custom measures), adding best-practice information, adding new features (e.g., time trends and benchmarks), and increasing collaboration (e.g., offering feedback, technical support, user groups).
Dr. Fraser noted AHRQ's new Science of Public Reporting Initiative, which has a goal of forging a coordinated evidence-based strategy for public reporting at the national and local levels. Other goals are to improve the science of public reporting, incorporate the science into reports, improve data, and assess impact. The first step in the Initiative was to hold a large meeting in March 2011 to discuss goals and strategies for advancement. The Initiative is a partnership among AHRQ, CMS, and the HHS Office of the Assistant Secretary for Planning and Evaluation. The Initiative is funded through the Affordable Care Act.
Utah's Hospital Comparison Reports Using MONAHRQ
Keely Cofrin Allen, Ph.D., Director, Office of Health Care Statistics, Utah Department of Health, and Executive Secretary, Utah Health Data Committee
Dr. Keely Cofrin Allen described progress in developing reporting in the State of Utah. In 1990 the State created an Office of Health Care Statistics, which is responsible for reporting on facilities, health plans, and Statewide episodes of care. The Office has incorporated AHRQ's Quality and Safety Indicators, comparing facilities to expected rates and awarding ratings. In 2010 the State made the decision to employ the MONAHRQ software program; that is, to move its data to a MONAHRQ site. The project is in the testing stages. The new MONAHRQ site will be launched in December 2011. The State of Utah hopes that the use of MONAHRQ will mean rapid production of reports, fewer staff hours, representation of more data, introduction of statistical maps, and significant cost savings. In addition, patients will become better informed.
Dr. Siegel encouraged MONAHRQ developers to consider including physician quality reporting. Dr. Thompson noted that the State of Washington will be launching a provider-specific Web site and would be interested in studying the MONAHRQ style guide. Issues of attribution and transparency are complicated and will have to be addressed.
Ms. Darling suggested that ZIP Code data could help focus on disparities. Ms. Haskell urged the MONAHRQ developers to link to the Centers for Disease Control and Prevention's National Healthcare Safety Network and its data. Dr. Casale encouraged the Utah developers to study who visits or uses the MONAHRQ Web site. Ms. Behroozi wondered whether a site could be customized for a beneficiary group.
Dr. Spitzer noted that his organization has a grant for mapping neonatal disease and outcomes and warehousing the data. He encouraged the MONAHRQ developers to consider future automated data extraction from electronic health records. Dr. Donaldson wondered about additional measures that could be incorporated into MONAHRQ, such as nursing measures.
Speaking of more general issues, Dr. Siegel noted that technological shifts are taking place that will affect data and reporting, such as the use of smart phones and tablets. Dr. Donaldson added that there are generational differences in engagement with these technologies, and questioned whether AHRQ should partner with AARP. Ms. Darling suggested working with caretakers of elderly persons.
Dr. Thompson wondered about the possibility of creating a process through which people can dispute data prior to the data going public. Dr. Conway proposed studies of what works and the use of open (machine-readable) data. Perhaps private organizations could be enlisted in design efforts. Dr. Sevilla stated a need to understand what consumers will use, such as younger consumers using the Internet to select physicians. Dr. Jane Sisk cited current HHS efforts to stimulate innovative uses of governmental data (especially by Todd Park, HHS Chief Technology Officer).
Dr. Siegel stressed the issue of balance between standardization and local innovation. Dr. Fraser cited discussions about how to allow tweaking of measures used in MONAHRQ. Dr. Conway suggested that, because the best format remains unknown, standardization be minimized. Dr. Latts suggested that use of an open-source strategy might lead to the discovery of best structures and practices. Dr. Fraser noted that AHRQ is focusing on evidence-based strategies.
There were no public comments.
Chairman's Wrap-Up and Final NAC Member Comments
Dr. Siegel reprised a main theme of the meeting—the large-scale diffusion of knowledge for various cases and various audiences. He noted that the meeting produced the following important topics to be considered for the agenda of the next NAC meeting:
- Geographic variation in health care.
- Academic detailing.
Dr. Siegel proposed a conference call in September 2011 to craft the agenda of the next NAC meeting. He asked for final comments from the NAC members, especially ideas for the next meeting's agenda.
- Dr. McGuire noted the great breadth of AHRQ's efforts. Should there be an analysis of its efforts and outcomes, and should we seek to ensure that consumers are using the information?
- Dr. Spitzer cited the issue of publicizing AHRQ's work.
- Dr. Latts cited the potential conflict between patient empowerment and the need for measurement and outcomes (e.g., some people refuse to immunize their children).
- Dr. Casale proposed targeting the issue of measuring and reporting patient functional status.
- Dr. Thompson proposed the issue of costs for States and issues in Medicaid.
- Dr. Keith J. Mueller noted issues related to upcoming changes in the health care delivery system. For innovations such as health insurance exchanges to thrive, we will need to study trends.
Dr. Siegel stated that the next NAC meeting would take place November 4, 2011. He thanked the NAC members, AHRQ staff, and invited guests and adjourned the meeting.