Bob Wychilus: Hi, my name is Bob Wychulis. I’m with the Florida Association of Health Plans. Our team was the question how does AHCA enable price and quality trade-off comparisons and some sub questions. Ken was on my team, Mike was on my team--was on my team.

We believe that our—I’m so sorry. Yes, you are on my team. And I believe—we believe that our goal date was November 8, 2012. So we were very future looking but, I don't know where I picked that up from my piece of paper, picked that up a lot of things.

00:50

So we were very future looking. I don’t know where but the date came from but that’s where we’re going. And the first thing we did was we actually defined the price and quality trade-off as something, I think, that we discussed a lot yesterday, which was value, on that somewhere between price and quality was the definition of value that just because it’s highest priced it may given the quality measure, may be the best value for the consumer.

01:21

And then we answered the subquestions first before we cut to a lot of different things in a very broad kind of a discussion about how to look at the future but the first question we answered was: What are the sources of information? 

And if we were looking at the future five years in advance, I think we came with a very good and robust definition which is all data from all segments went longitudinally over time, which basically equals on an electronic health record, which is something that the agency is working with through the Florida Health Information Network, combined with pricing.

And then we said, where will we get that information if it’s all settings and it has to be critical information from patient records. But it also has to be administrative data from claims data and the combination would give a very robust database to the agency to be available to measure pricing quality across a number of different procedures, settings and things that the consumers would be interested in looking at in terms of price and quality.

02:31

We then answered the cost of requiring and maintaining an update, and we didn’t attach a dollar figure to it but we thought why not think a little bit without how those costs are going to be addressed. And we said, we believe that was the state and the government, maybe the federal government stroll for tax incentives to be able to produce this data and give the data to the state.

We believe that it should be a multi-source so that it spreads the cost that it needs to come from the federal government, the state, employers, payers and providers and then we also thought that bonuses and rewards for use of some and contributing to electronic health records in the Florida Health information network was a good way to get buy-in from all of the stakeholders into supporting an accurate value and a robust database.

03:31

We set a parameter that—of confidentiality, in relation to the management of the personal info and in terms and the confidentiality with conferring the de-identification of the aggregated data. So that there was no way that you could identify the particular individual from this aggregated data.

And then we answered the question about what would be unique about AHCA's contribution to all of this. And we believe that it’s the only structure in the state that can really aggregate all of this data in a fair and objective manner, and one that, again, act as a referee or a source between multiple stakeholders.

04:19

Then we moved over to some very broad thinking and I’ll try to explain this in the best way that I can. There were pieces of it that came from each team member, in terms of some of the thinking. So, if you’re thinking about 2012 and you wanted the future in terms of price and quality, it’s not just going to be that one thing, it may be about many different things the consumer is looking forward. That’s where the type of level with care can from it. And I used some examples during the discussion.

My son, moved to Gainesville recently as a student. I was looking for a doctor for him. And so, some of the things I was looking for in terms of looking for a primary care physician was just the hours of operation. And so that was criteria. I wanted a family practitioner. I wanted to know that the family practitioner had evening and Saturday hours; that was a criteria.

05:13

And you may want to measure that over price but that was a quality measurement for me in terms of looking for a doctor for my son.

On the other side of the coin, just an example only, thank God, if he got chrone's disease and he’s looking for a gastroenterologist. And I was looking for a gastroenterologist for him in the Gainesville area. Well suddenly I’m going to be putting in a whole bunch of other parameters in terms of the kind of doctor that I’m looking for and maybe the criteria of the kind and the quality the doctor that I’ve been looking for some credentials and maybe diagnosis and procedure information and certainly some patient satisfaction information.

They come into the criteria on the quality side and then again, on the price side, when we started talking about that, we started about the price and some baseline information that gave some relational information to the person he was searching.

06:16

So, it wasn’t just the price. It was somehow tied to an average on something that you could at least compare the price as well. And then, I think one of the issues that we just have one look at some of this information in terms of particular procedure whether it’s an operation or keeping a patient safe that people maybe interested in episodes of care. So, that if they were getting a gold letter operation, it would be a visit, a surgery, inpatient stay, the follow-up care, it will be a whole episode of care in terms of both the cost and the quality.

And again, this is future thinking with a really robust database. All of this, in terms of technology, is certainly there in terms of relational database matching what we’ve seen yesterday. We’ve got some great examples yesterday of how the web works in terms of relational database, thinking and matching different criteria together in different pieces of information.

And then, the last thing we did was say, "Well, we concentrated on the enabled part, which is how does AHCA enabled this?" And they’re going to do some things which is they need to continue the development of the FHIM and statewide EHR. They’re going to get to this kind of database. They’re going to have to work with the stakeholders and the consumers, I mean for quality measures. They are going to have to get us to agree some of there on those.

07:48

And then last thing is, they’re going to have to determine appropriate pricing information with the stakeholders as well and act as referee in that regard also because we have different ideas about what pricing really is. So, I hope I represented that well and that was our project. Yes?

Female Participant 1: Can I just add a little bit? I think the biggest challenge that we’re going to have is defining and measuring value. Because value to one person is going to be different to another and when you look at the two and I think that there is one website where you can rate what’s more important to you and maybe if you don’t have insurance, cost is the driver and it doesn’t matter the quality and you could go in and maybe weighing that.

So, cost is more important so that question of how like that breaking the value maybe be different from one person versus another who is more interested in quality. So I think that it’s going to be a major challenge of how we measure it. But I think the key thing is this is also looking at the how we measure quality and that cycle.

08:56

Recently one of the hospital said that they guarantee, we’re going to—one price and no matter what happens to you, you’ll develop an infection there or whatever.

You don’t have to pay any thing more and I think that right now we define quality and price as once they walk in the hospital to work, once they leave, and that’s data that we got unfortunately but that hospital might be the most expensive but their patients never got an infection. They never admitted data and so I think it’s going to be that whole value is we got to really look at what data we needed in order to define value.

09:38

Bob Wychilus: And I think that’s what I think so. If i understand that right, that’s part of A and part of C, or excuse me, B.

Female Participant 2: A couple of questions and this may not be to your group but to all of the groups. As healthcare becomes more scarce, I mean, if you read all the health pulse in literature, you’ll understand that specialty care and specialty providers are becoming more scarce.

They will continue to become more scarce and because of that. I think what we'll see especiallyfor the insured population, the capability and the willingness of people that are outside of their local community for that specialty care and also outside of the state.

So, my question is, are we really thinking into the future in the way individuals will be accessing healthcare in relationship to providing them information on quality pricing and outcomes. We’re comparing Florida hospitals to Florida hospitals that they were all more to become as good as our neighbor, not any better than what we are in the standard or the best in the best in Florida. Where when you compare that nationally, we maybe on the low side of the bell curve.

So, I guess my challenge at this time is to start thinking about how do we create a more efficient, effective healthcare delivery system to communicate that to the consumers and compare ourselves to national providers. Because in the next 5 to 10 years, I think the competition for healthcare will go beyond our local borders, will go beyond out state borders and even our national borders as individuals travel to other countries to receive cardiac procedures where it’s cheaper to go to India and have a Harvard-trained physician do your cardiac surgery. You can stay in a hotel and come back. Sometimes that's cheaper than purchasing a year’s worth of insurance in the United States.

11:58

So, I guess my challenge to you all is, how do we create that’s useful today but is flexible enough and takes into consideration that viewpoint where all healthcares in local today that I really don’t see that in the future.

Female Participant 1: But Lisa, I think that if there is a system we can go to the national level with CMS. And I think the more we can detail into that, you can go out in CMS and commission. And right now it’s process measures. They’ll be adding output measures and I think that the more that we get into that, the better we our. We work towards on national system and don’t focus on the state system. But it’s happening that in the national level...

12:49

Bob Wychilus: But it still doesn’t address the issue, which is, it doesn’t matter how you keep score, the fact of the matter is, the marketplace is heading in a direction that people who can afford to go in and get the best or let it go and get the best. And you’re going to be left with not those people as your customers if they’re not performing as well. How do you demonstrate pure performance in a varied way?

Female Participant 2: I think she was saying to compare to the national insurance that are around here today. So, maybe it’s bringing various tools into the AHCA website. And maybe we will show Florida hospital or show Florida hospital compared what to regional, compared to the state average, compared to another facility in the country. There are opportunities to compare in abroad, in fact, it’s just in our own backyard, besides what I was thinking about.

Bob Wychilus: Did you—yes?

13:48

Female Participant 2: I think our most difficult task is defining costs because the costs are going to be very different based on your care source. Charges aren’t going to mean a lot to anyone, even the self pay, because charges vary based on who’s performing the surgery, what facility to perform that. What the policies are based on the facility for the top payer, the uninsured discount. On top of that, every health plan has different rates and those vary based on who performs the procedure in the hospital with each individual hospital.

So I think that the number of issues that we would have to overcome in order to identify costs and then on top of that you have your benefit plan design, and where you’re having that benefit plan aside from heavy metric deductible, have you not met your deductible, what is your common insurance? What are you going to pay, and all of these factors to really define costs in order to calculate the value of this?

14:43

Bob Wychilus: That’s 112.

[Laughter]

Female Participant 2: That’s pretty serious.

Bob Wychilus: Thank you very much. Yes.

Male Participant 1: In the work - I apologise but I ask a lot of stupid questions that were covered - but in all three of the presentations so far, it has been interesting and I think potentially valuable distinction between the person who is sitting at the key board in a relatively abstract situation. He's concerned by health and health issues and value but not concerned about his child today.

And the profile is tremendously valuable in that kind of contact and some are in terms of what I talked about push-pull kinds of information flow where in the profile, there can be lots of stuff coming to you as a result of the profile on a variety of providers.

15:46

But there’s a second set of things that by more instantly available. And they have to, with my situation today. They don’t have to do with my profile. With Margaret, we all end up in a world of anecdotes but twice in weekend, we go out on a Sunday afternoon, in my next birthday, we'll throw out his little finger, they get it thrown out.

[Laughter]

Male Participant 1: And it hurt enough so that he was worrying about it and this guy is a technical custodian man. But he didn’t get--he never thought of doing it with his keyboard, it never crossed his mind, he thought to cross the next door, which will accuse him of things.

[Laughter]

16:31

Male Participant 1: We ended up in this conversation about what if you go to that shanty. That’s not your broken little finger, they don’t care about it, you’re going to sit there for 10 hours. If you go up the AGH or North Florida ER, they’ll care a little bit more and let you sit there for three hours. If you just take a lot of drugs and wait 'till tomorrow, you might see somebody in the morning.

So, I’ve been thinking about that, if that guy... Now it was not an emergency, not like Jeffrey’s, he's not calling 911. He's not calling an ambulance or anything like that but it’s in this thing where I want to make the decision now, as opposed to I want to make a plan for my next best case.

Female Participant: That it was time and not money.

[Inaudible]

17:22

Male Participant 1: First couple of questions, after a while it became money too, because we went into a conversation. We decided he wasn't going to get his fingerprints that afternoon anyway. We drank beers and talked about it.

[Laughter]

Female Participant 1: Put that up as an option.

Male Participant 2: Right.

[Laughter]

Female Participant 1: Treatment options, we have treatment options.

[Inaudible]

Male Participant 2: I think we found the consensus point.

[Laughter]

[Inaudible]

Male Participant 2: ...drink a beer.

Bob Wychilus: …and the amount of information going to both directions as---

[Inaudible]

Male Participant 1:Because most of the time we get into this value conversation, it’s with regards to either an actual or a clearly predicted episode. People have went to their cardiologist and cardiologist then said, “You know, we need to start thinking about this." So we’re building that decision. We’re not having a decision this afternoon but they’re making it this point.

Female Participant 1: So, which friend?

Bob Wychilus: Drink beers.

18:31

Bob Wychilus: So, there’s still seems to be a lot of issues around how do you calculate the price, right? And I think that for a person who’s in business, so to speak, at the end of the day, you’ve got to figure out. You got to know what you should be charging so that you can at least tell people what you’re discounts are or what you... I mean, everybody—you can calculate just basic averages. I mean, there’s got to be a way to start getting towards this. So I think definitely for this team is we work in the future—

Female Participant 2: Averages or ranges.

19:13

Bob Wychilus: Yeah, I mean I’m not--

[Inaudible]

Male Participant 4: Why can’t there be a price?

Female Participant 3: It goes like a journey.

Female Participant 1: And that it includes the benefit of information—

[Inaudible]

Female Participant 2: We have seen it in a website done by a particular hospital on pricing. And what they’ve done is to create basic categories. If you’re insured and that HMO or a PPO, your range is going to be from this to this. If you’re self-paying, you’re range is going to be from this to this. If your Medicare, your out-of-pocket is going to be from this to this.

So, there are ways in which we could do that and at least provide the more detailed information than the average charge in which this talk of information would provide—

20:00

Bob Wychilus: So, that’s around facilities but I’d still like to understand, I mean, personally, I’d like to be able to go to my health plan and say, “Which doctors are in my health plan? Are these guys only getting the three-star quality, three-star price guys? Or is my plan actually, did they have some real specialists, the real rocket scientists of health care so to speak, in there that do charge. I mean, that would be a very interesting, I mean, from a consumer, that’s what I’m getting my 20 minutes of.

Female Participant 2: Someone who plans have their information on their website but come in and you can go out for a specific DRG and now estimate for you if your out of pockets are. They don’t just include the hospital, they include all of the hospital to surgeon, the hospital base docs. So they chart and put everything into a number for the individuals. But that is not exactly average, just an estimate, and it’s still a range.

Bob Wychilus: Absolutely.

Male Participant 5: Just from that side, people will work out really hard to try to get there. If you look at probably 3% of the hospitals that are do procedures, you’ll end up in other than for unknown information and the reason for that were simple, if you don’t, if I only got three cases a year, at one carrier by myself, there’s no way to create an average that comes even close to realistic.

21:29

And part of this, from my standpoint is for a lot of carriers out there, a lot of payers out there, until we can get  or see things like what exist in Florida, we’re not getting that the kind of information our members deserve.

Bob Wychilus: All right.

[Applause]