Enrollee Support for High Deductible Health Plans Workgroup Meeting - - PowerPoint PPT Presentation

Enrollee Support for High Deductible Health Plans Workgroup Meeting

January 8, 2015

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Steven Clauser, PhD, MPA

Program Director, Improving Healthcare Systems

Welcome and Introductions

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Question for this Working Group

Are there patient-centered comparative clinical effectiveness research questions that PCORI should fund in the area of providing enrollee support to positively impact access and utilization of health care services by persons enrolled in high deductible health plans?

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Agenda

Time Agenda Item Speaker(s)

8:30 – 8:45 AM Welcome and Introductions Steve Clauser, PCORI 8:45 – 9:05 AM Setting the Stage Steve Clauser, PCORI Robert Kaplan, AHRQ 9:05 – 9:15 AM Background and Objectives of Work Group Penny Mohr, PCORI 9:15 – 10:15 AM Discussion of Research Gaps: Why now and what are the important questions? Leah Binder, the Leapfrog Group Lynn Quincy, Consumers Union 10:15 – 10:30 AM Break N/A 10:30 – 12:30 PM Breakout sessions – Discussion and ranking of PCOR questions N/A 12:30 – 1:30 PM Lunch N/A 1:30 – 3:00 PM Plenary session: Report back and discussion of prioritized PCOR questions Penny Mohr, PCORI 3:00 – 3:15 PM Break N/A 3:15 – 4:15 PM Priority Questions for PCORI and Justification Penny Mohr, PCORI 4:15 – 4:30 Closing Remarks Steve Clauser, PCORI Bryan Luce, PCORI

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Housekeeping

Session is being webcast live and recorded; please use microphones when speaking and turn off your microphone when you are done Webinar participants can provide input via e-mail (info@pcori.org); via Twitter (#PCORI); or the webinar “chat” feature. Please submit questions as they occur to you. We will collect and synthesize these for inclusion in the meeting summary. We welcome additional input through January 23, 2015 at 5:00 pm ET via e-mail info@pcori.org

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How PCORI Manages the Potential for Conflict of Interest

The researchers, patients, and other stakeholders who have been invited to this workgroup will be involved in the process of determining the specific subject areas that we should address in the PFA. The broader community of researchers, patients, and other stakeholders who are participating by web, twitter and chat can be involved as well. Participants in this workgroup are eligible to apply for funding if PCORI decides to produce a funding announcement. Input received during the workgroup deliberations will be broadcast via webinar, and the webinar will be archived and made available to other researchers, patients, and stakeholders via the PCORI website.

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Webinar/teleconference and archiving this workshop This workshop is advisory! PCORI’s interest in collaborative funding of research

Reminders

Setting the Stage – Current State of Evidence

Setting the Stage

Steven Clauser, PhD, MPA

Program Director, Improving Healthcare Systems

Robert Kaplan, PhD

Chief Science Officer Agency for Health Care Research and Quality

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“The purpose of the Institute is to assist patients, clinicians, purchasers, and policy- makers in making informed health decisions by advancing the quality and relevance of evidence concerning the manner in which diseases, disorders, and other health conditions can effectively and appropriately be prevented, diagnosed, treated, monitored, and managed through research and evidence synthesis...and the dissemination of research findings with respect to the relative health outcomes, clinical effectiveness, and appropriateness of the medical treatments, services...”

PCORI’s Mandate

• - from Patient Protection and Affordable

Care Act

Compares two or more options for prevention, diagnosis, or treatment (can include “usual care”) Considers the range of clinical

• utcomes relevant to patients

Conducted in real-world populations and real-world settings Attends to differences in effectiveness and preferences across patient subgroups Often requires randomized trial design

How We Define Comparative Effectiveness

What Is Patient-Centered Research?

Compares effectiveness of important clinical management options that represent realistic choices faced by patients or other decision- makers Includes the range of clinical outcomes that are of interest to patients and their caregivers, including health, health-related quality of life, function, symptoms, safety from medical harm, survival and satisfaction with care

PCORI’s National Priorities for Research

Assessment of Prevention, Diagnosis, and Treatment Options Improving Healthcare Systems Communication & Dissemination Research Addressing Disparities Accelerating PCOR and Methodological Research

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IHS Goal Statement

To support studies of the comparative effectiveness

• f alternate features of healthcare systems that will

provide information of value to patients, their caregivers and clinicians, as well as to healthcare leaders, regarding which features of systems lead to better patient-centered outcomes.

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Distinctive Components of IHS Studies

Adapt PCOR model for CER beyond clinical treatment

• ptions to different levels of the healthcare system;

Require inclusion of well articulated and valid comparators, for both trials and studies using

• bservational data;

Focus on outcomes relevant to patients; Active involvement of patients and other stakeholders throughout the entire research process; Conduct research in real-life settings.

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PCORI Community

Patients/ Consumers Caregivers Family Members Clinicians Patient Advocacy Orgs Hospital/ Health System Training Institution Policy Maker Industry Payer Purchaser

PCORI Relies on Engagement in Setting its Research Agenda, Conducting Research and Disseminating Findings

PCORI also Collaborates with Other Funders

PCORI’s Board and its Strategic Plan express great interest in co-sponsoring and collaborative management of research with

• ther funding agencies
• Falls Prevention Trial with the National Institute on Aging
• Uterine Fibroids Registry with the Agency for Healthcare Research and

Quality

Contracts/MOUs from PCORI to manage targeted PFAs – PCORI provides funding, funding partner provides in-kind expertise In all cases, PCORI works with collaborators to ensure that its CER work complements, not conflicts, with the research mission

• f other funding organizations.

Enrollee Support in High-Deductible Health Plans Workgroup

Robert M. Kaplan AHRQ Chief Science Officer January 8, 2015

To produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and work within the U.S. Department of Health and Human Services and with other partners to make sure that the evidence is understood and used. AHRQ’s Mission

Priorities

Priority #1

Produce Evidence to Improve Health Care Quality Priority #2 Produce Evidence to Make Health Care Safer Priority #3 Produce Evidence to Increase Access to Health Care Priority #4 Produce Evidence to Improve Health Care Affordability, Efficiency and Cost Transparency

A Few Activities

• Evidence Based

Practice Centers (EPCs)

• United States

Preventive Services Task Force (USPSTF)

• Medical Expenditures

Panel Survey (MEPS)

• Healthcare Associated

Infections Program

AHRQ-PCORI Collaboration: Comparing Treatments for Uterine Fibroids

• Uterine fibroids

► The most common noncancerous tumors in women of

childbearing age

► Second most common reason these women undergo surgery. ► Cause significant pain, bleeding, and fertility problems

• Treatment options

►

watchful waiting

► drugs or hormones, ► embolization, ultrasound; ► partial or total hysterectomy.

• Little evidence about the effectiveness of these therapies
• r their outcomes, including fibroid reoccurrence and

women's ability to have children.

AHRQ-PCORI Study

• Data coordinating

center based at Duke Clinical Research Institute and nine clinical centers,

• The Observational

patient registry records real treatment experiences and measures Patient Centered Outcomes (PCOR)

AHRQ Activities

• Dissemination

and Implementation Research

Dickersin, 1987 Koren, 1989 Balas, 1995 Poynard, 1985

Balas & Boren, 2000

variable 0.3 year 6 - 13 years 0.6 year 0.5 year 9.3 years

Kumar, 1992 Kumar, 1992 Poyer, 1982 Antman, 1992

“PUBLICATION PATHWAY” Negative results

Submission Acceptance Implementation Reviews, guidelines, textbook Publication Original Research

Inconsistent indexing

Lack of numbers

Bibliographic databases Expert

• pinion

50% 46% 18% 35%

Balas & Boren, 2000

“PUBLICATION PATHWAY”

Implementation Original Research

years It takes

17 years

to turn

14 percent

• f original research to the

benefit of patient care

The Pivot- Some New Directions at AHRQ Accelerating Adoption of PCOR: Focusing on ABCS

• Accelerating Adoption of PCOR: Focusing on

ABCS

► Grants for dissemination of patient-centered outcomes

research to small- and medium-size primary care practices

► Focus: Million Hearts™ ABCS (aspirin use among

people with heart disease, blood pressure control, high blood cholesterol control and smoking cessation advice and support) campaign to prevent heart attacks and strokes

Do Cost Concerns Reduce the Use

• f Effective Services?

USPSTF Overview.

The U.S. Preventive Services Task Force…

• Makes recommendations based on rigorous

review of existing peer-reviewed evidence

► Does not conduct the research studies, but

reviews & assesses the research

► Evaluates benefits & harms of each service

based on factors such as age & sex

► Is an independent panel of non-Federal experts

in prevention & evidenced-based medicine

Recommendation Grades

Letter grades are assigned to each recommendation statement. These grades are based on the strength of the evidence on the harms and benefits of a specific preventive service. http://www.uspreventiveservicestaskforce.org/uspstf/grades.htm

Grade de Defin init itio ion A

The USPSTF recommends the service. There is high certainty that the net benefit is substantial.

B

The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

C

The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.

D

The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

I S Statement ement

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

USPSTF and Cost Sharing for Effective Preventive Services

• Under Section 2713 of the ACA, private health

plans must provide coverage for a range of preventive services and may not impose cost- sharing (such as copayments, deductibles, or co-insurance) on patients receiving these services.

• The required preventive services come from

recommendations made by four expert medical and scientific bodies, including the U.S. Preventive Services Task Force (USPSTF).

AHRQ Activities

• Provide data

MEPS Components

• Household Component (HC)
• Medical Provider Component (MPC)
• Insurance Component (IC)

Information on high deductible plans in the MEPS-HC and MEPS-IC

• MEPS-Household Component
• Questions added in 2011:
• Whether the deductible for a single or family plan

exceeds the threshold for HSA-eligible plans

• If yes,
• Whether there is a HSA, HRA or other type of

account to pay for medical care associated with the plan

• MEPS-Insurance Component
• Data available from 2006-2013:
• Amount of individual and family deductibles

(continuous measures)

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The Healthcare Cost and Utilization Project (HCUP)

HCUP Databases Research Tools User Support Statistics and Research

KID NIS NEDS SASD SEDD SID

HCUP is a comprehensive set of publicly available all-payer healthcare data Includes software tools, user support, descriptive statistics, research

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Conclusion

• AHRQ is a federal

research agency

• Dissemination and

Implementation Science has become a core component of

• ur mission
• Look for opportunities

in D&I at AHRQ

Setting the Stage – Current State of Evidence

Background and Objectives of the Workgroup

Penny Mohr, MA Workgroup Moderator

Senior Program Officer Improving Healthcare Systems

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‘‘(A) IDENTIFYING RESEARCH PRIORITIES.—The Institute shall identify national priorities for research, taking into account factors of disease incidence, prevalence, and burden in the United States (with emphasis on chronic conditions), gaps in evidence in terms of clinical outcomes, practice variations and health disparities in terms of delivery and

• utcomes of care,……”

Identifying Research Priorities

• - from Patient Protection and Affordable

Care Act

PCORI’s Research Prioritization Process

Prioritized Research Topics Topics Come from multiple sources Gap Confirmation Research Prioritization

(Multi-stakeholder Advisory Panels)

PCORI Website Workshops, Roundtables

• Eliminating non-

comparative questions

• Aggregating

similar questions

• Assessing

Research Gaps

• Preparing Topic

Briefs

1:1 interaction w Stakeholders Guideline Efforts, Evidence Syntheses

IOM 100 AHRQ Future Research Needs

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Post-Prioritization Process: Board Review and Final Disposition of Topic

• From Advisory

Panel Process

• From Staff or

Board with Advisory Panel Input

Prioritized Research Topics Further Topic Assessment and Refinement Landscape Reviews

Topic-specific Workshop Science Oversight Comm & Board Review

Board Approval Final Disposition

Place Topic in a Broad PFA Approve for Targeted PFA Place on PCS* List None of the above

“Fast track”

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*Pragmatic Clinical Study

Evolution of the Topic

1,000+ research topics collected 841 accepted 308 assigned to IHS program

• Program Director screened, consolidated, and rated topics

89 resulted from Program Director screening, and were scored 15 scored highest and selected for Advisory Panel consideration

• Topic briefs commissioned for all 15 topics
• Reviewed and ranked by IHS Advisory Panel – April 19-20, 2013

Link to PCORI Website - Full Description

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PCORI Advisory Panel on IHS

Topic was prioritized by IHS Patient and Stakeholder Advisory Panel in April 2013: Features of Health Insurance Coverage IHS staff worked with panelists and other stakeholders; two subtopics

• f interest arose: Enrollee Support for HDHPs and Effects of

Accountable Care Organizations (workgroup tomorrow) IHS staff commissioned updated topic briefs and conducted numerous key informant interviews to produce an initial set of PCOR questions Workgroup participants submitted additional questions, which we used to develop the final list

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Workgroup Objectives: Narrowing the Broad Topic

What types of enrollee support provided by employers, insurers, or health organizations positively impact access to and utilization of health care services and patients’ care experience in insurance arrangements with high deductibles? Are there patient-centered comparative effectiveness research questions that PCORI should pursue? If so, how would this multi-stakeholder group prioritize these questions in terms of importance?

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Taxonomy of Methods for Enrollee Support within High Deductible Health Plans

Incentive Structures in Benefit Design Price and Quality Transparency Tools Decision Support Tools With and Without Incentives Patient Advocacy Tools and Services Targeted Disease and Care Management Programs

Populations of Interest

Individuals in the workforce and their families; People with chronic or complex illnesses; People with low health literacy; and/or People with low incomes relative to their deductible.

Compares two or more options for prevention, diagnosis, or treatment (can include “usual care”) Considers the range of clinical

• utcomes relevant to patients

Conducted in real-world populations and real-world settings Attends to differences in effectiveness and preferences across patient subgroups Often requires randomized trial design

How We Define Comparative Effectiveness

What Research Questions are Within PCORI’s Mandate?

PCORI funds studies that compare the benefits and harms

• f two or more approaches to care.

Cost-effectiveness: PCORI will consider the measurement

• f factors that may differentially affect patients’ adherence to

the alternatives such as out-of-pocket costs, but it cannot fund studies related to cost-effectiveness or the costs of treatments or interventions. Disease processes and causes: PCORI cannot fund studies that focus on risk factors, origins, or mechanisms of disease.

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Examples of Out of Scope Questions

How does the average consumer find an expert physician with the tools they have available? What is the impact of a high-deductible plan on health care cost per year and patient out-of-pocket costs? How do patient-centered outcomes compare for those enrolled high-deductible health plans with those in enrolled in standard plans?

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How to make a PCOR question

How can members be educated and well-informed so that they can make better decisions for themselves when it comes to the use of preference-based surgeries? Is the use of a personalized web portal paired with interactive voice response technology more effective than a web portal alone in ensuring treatment choice reflects personal values and improves patient quality of life, functional status, and satisfaction with

• utcomes?

Comparators Patient-centered Outcomes

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Purchaser Perspective

Leah Binder, MA, MGA

President & CEO The Leapfrog Group

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SUPPORT FOR PERSONS IN HIGH DEDUCTIBLE HEALTH PLANS

January 8, 2015 Leah Binder, MA, MGA, President & CEO, The Leapfrog Group

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Overview

 One in 5 workers in a high-deductible plan with HSA/HRA  Average deductible over $2300/single & over

$4,300/family

 Different from other plans: employees typically pay every

dollar (excluding some preventive care) underneath the deductible.

 Creates a new kind of patient, suddenly price-conscious  50% escalation in overall deductibles for all types of health

coverage (ie PPOs, managed care, etc) since 2009

 New Numbers from CMS Actuaries (2013) finds stable

growth of health spending, continuing impact of HDHPs

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Gaps in research

 No studies relating directly to effects of

HDHPs on health for varying populations,

• r HDHP-specific decision support

 PCORI funds many studies relating to

informational support

 HDHPs are a relatively new but fast-

growing phenomenon, so research has not kept pace.

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Enrollee Support for Patients in High Deductible Health Plans

Presented by Leah Binder , The Leapfrog Group

 Significance

 Rapid escalation in HDHPs creates major shifts in

nation’s $2.7 trillion health care system--driven in large part by patient decisions

 Public and private sectors are grappling with ideas to

help consumers navigate, and need evidence on effectiveness of options that lead to best health

• utcomes

 Cadillac Tax in 2018 accelerating the movement.

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Potential Research

 Compare communication strategies for informing and engaging

patients who have HDHPs on choosing among providers, revealing price and quality of care, such that they achieve desired outcomes.

 Studies could compare strategies for reaching certain subsets of

enrollees, ie diabetic patients, maternity patients, low-literacy populations, etc.

 Studies could compare communication and education strategies

employers use, such as health plan materials, web-based materials, direct education, physician-based communication, to the extent enrollees make decisions that lead to best health outcomes.

 Studies could compare outcomes for benefits design strategies

within HDHPs such as: incentives for participation in disease mgmnt programs, exemptions from deductible for certain services

• r medications

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Questions

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 What are the best approaches to support people in

decisionmaking on price and quality of care?

 What are best practices for engaging key populations

with HDHPs, so that they get the best outcomes for themselves and their families?

 What strategies work best for employers educating

employees in making best use of HDHPs to achieve best

• utcomes?

 What are the effectiveness of different benefits

strategies within HDHPs to achieve outcomes for employees?

Consumer Perspective

Lynn Quincy, MA

Associate Director Health Reform Policy Consumers Union

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Lynn Quincy Associate Director, Health Policy PCORI Jan 8, 2015

High Deductible Health Plans: What Are Consumers’ Needs?

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Overview of High-Deductible Health Plans

Health plans with a “high deductible” HSA Qualified Plans (2015: individual deductible= $1,300) Plans with a funded HSA or HRA HSA= Health Savings Account; HRA= Health Reimbursement Arrangement

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Another Overview of High- Deductible Health Plans

Health plans with a “high deductible” “Consumer-Directed Health Plans” = HDHP with shopping tools HDHP with shopping tools that consumers use…

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While 98% of surveyed health plans

• ffer cost calculator tools, only two

percent of plan enrollees use them.

• CPR’s 2013 National Scorecard on

Payment Reform

Source: http: / / www.catalyzepaymentreform.org/ images/ documents/ NationalScorecard.pdf

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When thinking about future research…

… let’s firmly ground ourselves in what we already know

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We know a LOT about HDHPs

 Faced with high cost-sharing, enrollees cut back on both needed and unneeded care.  Once care is initiated, remaining course of treatment directed by provider, not patient.  According to one study: prices paid by CDHP vs. traditional enrollees did not differ significantly.  Vulnerable populations may experience adverse outcomes.

See: Goodell and Swartz, Cost-sharing: Effects on Spending and Outcomes, 2010; and Sood et al, Price Shopping in Consumer-Directed Health Plans, April 2013.

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After 10 years of experience, little evidence that HDHPs result in more price conscious or savvy health care consumers.

Bottom line:

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This is not surprising…

 Low enrollee understanding of HDHP/ HSA features.  Little in the way of trusted, actionable, just-in-time shopping tools.  An extremely blunt policy lever:

 Creates very different affordability propositions, depending on consumer income & health  Doesn’t signal where the good values are

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Many patients prefer NOT to include costs in treatment discussions

Four barriers:

 a preference for “best care,” regardless of expense;  inexperience with making trade-offs between health and money;  a lack of interest in costs borne by insurers and society as a whole; and  a willingness to act in their own self-interest although they recognize that by doing so, they are depleting limited resources.

Source: Roseanna Sommers et al, “Focus Groups Highlight That Many Patients Object To Clinicians’ Focusing On Costs,” Health Affairs, February 2013.

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Critical Research List

 How HDHP+ shopping tools compare to other, more targeted consumer interventions like VBID, tiered provider networks, reference pricing, and “fair” pricing.  More nuanced benefit designs that send better signals to consumer and take into account individual affordability considerations and overall value of the treatment/ provider.  Replacement for the expression: “skin in the game”

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Not on my list:

 Research into web-based shopping tools

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Thank you!

Resources from www.consumersunion.org:

• Consumer Criteria for Value-Based Insurance

Designs (Jan 2013)

• Creating a Consumer-Friendly Reference

Pricing Program (Aug 2014)

• Private Sector Approaches to Health Care Cost

Containment: A Closer Look (Nov 2013)

• Addressing Rising Health Care Costs:

A Resource Guide for Consumer Advocates (Nov 2013)

Questions? LQuincy “at” consumer.org

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Setting the Stage

Why this is an important area that needs research (what makes this compelling) Why this is an issue where PCORI can play a unique role- compared with other groups funding research in this area (what makes this a particularly patient centered question?) What are some of the key questions that PCORI research might address?

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BREAK

10:15 – 10:30 a.m.

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Penny Mohr, MA

Senior Program Officer Improving Healthcare Systems

Introduction to Breakout Sessions

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Questions Grouped Into Three Topic Areas

Communication and Education for Enrollee Support

• Location: Conference Room L
• Facilitator: Greg Martin
• Scribe: Andrea Hewitt
• Rapporteur: Ann Zerr

Social and Financial Incentives

• Location: Main Event Room
• Facilitator: Lydia Mitts
• Scribe: Katie Lewis
• Rapporteur: Mark Fendrick

Clinical Programs and Care Management

• Location: Conference Room O/P (4th Floor)
• Facilitator: Jake Galdo
• Scribe: Kaitlin Hayes
• Rapporteur: Dominick Frosch

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Key Questions to Answer

Describe effective models or approaches to provide enrollee support Why or why not are the questions particularly well suited for PCORI to fund? What specific questions would you recommend PCORI target? If you have developed more than one question – which

• f these is the most compelling and why?

What are the challenges raised in conducting research

• n these questions, and how might those challenges

be addressed?

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For each question

Clearly describe the comparators What populations should be targeted? Which patient-centered outcome should be examined?

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Collaborative Workgroup Discussion

Focus: Provide targeted input without scientific jargon Participate: Encourage exchange of ideas among diverse perspectives that are present today:

• Researchers
• Patients
• Other stakeholders

Be respectful: Disagree with ideas, not people

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Webinar participants are invited to submit questions via: Email: info@pcori.org Twitter: #PCORI Website: http://www.pcori.org/events/2015/enrollee- support-high-deductible-health-plans-workgroup

Additional Questions

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BREAKOUT SESSIONS

10:30 a.m.– 12:30 p.m.

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LUNCH

12:30 – 1:30 p.m.

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Moderated by Penny Mohr, MA

Senior Program Officer Improving Healthcare Systems

Report Back from Breakout Sessions

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Breakout Group 1: Communications and Education for Enrollee Support

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Breakout Group 2: Incentives

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Breakout Group 3: Clinical Programs and Care Management

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BREAK

3:00 – 3:15 p.m.

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Moderated by Penny Mohr, MA

Senior Program Officer Improving Healthcare Systems

Priority Research Questions for PCORI and Justification

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Priority Questions

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Criteria to Keep in Mind

Patient-Centeredness: is the comparison relevant to patients, their caregivers, clinicians or other key stakeholders and are the outcomes relevant to patients? Impact of the Condition on the Health of Individuals and Populations: Is the condition or disease associated with a significant burden in the US population, in terms of disease prevalence, costs to society, loss of productivity or individual suffering? Assessment of Current Options: Does the topic reflect an important evidence gap related to current options that is not being addressed by

• ngoing research.

Likelihood of Implementation in Practice: Would new information generated by research be likely to have an impact in practice? (e.g. do

• ne or more major stakeholder groups endorse the question?)

Durability of Information: Would new information on this topic remain current for several years, or would it be rendered obsolete quickly by new technologies or subsequent studies?

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Voting Sheet

1 (low) 2 3 (modest) 4 5 (high) Patient- Centeredness Impact on Health and Populations Assessment of Current Options Likelihood of Implementation Durability of Information Overall Importance

What are the most effective mechanisms to provide ongoing care/disease management support to the chronically ill population within high deductible plans and who should do it to most effectively improve patient outcomes? Score this topic from (1 – low / does not or barely meets the criterion) to (5 – High scoring / fully addresses the criteria). Please reference the scoring criteria guide as reference. The total score will measure how highly this topic is prioritized.

Given your consideration of all CER questions, which one would you recommend that PCORI should pursue and why?

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Steven Clauser, PhD, MPA

Program Director, Improving Healthcare Systems

Closing Remarks

Bryan Luce, PhD, MS, MBA

Chief Science Officer, Office of the Chief Science Officer

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We Still Want to Hear from You

We welcome your input on today’s discussions. We are accepting comments and questions for consideration on this topic through January 23rd, 2015 via email (info@pcori.org) We will take all feedback into consideration.

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Thank You for Your Participation

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