[This Transcript is Unedited]
Department of Health and Human Services
Hubert H. Humphrey Building
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Washington, D.C. 20201
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DR. MAYS: I'm going to call this meeting to order. What I'd like to do is to start with introductions, particularly because we have a new person joining us so I want to make sure that she feels very welcome, so that she stays. Dale do you want to start with introductions?
MR. HITCHCOCK: I'm Dale Hitchcock, I'm the staff to the Subcommittee on Populations. I work in the Office of the Assistant Secretary for Planning and Evaluation, my boss is Jim Scanlon, in the Office of Science and Data Policy in ASPE, which is in the Office of the Secretary.
DR. GUTIERREZ: My name is Nilsa Gutierrez, and I'm the Medical Director for the Region Two Office at Centers for Medicare and Medicaid Services. I'm trained in internal medicine, I have a Masters in Public Health, and I've actually spent equal time in both clinical care as a primary care internist as well as in public health, both at CMS and at the New York State Health Department as the Medical Director and then Director of the AIDS Institute for the state of New York. Most of my work, my clinical work, has been in the public setting. I trained at a public hospital at Harlem Hospital, and then worked in a variety of community health centers, but mostly at one of the primary care clinics of Harlem Hospital in Manhattan. So I have, and I spent about seven years there so I've got quite a bit of experience working in a community setting in very, very poor communities especially with large immigrant populations. So that's the summary.
MS. BURWELL: I'm Audrey Burwell, I'm staff to the Subcommittee, and I work at the Office of Minority Health, Office of Public Health and Sciences as a policy analyst.
DR. CANE: Virginia Cane, I'm Deputy Director of the Office of Behavioral and Social Sciences Research at NIH.
DR. FRIEDMAN: Dan Friedman, Massachusetts Department of Public Health.
DR. LENGERICH: Gene Lengerich, Penn State University, Subcommittee member.
MS. CRUTE: Sheree Crute, I am the writer for the Subcommittee.
DR. MAYS: Okay, because we have limited time, I want to jump us ahead. I know that, is that? I was about to say I know Paul asked for something that he wanted us to consider. Paul will you introduce yourself and then Barbara introduces herself.
DR. NEWACHECK: I'm Paul Newacheck from the University of California, member of the Subcommittee for today anyway.
DR. STARFIELD: I'm Barbara Starfield, I come from Johns Hopkins University, and this is my last time, too.
DR. MAYS: Ok, you wanted to bring up an issue.
DR. NEWACHECK: I just wanted to bring up an issue about the National Center for Health Statistics and the Subcommittee as well as the whole Committee's role in helping to support that agency. They've gone through different periods of budget largess and shortfall and that, it looks like next year according to the discussion I had with Ed Sondik, they're going to have trouble funding a full years worth of health interview surveys, they'll probably have to do some cut backs in it. They have money apparently for HANES from NIH subsidies and transfers and that but not for HIS.
I think it would be helpful if the Subcommittee were to draft a letter of support to the Secretary indicating the importance of the HIS and more broadly NCHS because I don't think, they get sort of buried within CDC and they don't really have a voice for them. To be just supportive of the importance of that activity and fully funding it, ensuring that it's fully funded. We did that a few years ago with one of the other surveys that was in the state and local area and we had telephone surveyors do a survey and I think it actually made a difference. We got a response back and then they ended up funding it from the Office of the Assistant Secretary for Planning and Evaluation. So I just wanted to make that recommendation.
DR. MAYS: What would be really helpful and I don't know if, is Ed still around, is if he could generate a little set of specifics so that we knew for example to say, this budget over the past years has decreased by such and such percent, we note that this year we're being cut, I mean because it's just a rah, rah, rah letter. I don't know will do much. I think a letter that particularly if they're on going down in terms of their budget, we know that costs are going up, that kind of thing. So if there was something that could be generated in that vein it would be very helpful. And then, do you know if he's still here? Are you going to see him?
DR. NEWACHECK: No, he left I think, but I think actually the person to do that.
MR. HITCHCOCK: Ed Hunter, he's the budget.
DR. MAYS: Okay, if we want it to be a full Committee then in a funny kind of way we do best if we have the letter ready tomorrow, so if there's any way that, if Jennifer's still there, maybe it could be telephoned, faxed, and then we can work on it at lunch, hope to have it ready during Subcommittee. How's that? Report out.
DR. NEWACHECK: Do you want me to call her?
DR. MAYS: Why don't you do that? It seems like it's simple enough if they're willing to help.
MS. COLTIN: Question, is there a role for the Data Council or how, I guess I'm probably fairly naïve about how all that works.
DR. NEWACHECK: I think we recognize the Secretary, and then the Secretary Office would give it to the Data Council, and then the Data Council would evaluate and respond, so you kind of go that route.
DR. MAYS: I just think in order for them to take it seriously we need some figures added or something.
DR. NEWACHECK: Some documentation. I think they are there.
DR. MAYS: Okay, I'm willing to see if we can try and if not then the next procedure would be to raise it, to say what its about, to ask if it then could be done by the Executive Subcommittee, so that would be the back-up procedure if it doesn't happen as quickly as we'd like. We can do that in the report out.
What I'd like to do today is to talk about the issue -- this Subcommittee has engaged in a number of activities, both of recent times in terms of its hearings and in past times, in terms of what I would have talked about earlier. But in past times making lots of recommendations around the issues around population health. What I had planned on talking about today, which I'm kind of glad that it's tomorrow that I follow Barbara because its like I had hoped that Barbara really was going to be the lead-in of really helping the Committee to understand, the full Committee to understand what population health is and how important population health is to the work of the full Committee and not just to the Subcommittee.
With that in mind, one of the requests was going to be, and we talked about this at our last meeting, is that where possible when Subcommittees give reports, make requests or action items to move forward, that they do two things. That they discuss in their presentation what the population health issue is. And they also discuss if they think the things that they're recommending have any specific impact, have any impact on specific populations. So it's like kind of doing both, so Barbara I think that tomorrow this will be great to have you do the presentation, for them to understand what we're going to ask from here forth.
John, at I guess, it was our last meeting, had raised the issue of, at the Executive Committee retreat as well as the last meting, raised the issue of getting the full Committee to talk a little bit more about population health.
DR. STARFIELD: Well, that was a good example of this discussion on the code sets. We discussed it, it was an issue of payment, and that's all it is, an issue of payment, it has nothing to do with what happens to the population, what is done upon the population, it's just how you get facilities mostly paid.
DR. MAYS: It's interesting because I was going to start off in terms of talking about code sets for that particular Committee is when I went back, it's like between you and Marjorie, you have been very consistent voices around some of these issues about the collection of data on race and ethnicity, but also in my presentation, I'll talk about, it's not just about that but why are you doing it, what do you want to use it for, and some of the impact issues. So we're going to look forward to this tomorrow. And then I think my presentation will probably come when we do the report out in terms of Subcommittee report out, so by then, I'm glad, it will make it an easier kind of thing.
The second piece to be talked about is, in all this work, we have lots of recommendations, letters have gone off to people, and part of what Sheree has been doing is gathering all the background to figure out, and some things we still can't find that we're looking for, but when these letters have been sent, the extent to which they've been acted on. So some recommendations are acted upon and others are probably as germane now as they were when they were sent probably six years ago.
What you have in front of you is I actually gave you just the summary that she pulled together of the Denver hearing for those of you who weren't there. But the other thing that I have in front of you is a model that I want to talk about for how to do reports in terms of these hearings that we've had.
But I want to back up and not deal with this as reports and pieces of paper that need to go. I want to deal with first of all what we want to accomplish, the best way to accomplish it, and then how these reports can be used. Part of what I greatly lament is those of you who are going off have many years of experience of knowing how to accomplish goals effectively. I'm not interested in there being a report or there being a letter if it just is something that is received, a thank you, people move on.
Instead what I want to figure out is what strategically are the best ways to make sure that we move our agenda. Our agenda has been in the series of the recent hearings as well as previously is on the issue of the quality of the data that is being collected, specifically for racial and ethnic minorities. It's been on the issues that surround that data in terms of whether or not we can determine health disparities, health status, quality of care. And so how do we proceed using the information we received recently as well as in the past to try as these activities are going on to have an impact.
As you know there's an IOM group that is currently looking at the adequacy of the collection of data on race and ethnicity. It has, it's something, this issue has been picked up by several people so it's not as if right now is what we're trying to do is get people's attention. Instead I think right now where we are is in terms of trying to determine the best way to make something happen. A lot of people are talking but I haven't seen much in the way of action. Suggestions? Questions?
DR. LENGERICH: One of the questions that we have is our historical information that Sheree is working on, and I think part of that would be, the expecting part of that would be also to help bring all of the issues that have been raised back to the forefront on this topic. So I think that that's a very timely piece in this whole process and in my own sense that may be some of the background that I need to evaluate, to give you more thoughtful answer to your question there.
DR. MAYS: I just got I think the last big chunk, which was looking at the Committee's discussion over time on OMB 15 Directive. What I've been trying to do is to, because I was just actually reading it, is to look through and see the kinds of the recommendations that have been made, how many have been acted upon. It actually turns out that, I don't know if it was just this Committee or it's this Committee and other Committees, but in the collection of data specifically for the census and some of the guidance, you can see that suggestions that the Committee made were adopted. So I think the thing that I can probably at this point do is to try and take all the reports and pull out, that has been the most difficult thing, to pull out or list for you all the specific recommendations. What we can't seem to do as well, is when letters are sent forth is then to be able to track those letters and find out exactly what happened. I think this is where relying on Marjorie, Dale, Jim, would be much more useful. I do think that that is a task to do in order to give you some materials and see kind of where to go. Any other questions, suggestions?
DR. NEWACHECK: I think a couple issues we need to think about in terms of having impact is first who our audience is going to be for the Secretary’s Office is a little bit broader probably, or is it NCHS, or all of the above. Probably if you're trying to do too much, or you might not be able to accomplish as much as we would like. And then I think the other issue is how broad a set of recommendations do we really want to make. Do we want to have a fairly tight set of recommendations or we're going to -- voice that's different from some other groups that are looking at this or do we want to be more broad-based in terms of the kinds of recommendations for covering the water front. I don't think we really have any, we've talked about these things in kind of in general terms but not really very specifically.
DR. MAYS: Let me suggest a structure and a format and see again whether or not this will fit well in kind of what the Committee wants to do. Again it's kind of like, in terms of Chairing this group, I have to kind of delve into its own why we end of -- jump into the recommendations, you always say no don't do it that way. First I think the issue that I've heard from this group is that audience is important, so I think having one big report that tries to throw everything in that we have talked about probably isn't useful.
As I've gone through the material, the areas that I think are probably the ones that we've had the most input into that also seem to be important have followed along the lines of some of the populations, and that is we have American Indians, Native Alaskans. We've had the issue of vital statistics. And kind of what happens in terms of vital statistics around the collection of race and ethnicity. We've had the state, I think the state hearing in and of itself was just very illuminating because the issues at the state are different than the issues at the federal level. We had a hearing on population based data sets. We have talked about wanting to do API and Language, well let's put that aside for now. So it might be that we reach our audiences best if what we do is to try and segment the report into pieces. So I would say do one on population based data sets, I gave you an outline of a hearing that I think could be a structure for doing a report. Do one on state, do one on American Indians, Alaska natives, do one on vital statistics, and consider whether we can still do something on API and language.
DR. NEWACHECK: Those would be separate reports on each of those?
DR. MAYS: Separate reports. We could consider, but what I want to do is talk about reports and talk about a letter. I think we should consider as our first strategy a letter that if possible incorporates broader issues that speak to all of these areas. And that that's what goes to the Secretary and that will be asked for also here is a place card holder to say that we also will be forthcoming with some reports that will explain these in greater detail. And that I think is something we should try if people are agreeable to do by February. So at the February meeting we have a letter and we try and get the letter through and done at that meeting.
And then in addition, I think in terms of trying to do the reports, the structure for the reports can be the same and then what you'll see is we could, the issues are different, the recommendations are different, but the structure pretty much might be the same across all of them, so some of the material would be repetitive.
And then I think we should, given our resources and our time, is determine which reports are probably the most important to get out first, because I'm not convinced at this time that without my resigning my day job or taking a leave from my day job that we can get all these reports done. So it might be where should we focus our energy on doing a couple of them.
I have a suggestion for example in terms of the American Indian one. I would like to see us commission that because I know someone who actually has incredible data information, you know California has one of the largest populations of Native Americans, and that person I think if he could get it done, it's Paul Ong(?) who currently is working with the American Indian Urban, I forgot their full name, and they've collected information. When he told me what he was doing I was like wow, that's almost what we need, so it wouldn't be a big start-up and he probably could get it done, he may even be able to get it done before February, I don't know.
So I'd like to see us commission that one. The one on the state, I'm torn between whether it's vital statistics, state or compilation would be --
DR. STARFIELD: Is the list of the ones you want to do somewhere here?
DR. MAYS: No, I'm sorry, that's just an example of the outline. I'll just run through them, it would be, this is what we've heard in terms of hearings, population based data, state data, vital statistics --
DR. STARFIELD: Population based data means federal?
DR. MAYS: Yes, I'm sorry, at the federal level.
DR. STARFIELD: National data, state data, and what was the third one?
DR. MAYS: State, and then vital statistics, Alaska Natives and American Indian, and the two pieces we've had, we haven't even done anything, are API and language, those are kind of on our plate also.
DR. NEWACHECK: Are you going to get some of the new members on the Subcommittee?
DR. MAYS: That's something I don't know.
DR. NEWACHECK: [Comment off microphone.]
DR. STARFIELD: I'd be surprised if he chooses this one. I think he's an operations research person.
DR. NEWACHECK: Well, he's got a public health focus, too.
DR. STARFIELD: I could easily be wrong.
DR. MAYS: Well, do either of you know this person?
DR. NEWACHECK: I've known him from a more populations side, he'll speak eloquently about that, too. I'm just concerned that you don't have anybody, it's just the two of you, that's not really a Committee.
DR. MAYS: That's an issue that I think, I don't know exactly what, that's one of those I don't know how to answer but I'm trying to move forth and hope that I can make some --
DR. NEWACHECK: Did you get to have input on they were selected?
DR. MAYS: No, I got to have input on making, as we all did at some point in time, I think it was the Executive Committee or something, we made suggestions.
DR. STARFIELD: I'm sure if you go around the table tomorrow many of our suggestions didn't make it.
DR. MAYS: Well, I can tell you, none of mine are there.
DR. NEWACHECK: It's a concern.
DR. MAYS: We sent lists up.
PARTICIPANT: It's just a comment, one of which is combining vital with the state or with the population health.
DR. MAYS: With the state probably.
PARTICIPANT: Then second, I do think that given the size of the agenda and the size of the Committee, somehow or another reconciling those two factors about is it going to take, and one thing you may want to think about is, I think about the end value from a report is probably more for the field than for HHS and I think a letter, even if it’s a long letter, such as the one we went through today, may be more valuable and more efficient than a report.
MS. CRUTE: Can you explain that? Because you say the value is for the field and not for HHS, so why would you pick a letter?
PARTICIPANT: Well I think a letter to HHS might be --
DR. STARFIELD: It's more succinct, it's more direct, it's more clear, it's more focused.
PARTICIPANT: But I think if the aim is to affect HHS and policy than if we're thinking about three or four or five reports, I think it might be better to just sort of boil them down and to focus on a brief summary of what was heard and then have detailed recommendations, discreet letters with detailed recommendations.
DR. NEWACHECK: I think the benefits of the reports, there's two benefits, one is that it is for the field, it's done in the field, and second it's sort of a historic record than like you come upon old stuff now and saying the Committee did this and that. One approach might be to do as Dan said, not to try to spend a lot of time on reports but maybe to farm them out, like there could be a consultant for each of these, operate under the guidance of the broader group, that is you guys would consult and talk with them about here's what we, here's our key findings, and blah, blah, blah, we want a report on this and then you'd edit it to fit the Committee. And then you could do a letter with each one or a combined letter for all of them or whatever.
MS. CRUTE: Let me just comment at least from NIH's perspective that we do use the reports that come out of various Committees to justify things that we want to do, but it is very helpful and a letter we probably would never see.
DR. MAYS: Well, part of what I did was I also suggested in here that each time we design one of these reports, that we do a report, that we start out with what is the audience, and in this it's like ok, well maybe a letter needs to go to HHS, but then you also say well maybe Stinson should get it, and then a letter goes to NCHS if it's about national population based data sets that we get, that it doesn't just stop, the letter doesn't have to just go to the Secretary, but even if it's just a matter of the letter saying we'd like to bring this to your attention, this is the letter that's been sent to, we hope that if any of the things fall under your purview you're able to respond or something to these recommendations. But I think the issue of the reports Dan is that the question of change, in terms of particularly when you're talking I think public policy is sometimes things that go both ways allow there to be a constituency response that may help the Department to --
DR. FRIEDMAN: Well I think you're right Vickie, ideally I would definitely vote for a report with maybe a separate letter.
DR. MAYS: You're talking about person resources.
DR. FRIEDMAN: But I'm talking about having --
DR. NEWACHECK: The only way to do it is to contract out.
DR. FRIEDMAN: Knowing that even contracting out, it still takes, would still take a lot of your and Gene's time. In my experience having worked with really good writers for the Committee, it still takes a lot of time.
DR. MAYS: But I think though that the contracting at this point isn't going to be about going to a writer to do this, I think it's going to be about going to an expert in the field to do it. Like for example when I was talking about the American Indians, they've already pulled data together, this is a person who is used to writing reports, articles, etc., and is at that level, and then maybe having a writer do some editing. But not having a writer who what you do is have to provide them with the science and then they pull it together. So I prefer that given the bodies, the dyad that exists, that we talk about contracting at a very different kind of person.
DR. LENGERICH: I guess I would also, while I was looking outside, I would also just ask for a reflection upon your experience, particularly with the 21st Century when you reported so closely with NCHS as partners, and I guess I would see them as being particularly in the vital statistics piece where they have engaged Stel Matkinson(?) to help with their re-engineering piece. I'm just wondering if that, is that a special type of contractual or understanding relationship that we might look to?
DR. FRIEDMAN: I think it can work very well if NCHS has somebody who has the knowledge and the time.
PARTICIPANT: And they're in the same sync.
DR. MAYS: I was just going to say --
PARTICIPANT: Our report worked out very well but it required a huge time commitment on the part of two senior CDC people.
DR. MAYS: See the other thing I think it depends on which of these areas we're talking about. There are recommendations that are different than what NCHS sees as the way to do it. Part of what we're asking is a little bit different in business, so what I wouldn't want is to have to spend a lot of time with the explanation of why it's done this way as much as it's acknowledged that it's done that way but there's actually requests in the field for considering a range of options, and NCHS may do it that way but other people may do it differently.
At least during our first hearing that was my sense of part of the struggle that we had in terms of the hearing voices beyond. I think that was the value of having the data user there as well as having sometimes individuals who also had, like Mork(?), who brought their own surveys and who approach it differently for example. So it allowed us to put on the table a variety of approaches. In that one, I don't know --
DR. LENGERICH: I was thinking of more of the vital statistics and that connection to the states.
DR. MAYS: And the vital statistics I would agree, I don't know if Dan would agree in terms of the state, because usually in the presentations it's the state representatives as something and then you see that the federal government sometimes says something a little different, at least in the articles that are coming out recently, I think there's been requests to the federal government to do business a little differently. But the vital statistics part I think there should maybe be some partnership there, but I just struggle with the recommendations.
DR. NEWACHECK: Or they can give us a consultant that spoke --
DR. MAYS: Delta.
DR. NEWACHECK: And he would have that kind of inside perspective but also --
DR. MAYS: And then there was a person who came up afterwards, Stephanie Ventura, she was very good, she actually had specifics around the things that, he had the general framework but she had specifics and actually provided us with the material that hopefully we will distribute to people. So I do think that there are places in which a partnership issue would work well.
Well I think the issue is whether or not there are the resources, and I don't know Dale if you know or Audrey if you know or Debbie if you know in terms of our ability to not be caught in six months but to be able to, I think, because I'm going to ask people about identifying people, but whether or not we can move ahead with some consultants to help us. Those consultants might also be depending upon what we could do, they might also be our own Committee members, or retiring or leaving or whatever they call themselves, whatever they want to call themselves, we like the last line of the letter. But anyway whether or not it's possible.
MR. HITCHCOCK: It's possible in a number of different ways. Every year ASPE sends money to NCHS that will help this Committee do various projects. NCHS, I don't know, they generally spend the money on that. But I do know that they can carry over funds from year to year, like a lot of agencies can't do, so it might be that they have a small pot of money that we could use for paying consultants. Beyond that we're caught up in this budget Continuing Resolution thing until the end of the year I guess, or until the next Congress or something, that we might not, if it was new money in this fiscal year we might not be able to get it until after we have a budget.
DR. MAYS: It always seems that when there have been discussions about NCHS whatever the segment of it is that responds to this Committee has been carrying money over so if there is some carry over it might facilitate.
MS. JACKSON: Marjorie has made it very clear that you're front and center in supporting the contractual needs for the Committee if that's the way, the passage you want to go, then we'll find a way to get it done. Timing wise is just access is still the same budget wise and then timing expectations to get someone up on board and to cut out the kind of document you're looking for.
I also wanted to mention that how you package your letters, whether you want to call them letters or whatever, there's flexibility with that, too. You can get them out in serial fashion and then at a point we can organize them, pull them together as a report statement document, we've done that before, to something that agencies and groups can hold onto and see what the issues have been, even if it's after a year. That doesn't mean you have to wait until a year to pull these things out on a serial basis, so that kind of flexibility to get your statements out by topic is fine, but also realize that we can always amass them in a report later on.
MR. HITCHCOCK: Debbie, what about mechanisms, what are those going to be, personal services contract, are there dollar limitations that we need to know about?
MS. JACKSON: Off-hand I don't have the figure as to what that top line is but we've been able to get that kind of writing support in pulling together documents from what I understand. When you get into the PSC, PSC I guess you get into larger figures of many of thousands of dollars.
MR. HITCHCOCK: After a certain, it's easier to sell a source to somebody as a consultant under a certain dollar amount.
DR. NEWACHECK: One issue about the letter that I wanted to just raise and maybe Dale or Debbie knows the answer to this. But my impression that all of our letters go the Secretary, we don't write letters to NIH or to other organizations, even within HHS, that everything goes to the Secretary and that's who we are.
DR. MAYS: Really? I can't send a letter --
DR. NEWACHECK: That's what I thought, I think we discussed this before on some other occasion where we wanted to send, there's some kind of a process.
PARTICIPANT: There is an exec sec process.
MS. CRUTE: There's a letter to Congressional Committees in our documentation today.
MS. JACKSON: Usually what you do is prepare the letter to the Secretary so that we can show directly where it's going and then we can use a transmittal, direct transmittal to whatever agency or group that's more specific as to --
DR. MAYS: What's direct transmittal?
MS. JACKSON: A transmittal indicating a task --
DR. MAYS: A cc?
MS. JACKSON: Yes, indicating here's a copy of something that may be of interest to you considering your area of interest and so and so, you can make something--
DR. MAYS: You can't ask like, for instance I can't send a letter to NIH and ask them to consider, because some of the recommendations will be recommendations that could be at NIH, at CDC, at NSH?
DR. GUTIERREZ: You send a letter to the Secretary, that is the ultimate decision maker and you send a copy to the agency and you can even attach more specific information to be more directive. Nothing precludes you from that, just do it, that's the way to go.
DR. NEWACHECK: My impression was that it was more like a political process where the Secretary's office needed to decide who will get this and who wouldn't get it.
MR. HITCHCOCK: We would send it too.
DR. MAYS: Ok, because I think recommendations will be at various levels.
PARTICIPANT: We could send it to Virginia and say please share.
DR. CANE: I'd probably end up answering it anyway.
PARTICIPANT: The whole respondence process that's what happens, it gets parceled out to the people they think should respond to it.
DR. STARFIELD: In terms of how short we are in personnel in these Committees it would be sort of nice if we could tailor reports, all of them, to the overarching documents of the NHII and the vision, of the 21st Century vision statement. Is there anything in any of these topics that relates to anything that's in those documents?
DR. MAYS: Yes, in a sense that, well I think if you start with the notion as I put it here, something about the importance of population health, and I had actually had hoped to borrow from those documents that they were finished and done, is I think in the beginning where you say well what is the frame? The framing of it if we're going to stick with what we're talking about, the framing of it is from a population health perspective. And if you really take seriously a population health perspective it really does require you, not even ask, but it requires you to do certain things, like ask about questions other than race and ethnicity if you want to know the health of vulnerable populations in particular. It requires you for example to know things about the context in which they exists, it requires you to know something about social economic status, because that's what a population health perspective does.
DR. STARFIELD: That's what I'm arguing.
DR. MAYS: I think that it would be a saving grace to do that because what we could do is borrow from the documents, keep referencing the documents and look like that we're somewhat coordinated in what we do. And it is, it's trying to bring us back to population health. I'm really trying real hard to make it that. Let's do two things then. Let's talk a little bit about who, just a list of names and then I'll work with this -- national data sets that gather data at the population level. If you'll remember that was things like NHANES, NHIS, BRPAS(?), I can't remember who else we heard from, the adolescent survey, that would probably be comments about the new --
PARTICIPANT: You heard that in a break-out.
DR. MAYS: Yes, that was in a break-out session, but it would include all of those surveys and the issues and I kind of put what I think are some of the recommendations for that that I have drawn out. But who the good people to think about serving as a consultant to help write that, should be someone, and I'm not asking for writers, but I'm asking for people who this is their area of expertise and that they know race and ethnicity. And they're not sitting on the IOM Committee. I also hope to engage what I call readers is that when we've finished it there are people who would be willing to give us quick reads, and those are people usually like Claudette Bennett who is at the Census, I thought about asking Roderic Harrison, these are names that can also be used, Roderic Harrison, Hortensia Marrow, I don't know how busy she is, David Tackagucci(?), I do know he's very busy.
PARTICIPANT: These are former members of the Committee.
DR. MAYS: I know, that's why I know because some of this is their work. When I went back I saw that and thought again, they are possibilities of at least common, I'm going to move us along because we can get names.
DR. NEWACHECK: Is there anybody from the 21st Century who we could get comments on stuff like that that comes to mind?
PARTICIPANT: I'll think about it.
DR. STARFIELD: We need someone who is going to go over all the transcripts right?
DR. MAYS: Well we have actually at this point some summaries, so they can look and ask for very specific things, they don't have to do all the summaries, and what we could do is, I'm kind of at the point where I can probably talk them through what the bigger issues are having now read everything, and they could talk to the writer also, Sheree could help them, so I don't think they need to come in and read the transcripts, I think they need to come in and get the summaries and then look at what specific things they want and give them all of our letters and recommendations.
DR. NEWACHECK: And also have some similar set of values.
DR. MAYS: Yes, I agree 100 percent. Ok, we'll combine the state and vital statistics, so got a suggestion here before you go?
DR. FRIEDMAN: Again, it's related to how much time, because it's in the abstract it's hard, if its, you're thinking about a weeks worth of time, these are people who have day jobs who may not be interested in doing more than that, I'm not sure if it's a smart idea.
DR. MAYS: In terms of the actual time, I'd say two weeks.
PARTICIPANT: [Comment of microphone.]
DR. MAYS: I think maybe that's where we are so I'll use other help, but if they could write the structure, and we give them the structure, and some pieces are inserted from other places, it depends on the area, in terms of the area some of this I can write, I have an annual review coming out soon, I have something else coming out, so some of this I actually --
MS. CRUTE: A general comment that sometimes if you know of people who are, and I don't have anyone in mind, more junior people they'll have the time but some of the more senior people don't. I was just saying sometimes some really good more junior people have more time and I don't have any particular suggestions but we might think about that.
PARTICIPANT: Olivia.
DR. MAYS: I thought about Olivia, I think that's, Olivia has now moved from being at the federal government to being at the University of Maryland, so it puts her in a totally different category. She's just starting so I know she has a new course and a bunch of students, but she's a possibility, too.
DR. NEWACHECK: But there's also if we talk to somebody more senior they may have a brand new student or somebody --
PARTICIPANT: Or a junior faculty or such thing.
DR. MAYS: Ok, and for, and I've already identified at least one person, I can talk to Edna for the Alaska Natives --
DR. NEWACHECK: I think -- would be another possibility.
DR. MAYS: Who?
DR. NEWACHECK: She's someone who, she did that report on American Indians.
DR. MAYS: Can I get you to look at this? You should have it, it's two sided and it starts off with the collection of data on race and ethnicity in federal data and the determination on health disparities in racial and ethnic minorities. It just gives you an idea of the kinds of things I was thinking to include in a structure for the reports. An executive summary, we have in that executive summary there are a list of recommendations, these are the recommendations that I could pull out and find and things that I think hold up for the top one.
Then an introduction, which I think probably is to do with a little bit HealthePeople history as to why we're focusing on race ethnicity, the OMB 15 Directive, which I think is very salient. And then the importance of population based health statistics and their value for racial and ethnic groups. And some of this may be just twisted around or something like that. So that's the intro. See that would be the intro for all of the reports to some extent, and if they're doing a specific population, we would highlight more of the data of that population.
Then we go and talk about what the Committee's done and then we talk about we've had hearings in the past, what recommendations we've made, so we pull that from other things. And then I think what we should is talk about well, has HHS made progress in terms of those recommendations, and then some implications now of OMB 15 Directive for whatever the particular topic is.
We then say well here's what we've done to look at this issue in recent days which is one of the questions we ask, the hearings we've had, who did we hear from, and refer people to any particular materials that might be useful. And then we could get into what was learned, the highlight of the issues. Like for example in population data, it's the issue of the multiple race category, the issue of race and ethnicity, how it's defined, the tabulation, the bridging, does it have questions, whether ethnicity really is, what is it we mean by ethnicity, whether or not these data sets can measure disparity.
The funding issue, I was going to tell you, and I already thought ahead about that and came up very, I don't want to say directly, but it was clear that this funding issue is what's really impacting some of the difficulties we're having because every time they cut back, the group that loses the most is really the racial and ethnic groups, so that's important. Now what the infrastructure needs are, misclassifications are steeped in the sub populations, like what happens when they're lumped together, the issue of the sampling plane, I think that's a money thing, too, what we get in over sampling. And partnerships in terms of people keep saying that you don't have to do it all themselves. And then what our recommendations would be, which is actually we can start them again.
And then I think a section on partnership, because we are not I don't think going to be able to get all the money from the federal government for some of these problems that need to be overcome. Which is people being reluctant to participate, such as some of the research that's called for we sometimes can find from the Canadian statistics what they're experience has been, some of the academic survey centers can provide some of this background information as opposed to NCHS or NIH has to do it every time. Actually some of this is done by other groups.
And then the appendix would be whatever materials we want to put in. So let me open that up for comment, see what you think about it and, see if that's why we get some of it, or all of it--
DR. NEWACHECK: Yeah, I like it, it looks like two, three, four and five could be cookie cutter with some minor, minor edits.
DR. MAYS: Exactly.
DR. LENGERICH: When you say outlet public health reports, can you talk a little bit about that?
DR. MAYS: Part of what I also thought was important is to think about the audience and to think about outlets. I think reports per se will be nice in the sense that they can get distributed. But at the same time, if we move it into a science realm, can we for example put an article on public health reports, like I'd like to see that each of these, each report goes somewhere where it is then distributed in a peer review setting to a wide audience and I think what that does is that it actually pushes dialogue beyond just waiting for HHS to have a dialogue, but you have researchers then and public policy people and advocates having a way that they get it, that helps them to advocate in other levels.
DR. NEWACHECK: Can we do that? Are there issues with that -- [comment off microphone]?
DR. MAYS: But that's what they're doing, Dan and Barbara, no they've got two or three articles they're putting in the HAPH.
DR. NEWACHECK: They're not actually part of NCVHS --
MR. HITCHCOCK: -- we had Dr. Satcher basically write an editorial for someone when he was still here on the importance of collecting race and ethnic data and he talked about recommendations -- if they could do that in the Subcommittee -- either in the Department or from somebody from the outside to --
DR. MAYS: Well public health reports stuff belongs to the federal government so it might be --
MR. HITCHCOCK: Tony Robins, I remember him.
DR. MAYS: That's why when you put your stuff in there you don't have to copyright it anymore, it can go wherever, you don't even get asked. I guess what I was thinking about was that whole series of HAPH articles on Census 2000 that Kathy did, Dan, that we could accrue that seemed to be involved, I guess I thought kind of innocently all that flowed from this. But we'll find out.
DR. NEWACHECK: We could even do -- as a special issue in some Journal that could be paid for --
DR. MAYS: I think that what we would do is we'd actually take the report and write an article in the way that article needs to be written, we'd drop the whatever we'd need to. What I was thinking in terms of the state one is seeing if we could get, because I see on the board, the American -- the state presentation -- some of them were very good. And they could be turned into papers, they have to go with those papers, and it really is impacting upon epidemiologic data, but that might be a place for that to go. I could ask the editor. -- it was felt they'd be a lot more interested in the supplements.
So does this structure seem to be workable, like we want to kind of do this in terms of the report? And you can see how there's some costs that I think in terms of, can I give people in the time that we have to talk a little bit about some of these recommendations. This is what the meeting stuff I was able to pull out, and of course I'm sure there are other things, but I just want to hear from people like whether this seems to hit the mark. And I'll just go through them and if maybe if we could have just a bit of discussion, where possible consistency and measurement of concepts across surveys. We have people coming in the room who will talk about some concept and that it was all being measured differently. Now I'm not big on telling people what they should do, but if there is at least discussions so that if it fits it's fine. Because different surveys have different things that they want to do, and I think that sometimes telling somebody that they have to use the same variables across the surveys is micromanaging, but when there's possible to use the same variables I think that that's very reasonable, so what that really says is that there should be some kind of group in an HHS or something that at least has a meeting or something to talk about this.
DR. NEWACHECK: That's consistent with the Department's data immigration policy.
DR. MAYS: Ok, so I'll refer to data immigration policy.
MR. HITCHCOCK: Also, what we tend to do is look to the HIS as a model, the various surveys being, our health survey as being threatened, we need to make sure that we point that out in our report to about the HIS.
DR. GUTIERREZ: I would suggest that rather than focusing on variables that may be common to various surveys, what is it that the agency, that the Department believes that it has to have information on for every population group? Regardless of who the survey is going to, is there some baseline information that they should use that survey as a vehicle to obtain that information? That's a discussion that actually goes to the Data Council.
DR. MAYS: What it is, is that --
DR. GUTIERREZ: Rather than discussing individual variables and arguing whether one variable is of value to one survey or one instrument versus another, if what are the, what is in effect essential information that the Department needs to gather across all surveys because it is gathering them in different populations? In other words, what is sort of baseline information that it wants to get from all the information vehicles it funnels through each of the agencies? It's asking a different question because it doesn't get to the individual --
DR. MAYS: Well the question you're raising is, I would kind of frame it as, in terms of racial ethnic minorities, are there specific --
DR. GUTIERREZ: Or all population groups, or all population groups.
DR. MAYS: Well, for right now this is really on the data collection, I mean the hearings, we have to get back to that it's on racial and ethnic minorities, is that relative to that group, is there a basic set of questions that should occur in all surveys?
DR. GUTIERREZ: The only, what I think is problematic with that is that each agency will then say well we have no instrument or data collection tool that segregates groups out by race ethnicity.
DR. MAYS: They have to now.
DR. GUTIERREZ: Wait a minute. What they have to and what they have and how they get there to have it is an entirely different subject. But if you can say for now, I think it's as important, I think it's much easier to establish an across the board set of information or data pieces that will allow us to better understand the profile of certain racial ethnic communities in this country and you can accomplish that by applying those questions to every instrument across the entire Department, across all agencies, because you will be nickel and dimed on what it is that is and is not possible, because it's essentially creating sort of a sub set, another data set for specific groups. I don't know, that's my opinion, it will take much longer.
DR. MAYS: Actually, I don't think I was talking about questions that would be only asked of racial ethnic groups, but that questions that are in the data set because I think for all of them, that it kind of has to be that way unless you've branched off in a question where you're asked if you say yes to something, and then you get a special set of questions, like a discrimination question, if you're discriminated against then you get a whole ten questions you have to answer. But that no, I think in terms of the data sets the way it works everybody has to be asked the questions.
DR. NEWACHECK: You're talking about how to ask questions about race and ethnicity.
DR. MAYS: Yes, how to ask questions about race and ethnicity but also as it came out in the survey, there were other concepts that are important in terms of the health of racial ethnic groups, like SES, like --
DR. NEWACHECK: Some consistency across a common set of measures that have either race ethnicity or directly related to those, for the analysis of race and ethnicity.
DR. MAYS: Exactly, that would be it.
DR. LENGERICH: Where would you put something like Nancy Kreigers work -- I guess I felt like that was quite impressive what she was doing with --
DR. MAYS: Area and regional surveys are also one of the things, I don't know if it's here, here it is, inclusion of data for geo-code smart area analysis, so it's interesting because when I do this presentation on the issue of privacy does impact geo-coding, but geo-coding is very important I think in terms of racial ethnic groups, but we have to deal with privacy issues. And I think to deal with it just means that they have to create more data centers where you can go in and use that data as opposed to saying we can't use it, we don't want to collect it, it's just a cost of data centers I think in order to facilitate it. But that's the kind of stuff that she's talking about as really being able to get into areas and kind of the variables that you would use to do that, the value of using zip codes. I actually had a consultation with her yesterday before I left, running to get to the plane, because I wanted to ask her some more about that.
DR. LENGERICH: She needs the geo-coded data to the analysis but what she then comes back up with is having reflections upon measures of socioeconomic status which are in close relevance to her work, so I see it fitting in in both places.
DR. MAYS: And for her what she actually was coming up with is that while we've been talking about a socioeconomic status she's trying to narrow it down as to how we measure that, and for her it was the issue of the measurement of those who were below poverty. So we might say well, let's do talk about socioeconomic status and maybe that the recommendations that we think about poverty as an important element of socioeconomic status.
Finally, mechanisms for the surveys. The actual mechanisms I think needs to be, not money but the mechanism that's used to fund it I think to some extent has a big impact on surveys themselves and so we should comment on that. And then of course it's money for the surveys just separately. There needs to be more research done in terms of ethnicity and racial identification. These are the issues about the palidity(?) for example of race, what the implications of that are in terms of like when you try and do bridging and you're going to go from one survey to others, or you're going to follow people up over time, or you have people who are participating in these surveys over the long haul, we heard comments about that. Leadership from HHS in terms of tabulation and bridging of data, that has come up several times. Maybe ask the National Academy to determine how well the racial ethnic populations are surveyed. Now what this involves is the whole notion of particularly the sampling frames keep getting cut back, who you really have in the studies is an issue and the extent to which we're measuring kind of the heart of these populations.
To me that's a very important issue because if you're trying to think about health care delivery, and you're also trying to think about some of the emerging trends in terms of health behaviors, if you have a very narrow group of people because you tend to use telephones, or if you have a narrow group of people who are very trusting of the government, then you have a whole segment of people who I think you don't know whether or not you're actually surveying them well, so I think that really takes kind of a special set aside because it means looking at the sampling frame. It means really commissioning some people to look at the difference between institutionalized and non- institutionalized populations.
The area of regional surveys, this has come up. One of the things we wanted to do was to have Slates(?) and Radar(?) come back, I think Radar has some very well developed ideas we'd like to hear from him. So it may be that one of the ways to do that and get it in is to try and interview Radar or have Radar come and talk to us in some point in time because I think he's been on both sides of this issues in terms of navigating at NIH, but then being on the other side of being at NCHS.
There were specific recommendations for certain surveys, I just put some of them down, I think we have to go back through and see what those are. I think it recommended a data user meeting. We need some place where people can talk about this, I mean that kind of came up. Even to having the people who run the surveys talk to each other was an issue. So it seemed to me that the data user, I was trying to put it in something like that would be doable, that would be a perfect one to make that the topic of one of the upcoming meetings.
The development of a body of science. We often do see that there are discussions around cognitive testing, but we really don't get the papers out, we really don't get the information out to a broader audience. So the question of how do we do that, like maybe we can pull NIH into this work a little bit more also.
Training, that's come up on -- about the training of people to do this particularly making sure we have racial ethnic minorities. Language, the issue of language proficiency, the issue of the extent to which these surveys are translated into languages. Geo-coding, get the data centers in partnerships.
Now those were from work that I've done in terms of going through a lot of the material that we've had, this is what emerges. Some of them may be my interpretation of it so people are free to comment if they thought it was different. But if there are also other things that you think are important to include, please comment.
DR. NEWACHECK: One piece, I'm not sure if it's here, is the issue of over sampling, we talking about that.
DR. MAYS: I think I had that. Let's put in a recommendation because I know you're right, I mean the last hearing we asked, so let's, there's some issues though with over sampling, some pros and cons, but I'd rather have numbers than not have numbers.
DR. NEWACHECK: Now would your thinking be that all of these recommendations would be getting to report, modify it for that particular thing or would some of them be like pulled out like cross cutting ones go in the population data kind of report, or --
DR. MAYS: These are the ones I thought were very specific to populations. I think that they may be relevant, I haven't looked yet, I was doing it kind of one by one, I hadn't even gotten yet to, some of these I bet are relevant for state --
DR. NEWACHECK: Yes, definitely, over sampling is basically relevant to --
DR. MAYS: Well we may be able to cheat on one, too, then. Maybe some of these we can't figure out the extent to which they fit and several and then as we approach a particular topic we need some that may be very specific to that topic. Like for example the issue of ethnicity. What you say about it that's done at a federal population based level may be different than what you hear in the state level.
DR. NEWACHECK: It might be good to pull out sort of cross cutting issues and some specific ones that go in to the reports.
DR. MAYS: Ok. Then we'll start with these and see how they are modified for each of the reports, so that might be helpful, I haven't, I still need to go through the others, so there may be other things that will emerge, but this was like the first one that I started with.
MS. CRUTE: I'm not sure what you were thinking about on the language issue. The issues go well beyond translation but really has to do with coverage of the populations so it would fit in as well with how well are the regional and ethnic groups being surveyed.
DR. MAYS: Tell me what you mean by coverage of the populations.
MS. CRUTE: There are some languages that things are simply never going to be feasibly translated into because they're so small and leaves out a huge, it's relatively small compared to some of the other population groups, but it leaves out a certain segment of the population if they can't be surveyed in English.
DR. NEWACHECK: And there's this issue of cultural differences in interpretation of the same word even if the words are understandable.
MS. CRUTE: Right, and that I think fits in with the translation issue in ways of translation but sometimes there are going to be groups that are just left out if they can't answer in English.
DR. LENGERICH: It's not just English, I mean there are multiple languages, but there are those groups.
DR. MAYS: Let's put that into where this National Academy of Science thing I'm asking for because I think that that's important because again that's another way that it's a group that you don't hear from and if we had time to do the language hearing I think that the CHIS, California Health Interview Survey is a perfect example, they'll come in and tell you a little bit about, because it was translated into seven languages.
MS. CRUTE: NIH actually did a small group on this and came out with a little report which I can certainly share with this Committee.
DR. MAYS: I couldn't remember who did it, that's one of the things, we've kind of got that report and so that would be a source that I would also look towards if for example we don't end up being able to have a hearing. So instead what we would do is at the Committee look at those recommendations and say they've already had all this testimony, what is relevant, and then maybe have one or two other interviews or reports or something that would help and decide from that.
DR. NEWACHECK: It would be interesting also to ask the state's people at NCHS what portion -- they have two versions of their questionnaire, English and Spanish, but they have translators for a lot of the other languages, because with the telephone you can do that, they're on staff. They can tell us what proportion were Chinese, what proportion were German, or whatever -- they did and we'd get some idea so the language preferences of the interviewees.
MR. HITCHCOCK: That's a big methodological issue, too, I think you can just use a pool of telephone company interviewers.
DR. NEWACHECK: I think there are, sometimes they use AT&T translators and sometimes they have their own on staff.
MR. HITCHCOCK: You get a greater literal translation.
DR. MAYS: For one who spent quite a bit of money on translating one of my questionnaires and then gave to, I now have many more staff who are Latino, and they said this tells you the file cabinet that holds the papers, I said what? They said it, the companies can use programs and really go in and now, so that's what I paid for.
DR. NEWACHECK: There other issues like at NHIS unless they've changed things, they do things on the fly, and so the interviewers are kind of, if they don't speak Spanish, well they kind of try sort of, and they really butcher things.
DR. MAYS: Maybe in terms of the training, some of that stuff maybe we should write about somewhere in the report, in one of these reports, I don't know which, but some of those issues. But I think maybe it will come up in terms of language, because again, sitting on a multi-cultural technical advisory groups for CHIS, I'm learning a lot about, there are things that just didn't translate, things like the nutrition section, we had problems translating ketchup, other people have salsa, they don't use ketchup. There were a lot of interesting things that we had problems with.
MR. HITCHCOCK: [Comment off microphone.]
DR. MAYS: Ok, anything else in here that you can think of? This is very good because I think it's helping us to get a lot of this out, I'm glad this is kind of helpful, so that we can see how much we can -- Eugene in terms of similarities in these sections.
Ok, I'll work a little bit more on flushing this stuff out because what it means is that I have to take the transcripts and stuff and I look through it and I see if I can like flesh this out more and then maybe put a little more detail in this and send this out and kind of do another iteration of this. Then I think if we have people come on board then they'll know what it is that we're talking about and we want them to work on.
MR. HITCHCOCK: You don't want to use quotes?
DR. MAYS: They know how to use quotes. What happens --
DR. LENGERICH: I guess I'm thinking also of the format letters that probably not going to be used -- but if that's going in, is the only report going to be in something like public health reports and would quotes be the right thing, the right --
DR. MAYS: No, no, no, what it is is we'd have a letter, the letter to HHS, we'd have the report, and our report would have a whole lot of stuff in it, they'll even get the stuff in your books if they want. Then we just distribute those wherever. And then the third would be now can we boil down those two things and make an article that's in the whatever the format is that's required. And that's where maybe that some of the presenters, if you're a special issue or something, could come back to them and ask them to take those presentations and now write them up so that they'd fit into something. But I think in the report you can have quotes.
And I think we should do these in that priority, which is the first thing to get out would be a letter, so it would be a matter of can we write a letter to Tommy Thompson that really summarizes a number of issues that we're concerned about and then put the place card holder for the reports. Then next thing you do reports and then next you do this other thing. So if we never get to the third thing, we've gotten there because it's too much work, then so be it.
Alright, I don't know that we have time for a lot else, like anything, but is there, somebody else wanted -- can you have that issue of something that you do? Kathy's not here. Kathy had asked whether or not the Subcommittee wanted to comment and I told her the Subcommittee was cut small, but if this group wanted to do it, start it today and give it to them to finish it, on the Disparities Report that is currently out for comment by ILM.
If you'll remember, the Agency on Health Care Quality Research initially came to us wanting to think through a relationship where it might be us that would be holding hearings and doing activities for them but instead they went to the ILM. How dare they? Aren't we as prestigious as the ILM? But anyway, so instead they went to the ILM and there's currently a report that is on the web-site for comment. So I think Kathy was saying that she thought it might be important for us in terms of particularly that relationship with them to comment.
So I said it was up to the group. No, no, no, if I put in the request, I'm going to get the request today before you're officially off duty, and then when it gets done is a little different. You're on duty until the end of tomorrow, see I have my plan. I have my lap top, I'll go back to the hotel and send it. -- as to whether or not you think that that's a useful thing to do.
DR. LENGERICH: I hate to be pragmatic, but what's the time deadline?
DR. MAYS: I don't know, but I think that it's, I think, I may totally like not remember, but Stan is sitting back there, hi. Do you know, I mean I know you're in another area, but for your Quality Report that is currently out there with ILM and that they want some comment on, do you know what the comment period is?
STAN: For the National Quality Report is supposedly to have something -- by around February or March supposedly. I think they wanted to get something out by September so it probably would be very soon.
DR. MAYS: Yes, so I think the comments, I wanted to say January is what I vaguely remember from looking on the web-site, so it may be January.
STAN: Kathy asked Ed Kelley for some summaries of which she was trying to get them, so they'll probably have that in about a week or so. -- since the holidays are coming up, Christmas and all that, probably you'll have them by the end of, January probably -- once the holidays are over.
DR. MAYS: Can Populations comment on something without going to the full Committee?
DR. LENGERICH: That's my understanding --
PARTICIPANT: All your statements are actually coming from the Committee itself.
PARTICIPANT: So the question is, is a comment from the Subcommittee itself --
PARTICIPANT: The Subcommittee does exist in terms of doing the work component of the full Committee.
DR. GUTIERREZ: I think what she is asking is if there are commentaries, does there have to be full buy-in and passed through in the Committee level.
PARTICIPANT: The statement from the NCVHS did full Committee.
DR. MAYS: Do you have any idea if we're having an Executive Subcommittee conference call?
DR. GUTIERREZ: You can always set something up. The time period, you've done a lot more in less time if you're talking about getting something in January or February.
DR. MAYS: Ok, let me do this. Because I don't see us killing ourselves to want to do this and it's like we have this to do. Let me have a discussion with Kathy, figure out really what strategically is needed and then I can send an email and if people respond that's good, if they don't then we can figure out whether it's important enough that we draft something, I'll draft it in the Executive Committee comments on or something like that. Let me just see the extent to which this is an necessary ingredient.
DR. GUTIERREZ: That's a tactical question, I would imagine that people here that have an opinion about the value of the Committee, whichever Committee and led by this Subcommittee to respond officially to this report. Work aside, let's just put that aside for a moment, tactically is it a missed opportunity if we do not do it? In a sense is there value lost to how this Subcommittee can drive some of these issues in the context of the larger Committee if it doesn't take that opportunity?
DR. MAYS: Stan, can you talk to us? We're putting you on the spot. I think this is important, Stan might be able to shed some light on that, because I think that was Kathy's perspective about it's a good opportunity but if the question is if we don't do it then our only opportunity or will we by function of this Committee have other opportunities. Sometimes --
DR. GUTIERREZ: The answer is yes, yes, and yes. The answer is that there's always going to be opportunity, an opportunity that either the larger Committee creates, the Subcommittee creates, the politics creates, the communities create, there's always opportunity. The question is how much would the larger Committee, driven by the Subcommittee, be forced to state a case, an opinion, a comment on something that they might not otherwise do if the Subcommittee wasn't dragging it?
DR. MAYS: I get you.
PARTICIPANT: This has been on the agenda item for the full Committee understanding that the ILM report was out there.
DR. MAYS: It is?
PARTICIPANT: Well, not, one of the background pieces that we were looking at how we were going to bring it up for the discussion, so it's not like it's a foreign area, the Committee was aware that the Subcommittee had an interest in this, so it's not something that, I think it's something that would be helpful if we could take advantage of that, of the time period, the window to make a commentary.
STAN: In general, even staying in our own agency, usually getting comments earlier is better than afterwards. Once people have either gotten stuff down on paper it's really difficult to change your own mind about what you think as opposed to -- written something and then afterwards sort of in some cases may be critical of what's been put down. And since they haven't actually print something to paper yet I think it probably the time now --
DR. MAYS: Ok, let's see what we can do, we have asked Caroline to come here, we've kind of used the time, being collegial might be something we ought to think about here. So let me see what I can do. I hear that it's a good idea but what I also am aware of is good ideas end up back on my plate, and my good idea plate is a piece of china that's going to break. So I have to kind of watch out that the fine china can stay. So let me see what I can do.
[Whereupon, at 4:30 p.m., the meeting was adjourned.]