1. Innovative Health Care Policies: Using ACO Principles and Financial Incentives to Improve Health Outcomes Web Seminar January 29, 2013 Follow this event on Twitter Hashtag: #AHRQIX

2. Today’s Host Judi Consalvo Program Analyst at AHRQ Center for Outcomes and Evidence 2

3. Using the Webcast Console Speakers or headphones are required for the audio portion of the Web Seminar Speakers or headphones are required for the audio portion of the Web Seminar Having difficulties with audio-stream? Having difficulties with audio-stream? Dial (888)-632-5061 and enter Conference ID number: 51722494 followed by the # sign. Or click on “help” 3

4. Submitting Questions Click on “Ask a Question”, complete the form and click “Submit” Click on “Ask a Question”, complete the form and click “Submit” Technical questions? Click on “Answered Questions” Technical questions? Click on “Answered Questions” Substantive questions will be answered during the Q&A portion of the Web Seminar. Substantive questions will be answered during the Q&A portion of the Web Seminar. 4

5. Accessing Presentations Slides used during this Web Seminar may be downloaded Slides used during this Web Seminar may be downloaded Click on “Supporting Material” for slides Click on “Supporting Material” for slides 5

6. What Is the Health Care Innovations Exchange? Publicly accessible, searchable database of health policy and service delivery innovations Publicly accessible, searchable database of health policy and service delivery innovations Searchable QualityTools Searchable QualityTools Successes and attempts Successes and attempts Innovators’ stories and lessons learned Innovators’ stories and lessons learned Expert commentaries Expert commentaries Learning and networking opportunities Learning and networking opportunities New content posted to the Web site every two weeks New content posted to the Web site every two weeks Sign up at under “Stay Connected” Sign up at http://www.innovations.ahrq.gov under “Stay Connected”http://www.innovations.ahrq.gov 6

7. Innovations Exchange Web Event Series How to find archived materials Go to http://www.innovations.ahrq.gov to the Events & Podcasts tab. A transcript of this event along with the slides will be available within two weeks http://www.innovations.ahrq.gov Next Events Join our Tweetchat – February 27, 2013 Chats on Change: Supporting Priority Populations 7

8. Today’s Event Moderator Gerry Fairbrother, PhD Senior Scholar at AcademyHealth 8

9. Identifying Health Care Policy Innovations AcademyHealth is pleased to work with Westat and AHRQ on identifying health care policy innovations AcademyHealth is pleased to work with Westat and AHRQ on identifying health care policy innovations Major policy innovations in 2013: Accountable Care Organizations, payment reforms, quality improvement initiatives Major policy innovations in 2013: Accountable Care Organizations, payment reforms, quality improvement initiatives 9

10. Innovations Presented Today The Blue Cross Blue Shield of Michigan and Montefiore Medical Center The Blue Cross Blue Shield of Michigan and Montefiore Medical Center A payer driven quality improvement initiative and an ACO A payer driven quality improvement initiative and an ACO Both timely and cutting edge innovations Both timely and cutting edge innovations 10

11. David Share, MD, MPH Blue Cross Blue Shield of Michigan Lauren Henrikson- Warzynski, MPA Health Care Analyst Senior Vice President of Value Partnerships 11

12. Improving Healthcare Through Collaborative Partnerships 12

13. What are Collaborative Quality Initiatives? Structure of Collaborative Quality Initiatives (CQIs): developed and administered by Michigan physician and hospital partners, funded by BCBSM and its HMO, Blue Care Network Structure of Collaborative Quality Initiatives (CQIs): developed and administered by Michigan physician and hospital partners, funded by BCBSM and its HMO, Blue Care Network Support continuous quality improvement and the development of best practices Support continuous quality improvement and the development of best practices Leverage inter-institutional data registries Leverage inter-institutional data registries Why? Reduce avoidable adverse events, provide incentives and track performance Why? Reduce avoidable adverse events, provide incentives and track performance 13

14. Why Do We Need CQIs? Quality of health care remains suboptimal, with wide variations in performance across institutions and avoidable adverse events Quality of health care remains suboptimal, with wide variations in performance across institutions and avoidable adverse events Suboptimal quality affects patients’ health; drives up costs Suboptimal quality affects patients’ health; drives up costs Regional collaborations can provide incentives and infrastructure to systematically track and improve performance Regional collaborations can provide incentives and infrastructure to systematically track and improve performance 14

15. Overall Goals of the CQI Program Examine the link between care processes and outcomes in complex, highly technical areas of care Examine the link between care processes and outcomes in complex, highly technical areas of care Measure the quality of care within and across systems Measure the quality of care within and across systems Create a feedback loop for continuous quality improvement with participating institutions Create a feedback loop for continuous quality improvement with participating institutions Identify “clinical champions” at each participating hospital Identify “clinical champions” at each participating hospital Implement fast-track quality improvement initiatives targeted at specific, high-leverage procedures Implement fast-track quality improvement initiatives targeted at specific, high-leverage procedures Continue to demonstrate to consumers and purchasers of care that CQIs positively impact systems of care Continue to demonstrate to consumers and purchasers of care that CQIs positively impact systems of care 15

16. The Beginning Collaborative study on the variation in angioplasty procedures and treatment (1997) Collaborative study on the variation in angioplasty procedures and treatment (1997) Resulted in decreases in mortality, kidney failure, emergency bypass surgeries and other complications Resulted in decreases in mortality, kidney failure, emergency bypass surgeries and other complications Fostered development of a culture in which stakeholders pool efforts and best thinking to optimize practices, systems and outcomes of care Fostered development of a culture in which stakeholders pool efforts and best thinking to optimize practices, systems and outcomes of care Collaboration was necessary for real change Collaboration was necessary for real change 16

17. Current CQI Programs BCBSM/BCN Collaborative Quality Initiatives Hospital-based 12 New Hospital-based (2013)2 Hospital/Provider-based1 Professional5 17

18. CQI Program Framework Participating Sites Coordinating Centers BCBSM Offer neutral ground for collaboration Program funding and incentive payment design Data Analysis Data Reporting Develop Best Practices Data Collection Clinical leadership Analytic and quality improvement support CQI Continuous Quality Improvement Contribute to the all- payer registry Share and learn from best practices Consortium 18

19. CQI Financial Support Hospital CQIs: Data collection for BCBSM/BCN, Medicare and Medicaid, and uninsured members (estimated 80% of data collection costs) Data collection for BCBSM/BCN, Medicare and Medicaid, and uninsured members (estimated 80% of data collection costs) The CQI Coordinating Center The CQI Coordinating Center Professional CQIs: Registry-based CQIs: Data collection for BCBSM/BCN, Medicare and Medicaid, and uninsured members (estimated 80% of data collection costs) Registry-based CQIs: Data collection for BCBSM/BCN, Medicare and Medicaid, and uninsured members (estimated 80% of data collection costs) Non-registry-based CQIs: a portion of staff resources for CQI-related processes Non-registry-based CQIs: a portion of staff resources for CQI-related processes The CQI Coordinating Center The CQI Coordinating Center 19

20. CQI Incentive Payment Hospital CQIs: Active participation and improved outcomes are rewarded through BCBSM’s incentive program Active participation and improved outcomes are rewarded through BCBSM’s incentive program Engaged physicians for select CQIs may receive a recognition payment through service codes beginning February 2013 Engaged physicians for select CQIs may receive a recognition payment through service codes beginning February 2013 Professional CQIs: Active participation and improved outcomes as reflected in the metrics through the Physician Group Incentive Program Active participation and improved outcomes as reflected in the metrics through the Physician Group Incentive Program 20

21. CQI Participation High levels of participation throughout Michigan 95% of eligible hospitals participate in at least one Hospital CQI 95% of eligible hospitals participate in at least one Hospital CQI 73% of hospitals participate in all of the Hospital CQI programs for which they are eligible 73% of hospitals participate in all of the Hospital CQI programs for which they are eligible Over 329 physician practices participate in at least one Professional CQI Over 329 physician practices participate in at least one Professional CQI 21

22. Angioplasty CQI: Outcomes Between 2002 and Q3 2011, death has declined by 20%, contrast induced nephropathy (CIN) by 38%, transfusions by 38%, vascular complications by 44%, emergency coronary artery bypass grafting (CABG) by 92% and revascularizations by 17% 22

23. Hospital CQI Savings Over 2-3 years, 4 participating programs produced $232.8 million in health care cost savings Over 2-3 years, 4 participating programs produced $232.8 million in health care cost savings Complications and mortality rates lowered for thousands of patients Complications and mortality rates lowered for thousands of patients Michigan Surgical Quality Collaborative (general surgery) 2009-2010: $ 85.9 million statewide savings; $49.2 million BCBSM savings Michigan Surgical Quality Collaborative (general surgery) 2009-2010: $ 85.9 million statewide savings; $49.2 million BCBSM savings Michigan Society of Thoracic and Cardiovascular Surgeons (cardiac surgery) 2009-2010: $30.3 million statewide savings; $2.4 million BCBSM savings Michigan Society of Thoracic and Cardiovascular Surgeons (cardiac surgery) 2009-2010: $30.3 million statewide savings; $2.4 million BCBSM savings Michigan Cardiovascular Consortium - Percutaneous Coronary Intervention (angioplasty) 2008-2010: $102 million statewide savings; $13.8 million BCBSM savings Michigan Cardiovascular Consortium - Percutaneous Coronary Intervention (angioplasty) 2008-2010: $102 million statewide savings; $13.8 million BCBSM savings Michigan Bariatric Surgery Collaborative (bariatric surgery) 2008-2010 : $14.6 million statewide savings; $4.7 million BCBSM savings Michigan Bariatric Surgery Collaborative (bariatric surgery) 2008-2010 : $14.6 million statewide savings; $4.7 million BCBSM savings 23

24. Award Winning Partnerships Best of Blue Clinical Distinction Award Michigan Surgical Quality Collaborative (2011) Michigan Surgical Quality Collaborative (2011) Michigan Bariatric Surgery Collaborative (2011) Michigan Bariatric Surgery Collaborative (2011) Quality Oncology Practice Initiative (2011) Quality Oncology Practice Initiative (2011) BMC2 – Percutaneous Coronary Intervention (2012) BMC2 – Percutaneous Coronary Intervention (2012) PGIP – “Fee for Value” (2012) PGIP – “Fee for Value” (2012) Michigan Cancer Consortium Spirit of Collaboration Award (2011) Quality Oncology Practice Initiative Quality Oncology Practice Initiative Michigan Breast Oncology Quality Initiative Michigan Breast Oncology Quality Initiative Michigan Oncology Clinical Treatment Pathways Michigan Oncology Clinical Treatment Pathways Cancer Innovator Award (2011) eValue8 Health Plan Innovation Award (2008) 24

25. CQI Model: Why It Works Empowering the provider community to use comparative effectiveness research in a collaborative context Empowering the provider community to use comparative effectiveness research in a collaborative context Measurement to inform is more powerful than measurement to judge; BCBSM does not see individual hospital data Measurement to inform is more powerful than measurement to judge; BCBSM does not see individual hospital data Intrinsic motivation of professionals is harnessed when the work is owned and conducted by them Intrinsic motivation of professionals is harnessed when the work is owned and conducted by them Incentives focused on: Incentives focused on: – Participation to help pay for the cost of data collection; and – Performance, to reward active and results-oriented participation catalyzes engagement and improved results. Focus on long-term transformation of care processes improves systems of care Focus on long-term transformation of care processes improves systems of care 25

26. Key Takeaways CQIs support continuous quality improvement and development of best practices for areas of care that are highly technical, rapidly-evolving, and associated with scientific uncertainty. CQIs support continuous quality improvement and development of best practices for areas of care that are highly technical, rapidly-evolving, and associated with scientific uncertainty. Collaborating across institutions accelerates improvement; more can be learned from variation in care processes and outcomes across groups than within groups. Collaborating across institutions accelerates improvement; more can be learned from variation in care processes and outcomes across groups than within groups. CQIs target common clinical conditions and procedures associated with high costs per episode. CQIs target common clinical conditions and procedures associated with high costs per episode. CQIs gather data on patient risk factors, processes and outcomes of care. Use data to generate risk adjusted comparative performance analyses and guide quality improvement interventions. CQIs gather data on patient risk factors, processes and outcomes of care. Use data to generate risk adjusted comparative performance analyses and guide quality improvement interventions. CQIs help to further BCBSM's social mission of cultivating a healthier future for all Michigan residents. CQIs help to further BCBSM's social mission of cultivating a healthier future for all Michigan residents. Patients, regardless of payer, benefit from improved care processes developed through an all-patient approach to practice transformation. Patients, regardless of payer, benefit from improved care processes developed through an all-patient approach to practice transformation. 26

27. The Future of CQIs Ongoing CQI and Overall Program Evaluation including NIH-funded ROI analysis Michigan Spine Surgery Improvement Collaborative Michigan Spine Surgery Improvement Collaborative Aims: To improve the quality of care of spinal surgery by enhancing patient-reported outcomes following spine surgery; reduce surgical complications; reduce average costs of surgeries and episodes of care; and reduce the rate of repeat spine surgeries. Michigan Value Collaborative Michigan Value Collaborative Aims: To profile approximately 20 common inpatient conditions and procedures; to partner with existing CQIs to present findings and lead discussions; and collaborate in designing and evaluating improvement interventions. 27

28. Montefiore Medical Center Stephen Rosenthal, MBA, MS 28 President and Chief Operating Officer at the Montefiore Care Management Organization (CMO)

29. Montefiore: More than a Hospital 29

30. Where We Are High-Cost, High-Volume Environment High Volume: Over 90,000 admissions annually Over 90,000 admissions annually 3.5 million ambulatory care visits annually 3.5 million ambulatory care visits annually 500,000 home care agency visits annually 500,000 home care agency visits annually Bronx, New York: 1.4 million people, 31% poor (vs. 21% across New York) and 90% Hispanic and/or Black 1.4 million people, 31% poor (vs. 21% across New York) and 90% Hispanic and/or Black Higher prevalence of diabetes, obesity, asthma, other chronic conditions than New York City Higher prevalence of diabetes, obesity, asthma, other chronic conditions than New York City 20% higher per capita medical expense than US 20% higher per capita medical expense than US 8% of population  50% medical expense 8% of population  50% medical expense 30

31. Our Structure Formed in 1995 Formed in 1995 MD/ Hospital Partnership MD/ Hospital Partnership Contracts with managed care organizations to accept and manage risk Contracts with managed care organizations to accept and manage risk Over 2,400 physician members Over 2,400 physician members – Over 500 PCPs – Over 1,900 Specialists Established in 1996 Established in 1996 Wholly-owned subsidiary of Montefiore Medical Center Wholly-owned subsidiary of Montefiore Medical Center Performs care management delegated by health plans, other administrative functions, (e.g. claims payment, credentialing) Performs care management delegated by health plans, other administrative functions, (e.g. claims payment, credentialing) Licensed Utilization Review agent and certified claims adjustors Licensed Utilization Review agent and certified claims adjustors Montefiore IPA Integrated Provider Association Montefiore IPA Integrated Provider Association CMO Care Management Company CMO Care Management Company 31

32. MIPA and CMO Cont. Premium $ Insurance Company CMO MIPA Hospital Savings Specialty Care Primary Care 32

33. How We Got Started Catalysts for Innovation Reality of population Montefiore serves: low income, with chronic illnesses Reality of population Montefiore serves: low income, with chronic illnesses Early advent of managed care and the need for Montefiore to manage the premium Early advent of managed care and the need for Montefiore to manage the premium Significant competition among insurance companies  insurers saw partnering with us as opportunity to grow market share Significant competition among insurance companies  insurers saw partnering with us as opportunity to grow market share Also substantial competition among provider groups 33

34. How We Got Started Early Questions Why Fill the Care Management Gap: Dominant presence in the Bronx Dominant presence in the Bronx Developed diverse set of primary care practices through which to serve beneficiaries Developed diverse set of primary care practices through which to serve beneficiaries Improved relationships with providers in the community Improved relationships with providers in the community Decision Points: Determining the structure - combination of legal parameters and financial considerations Determining the structure - combination of legal parameters and financial considerations Seeking risk arrangements with payers vs. becoming a payer Seeking risk arrangements with payers vs. becoming a payer Focusing on particular care management and network support functions Focusing on particular care management and network support functions Which payers to target initially and longer term Which payers to target initially and longer term 34

35. Implementation Worked with a few key partners: Collaborated with healthcare leaders to brainstorm Collaborated with healthcare leaders to brainstorm Participated in National IPA coalition to learn about practices used across the country Participated in National IPA coalition to learn about practices used across the country Developed agreements with payers: First needed to understand their populations First needed to understand their populations Getting the correct payment was critical Getting the correct payment was critical Used a consistent model (full risk) Used a consistent model (full risk) Getting up and running: Cultivated a dedicated workforce Cultivated a dedicated workforce Focused on transactional aspects of the business e.g. timely claims payment Focused on transactional aspects of the business e.g. timely claims payment Understood the benefit packages and what employers expected of insurance companies Understood the benefit packages and what employers expected of insurance companies At start, systems limitations were challenging At start, systems limitations were challenging 35

36. Our Current Portfolio 36 Initiative 2012 Population 2012 Est. Revenue 2013 Population 2013 Est. Revenue Risk Contracts140,000$850 m185,000$1,085 m Shared Risk78,000$490 m80,000$685 m Medicaid Health Home (Care Coordination) 10,000$10 m10,000$18 m TOTAL228,000$1,350 m270,000$1,788 m

37. Strategic Approach Population Stratification 37

38. Care Guidance Model 38

39. Outcomes Post-Discharge Call Program Readmission Rate Decreased 33% 39 At-risk patients defined as: age >69; having had a readmission in past 60 days; or having had home care services prior to admission

40. Outcomes Effective Management of Diabetes 12% Drop in Total Costs 40 Source: CMO Paid Claims; Author: H. Shao Notes: Rx costs not available. Projected Costs Estimated using healthcare inflation trend of 16%

41. Key Takeaways Care Coordination 41 Individual level: Focus assessments on medical and psychosocial issues Focus assessments on medical and psychosocial issues Expand capability to work with participants face to face Expand capability to work with participants face to face Incorporate tools to support individual behavior change Incorporate tools to support individual behavior change Provider level: Improve access and availability Improve access and availability Expand PCMH infrastructure Expand PCMH infrastructure Incorporate behavioral health expertise into care management Incorporate behavioral health expertise into care management System level: Support organizational behaviors that reduce preventable utilization Support organizational behaviors that reduce preventable utilization Partner to identify vulnerable patients and create comprehensive care plans Partner to identify vulnerable patients and create comprehensive care plans Develop IT infrastructure to support cross-organizational communication and data exchange Develop IT infrastructure to support cross-organizational communication and data exchange

42. Key Takeaways Promoting an Accountable Delivery System Organizational governance, structure, alignment, and data are the foundation Organizational governance, structure, alignment, and data are the foundation Must define and understand the population Must define and understand the population <20% of the population determine the costs 100% determine the quality of care <20% of the population determine the costs 100% determine the quality of care Sustainable cost reduction, improve performance and patient-centered care only with delivery system transformation Sustainable cost reduction, improve performance and patient-centered care only with delivery system transformation 42

43. Key Takeaways Setting the Stage for Growth Use empirical evidence to support the spread of your best practice Use empirical evidence to support the spread of your best practice Develop or engage in forums for sharing information (like AHRQ’s Innovation Exchange) to engage new champions Develop or engage in forums for sharing information (like AHRQ’s Innovation Exchange) to engage new champions Leverage technology to advance your success; need technology to move information to the right people at the right time and to enable staff to practice at the top of their license Leverage technology to advance your success; need technology to move information to the right people at the right time and to enable staff to practice at the top of their license 43

44. What’s Next? New targeted interventions for select groups New targeted interventions for select groups Additional interventions for skilled nursing facility (SNF) residents Additional interventions for skilled nursing facility (SNF) residents Expand linkage with community-based providers Expand linkage with community-based providers Expand strategies for beneficiary engagement Expand strategies for beneficiary engagement Focus on patient satisfaction (33 ACO quality measures) Focus on patient satisfaction (33 ACO quality measures) Expand current programs Expand current programs 44

45. Respondent Xavier Sevilla, MD, MBA, FAAP Vice President for Clinical Quality Catholic Health Initiatives, Denver, Colorado

46. Quality Health Policy Background 2000 To Err is Human: Call to improve the delivery system as a whole 2000 To Err is Human: Call to improve the delivery system as a whole 2001 Crossing the Chasm: 6 Quality Dimensions, 10 Rules for Redesign of Health Care 2001 Crossing the Chasm: 6 Quality Dimensions, 10 Rules for Redesign of Health Care 2007 Joint Principles of the Patient Centered Medical Home 2007 Joint Principles of the Patient Centered Medical Home 2007 IHI Triple Aim 2007 IHI Triple Aim

47. Quality Health Policy Background New approach to measuring quality: National Quality Strategy April 2011 Better care Better care Healthy communities Healthy communities More affordable care More affordable care ACO Medicare Shared Savings Program 2012

48. Current Landscape in Health Care Policy/ Quality Using data to build a culture of quality: Slow improvement in quality (2.5% per year) Using data to build a culture of quality: Slow improvement in quality (2.5% per year) Delivery system transformation Delivery system transformation Aligning payment policies with quality Aligning payment policies with quality Bending the cost curve: $2.7 trillion, $1 out of every $6 in the economy Bending the cost curve: $2.7 trillion, $1 out of every $6 in the economy

49. Using Data to Build a Culture of Quality Pediatrix Medical Group Clinical Data Warehouse Automated data extraction from EHR Automated data extraction from EHR Accessible and easy to use at the bedside Accessible and easy to use at the bedside Extensive data validation Extensive data validation Decreased clinical variation Data down to individual clinician Data down to individual clinician Change culture to ongoing continuous quality improvement Change culture to ongoing continuous quality improvement

50. Delivery System Transformation HealthPartners in Minnesota “Prepared practice teams interacting with informed, activated patients through continuous healing relationships supported by ongoing availability of health information” “Prepared practice teams interacting with informed, activated patients through continuous healing relationships supported by ongoing availability of health information” Care Model Process (Delivery System) Care Model Process (Delivery System) Team based care Team based care Primary care based system Primary care based system Reliable, timely and actionable data Reliable, timely and actionable data Change of clinician’s culture Change of clinician’s culture

51. Aligning Payment Policies with Quality Improvement Zero sum game between payers / providers: wrong kind of competition, shifting costs, increase bargaining power, restrict choice Zero sum game between payers / providers: wrong kind of competition, shifting costs, increase bargaining power, restrict choice Competition should be on creating value Competition should be on creating value Shift from pay for performance to pay for value Shift from pay for performance to pay for value

52. Status of Pay for Performance Quality and Outcomes Framework Britain’s National Health Service (2004) “Overall only a modest improvement in quality” “Overall only a modest improvement in quality” “Pay for performance had no discernible effects on processes of care or on hypertension related clinical outcomes” “Pay for performance had no discernible effects on processes of care or on hypertension related clinical outcomes” – BMJ 2011;342:d108

53. Alternative Quality Contract BCBS of Massachusetts Unique Contract Model: Accountability for quality and utilization, long term - 5 years Unique Contract Model: Accountability for quality and utilization, long term - 5 years Controls Cost Growth: Global payment, payment to adjust for inflation, incentive to eliminate overuse Controls Cost Growth: Global payment, payment to adjust for inflation, incentive to eliminate overuse Improved Quality and Outcomes: Bonus payments up to 10% of the total contract, used widely accepted quality measures, outcome had more weight than process, frequent performance reports Improved Quality and Outcomes: Bonus payments up to 10% of the total contract, used widely accepted quality measures, outcome had more weight than process, frequent performance reports

54. Bending the Cost Curve Bellin Health (Wisconsin): decreased health cost, health care costs below the national average for external employers Bellin Health (Wisconsin): decreased health cost, health care costs below the national average for external employers Health knowledge of the population: health risk assessments for all patients Health knowledge of the population: health risk assessments for all patients Care management for at risk patients Care management for at risk patients Integrated system of care coordination: nurse call line entry point, primary care Integrated system of care coordination: nurse call line entry point, primary care Created a culture of health Created a culture of health

55. Conclusions Reform of the health care system is not only possible, but is flourishing in a number organizations such as Montefiore and BCBS Michigan Reform of the health care system is not only possible, but is flourishing in a number organizations such as Montefiore and BCBS Michigan Visionary leaders are not waiting to see what the new healthcare environment will look like but are innovating to improve their organizations today and position them for the future Visionary leaders are not waiting to see what the new healthcare environment will look like but are innovating to improve their organizations today and position them for the future

56. The Future of Health Care Policy Innovations Partnerships and collaboration Partnerships and collaboration The new roles for patients The new roles for patients Sick care versus wellness Sick care versus wellness Health versus healthcare Health versus healthcare

57. Question and Answer Click on “Ask a Question” below this presentation. Complete the form and click “Submit.” Click on “Ask a Question” below this presentation. Complete the form and click “Submit.” 57

58. The Innovations Exchange  Visit our Web site: http://www.innovations.ahrq.gov/  Follow us on Twitter: #AHRQIX  Send us email: info@innovations.ahrq.gov 58