DEPARTMENT OF HEALTH AND HUMAN SERVICES
Meeting of: Secretary's Council on National Health Promotion and Disease
Prevention Objectives for 2010
September 12, 2000, Proceedings
Agenda Item: Open Discussion
DR. SATCHER: Thank you very much. Questions, comments?
DR. TAKAMURA: Did you arrive at this singular purpose through some kind of retreat within the American Public Health Association? How did you get the consensus?
DR. AKHTER: It took us four years. The American Public Health Association has 78 different sections. It's just like this room full of people. Everybody has their own interest. The environmental people want to do their work, and the nurses want to do their priority. That's the way it has been for 127 years.
So after 127 years, we finally said, let's see what it is we could do to make the difference in the life of the American people that nobody else is doing. By a process -- going through this three-year process, finally the organization arrived at a conclusion of saying, this is what we need to do: to deal with the issue of racial and ethnic disparities is the call at the turn of the century. This will go in the history books as an historical event that the APHA did.
We are very fortunate to have the leadership of Dr. David Satcher, who is also one of our members and our leader, and Secretary Donna Shalala, who joined us in saying, yes, it's a good idea to move forward. That's what's happening.
DR. SATCHER: All 55,000 members had an opportunity to have an input into what should be the priorities for the next 10 years, and this one came out first.
DR. RICHMOND: First, as a member of the APHA, a long-term member, I'd like to congratulate you and the leadership. You talk about the diversity of the membership and the various aspirations of constituencies within that membership. I think all of us in this room understand the complexity of what has been accomplished.
So my point is that the leadership deserves a great deal of credit, because groups like this don't come together and develop a consensus and a focused target in terms of goals, if there isn't this kind of very creative leadership. I think we are all in your debt and those who collaborated with you.
The other point that I would like to make picks up on something we commented upon earlier. That is, the data that we get from the Genome Project, interestingly enough -- and Ruth Kirschstein said this better than I can -- really reinforces the importance of this effort in dealing with environmental issues. The ecological issues in which the organism grows, that is, creating favorable -- or if we don't create favorable environments, unfavorable environments that may prevail and fail to nurture our young in appropriate ways.
I think the data from the Genome Project are important, because as I've heard Francis Collins, the director of the Genome Project, talk about this -- he talks about the commonality of our genetic pool. So a lot of the old arguments about constitutional factors being immutable really kind of get rubbed out. I don't mean to oversimplify.
But the question now that I want to get to -- after saying that I think this is a very important emphasis, and this partnership is extremely important and potentially valuable to the nation -- is, how the 2010 goals are being utilized in this enterprise, and how you see them as being implemented through this kind of effort?
DR. AKHTER: First of all, Dr. Wykoff and his staff have been partnering with us, working on this to see how we could do this particular issue that you brought up. But there are two distinct ways that we are looking at this.
First, the data collected by these objectives will be monitored and will be looked at. Correct me if this isn't the way it is. We will see what kind of progress has been made in meeting these objectives, state-by-state and as a nation, in eliminating the gaps between the racial and ethnic communities.
Second, to see where we are not meeting the gap, to see what additional things need to be brought to bear; what kind of research effort we need to carry out, or what is it that we are not doing not to be able to narrow the gap and to be able to eliminate the gap.
The second thing is, these objectives clearly provide us a goal, which subsequently has been translated at the state level -- state-level people are now developing their objectives, and many have developed their objectives -- so it provides us the goal to meet at the state level, and the monitoring at the state level. The action is going to be at the state and local level, and that's how these objectives sort of fit in with our plan.
DR. SATCHER: For example, as I see it -- and as Dr. Akhter points out, this is still evolving -- if you take the Leading Health Indicators, which I guess I keep going back to, and you focus on those ten and look at the way they impact upon cardiovascular disease and cancer, just a whole gamut --. When you focus on those -- I guess we have two or three measurable objectives under each one that we are going to monitor from year to year -- this is something we all can do together throughout the country.
Then, in all of these areas of heart disease, cancer, et cetera, we can monitor what's happening to morbidity and mortality as we pursue the strategy of changing communities and lifestyles, improving access to care, strengthening the system of services to people at every level. So I think we have something to work with nationally, but we also have all of these objectives that we are monitoring in different ways.
Also, with the American Heart Association, we hope that we can have a very strong partnership looking at cardiovascular diseases and working with communities throughout the country. They have such a great network, great infrastructure for working with communities.
So that's what's evolving. I think getting this leadership -- I've been impressed with the people who have said, yes, to coming on and providing some steering committee leadership and helping to develop a national strategy that reaches down to every level of the community. So it's sort of a parallel strategy to the other things that are going on.
Any other questions?
DR. AKHTER: Thank you very much. I appreciate it.
DR. SATCHER: Thank you. Okay. We've come to the point now where we would like to open the floor for a sort of review and appraisal by Council members of all that has gone on today. It's also a chance to bring up any matter regarding implementation of 2010 that has not already been introduced.
So who would like to begin?
DR. WINDOM: Well, David, I think that we've learned a lot today, and you have brought us up to date. The question is, where to go from here? I did hear earlier this morning -- it sounded like some problem with data collection, inconsistencies or inefficiencies within counties and states. I wonder how that can be improved in some way to make it better for us to really track where we're going. Is that possible or is that impossible?
DR. SATCHER: I think it's possible. Nikki, did you have a question?
DR. LURIE: I'm sorry.
DR. SATCHER: He has raised a question about problems with data collection and inconsistencies. Within the Department, we've made a priority of the integration of data over the last few years. We have a Departmental Data Council that's meeting on a regular basis. I know a lot of the problems have to do with the infrastructure out there for data collection, and the systems, and the state of development of those systems. Do you want to say anything else about it?
DR. LURIE: Yes. Clearly, our ability to make progress, and know whether we are making progress or not, is going to rest on our ability to collect the data. Clearly, if you look at the documents that were passed out at the conference, as well as the final edition, you'll find a lot of places where we don't have data now. Some of them are developmental objectives, but for many, many of the objectives, particularly for smaller subgroups -- and this is a huge issue for any of the disparities that we're looking at -- we don't always have the data to know where we're going.
We have been working very closely with the Data Council. We have identified what we think are the highest priority areas for investment, moving forward this budget year and in budget year '02. But the reality that we all have to face is that people don't die from data or lack thereof. So we're challenged to think about what the advocacy for data and data collection looks like, especially as we try to get it at a state level and for all of the different kinds of subgroups that we're looking at.
I think we've made a lot of progress. We've taken a much harder look at our systems to see where we can integrate better, where we can stretch some systems to do better. But we have to face the fact that we've got some fundamental challenges here that we're going to have to overcome to move forward. I think other thoughts about strategies to accomplish this are very welcome.
DR. SATCHER: An example, of course, is -- when we try to segment the Hispanic population, which almost has to be segmented because it is such a differentiated population -- Mexican Americans, Cuban Americans, Puerto Ricans -- the more you segment, the less the adequacy of the data. The same thing is true for Asian Americans.
DR. MASON: I understand in the past there have been funds for the National Center for Health Statistics to track, specifically through the national health surveys, some of the Healthy People data, and that that didn't get funded. Is that going to compromise what we can do?
DR. SATCHER: Chuck, you're shaking your head. Do you know the status of the budget?
MR. GOLLMAR: It is not in the current budget. How much it's going to impact on the data collection -- NCHS does everything it can to collect all the data it can on Healthy People, but additional specific funding for that effort would be important.
DR. WAGENER: And it's currently not funded for next year, which is the year that we were going to do the state supplement. However, it was identified, as Nicole said, as one of the priority areas to look at.
DR. LURIE: What we did is, we said, if you just take the 10 Leading Health Indicators and the six clinical areas that have been the focus of the racial and ethnic disparities initiative -- if we only took those and said, what is it going to take us -- it's probably six core data systems or so -- how much investment in those to get so that we could have -- at a macro level for Hispanics and Asian Americans, not even for a subgroup level -- good data? We were able to identify the investment there.
The good part of this was, if you made the investment to do that much, you would hit, I think it was like, 96 Healthy People objectives, plus have state-level data for almost every state around the country, which would let states own their own issues and data and be able to track their progress, so that they could take this on. That investment remains terribly important and whether we will get there this budget year or next.
DR. SATCHER: It's helping to have people like Senator Frist in the Congress, because I think they are people who understand the importance of this. It's been very difficult to get infrastructure funding. As long as the funding is tied to a disease, it's easier to find a champion than it is to find funding for infrastructure. So that's our struggle.
We have gotten some funding in recent years for prevention research centers, but even that's difficult to sustain. I think we're up to 23 prevention research centers now. But infrastructure funding is very difficult. That's where we've got to make a lot of progress in the next few years. We need a lot of help in that area.
DR. FLEMING: A comment on that. I may be stating the obvious, but data are most useful for talking about implementing Healthy People 2000 at the unit of intervention. Basically, the people who are doing the work need to know whether or not what they are doing is making a difference.
DR. MASON: Or whether they need to do it.
DR. FLEMING: Exactly right. In that context, I think what we've heard today is a critical need for data at the state level, but the reality is that public health is local. Coming from a state, I can assure you that the biggest data concerns that we have are being able to provide data to the local unit of intervention, the community level, the local health department. That really is going to require, I believe, a rethinking about what our priorities in data collection are, and how we go about collecting it. We're not going to be able to get very far investing communities in Healthy People 2010 until we are able to give those communities back the data for their community on these indicators. That's really, I think, our challenge.
DR. LURIE: This is a place where the technology has already helped us tremendously in developing ways to give people back the information that's there. But we're still challenged to think about how to use all that new technology better to get more information at a local level.
DR. SATCHER: Pam this morning was discussing the heterogeneity of local health departments. You look at the kind of data that we're getting out of Los Angeles County now. Some of it is enviable, in terms of what they are able to determine about their population. Somebody has to do it. What's the proposition in California that is providing money for the health of children? Was it 55?
DR. LEE: Prop 10, David.
DR. SATCHER: Prop 10. That's really helping them, and we're getting some really interesting information about disability-adjusted life years in Los Angeles County and things like that. But Los Angeles County is bigger than a lot of our states, certainly in terms of resources. We have a lot of counties out there that have maybe one or two board members, total. They don't have the resources.
DR. LEE: If I could comment on the data issue, David?
DR. SATCHER: Please.
DR. LEE: There's a very big need -- I couldn't hear who made the comment about the local data needs. There's not only a need for feedback at the local level, but there's also need to develop methods to evaluate the effectiveness of community-based or population-based interventions.
There's some work being done on this. There's a great deal of activity: Casey Foundation, Kellogg Foundation, Robert Wood Johnson, CDC, all doing some different activity in this area. But there really is a need to look and provide for the partnerships for the community-based organizations, because they're not just local health departments. It's community-based, nonprofit, business, faith community, a whole set of actors. They're all doing different things.
People need to know what's effective -- is that effective or does something else work? So we need better tools for measuring the effectiveness of these community-based or population-based interventions.
DR. SATCHER: That's especially critical, now that we have the REACH programs funded through CDC, where we're funding these communities. REACH stands for Racial and Ethnic Approaches to Community Health. These are demonstration models of how we eliminate disparities.
But we've got to be able to measure the impact of different strategies. Flint, Michigan is looking at infant mortality; the community of Detroit is looking at diabetes. But we've got to be able to really measure what they're doing, the impact it has had.
DR. FLEMING: Can I add onto that? I think that what you're saying is so true. What we need to do though, in addition to measuring impact, the outcome, is, we need to bite the bullet and make sure that we're also investing in measuring the process. What happens over time is that, if you go to a community and intervention is attempted to be implemented, and at the end of the day you see no results, unless you measure the process, you don't know whether it was that the intervention didn't work but was implemented correctly, or alternatively, it was just not implemented as planned. In the absence of knowing that, you don't know what your next steps should be.
So the data collection piece is more complex than just local-level outcome data. It's also investing in that process piece, so we know whether or not what we think we're doing was actually done.
DR. LEE: I certainly agree with that, and I think it's very, very important. Roz Lasker of the New York Academy of Medicine has developed this concept of synergy. Measure what creates this synergy. It's a very important issue and process is critical in making it work.
DR. MALONE: Another sector that we want to work with in terms of data -- and Nikki has done a lot of work on this -- is the business sector and the managed care groups, who seem not to even know that they can actually collect the data that would specify the ethnic and racial background of their membership, their enrollees. I know that you have worked with Aetna in terms of doing that.
I know that our Office of Civil Rights is also very interested in how they can work with us around that, and in sending around something that's saying that you're not breaking the law if you collect the data. So there was that whole issue about what's legal to do in terms of collecting data around ethnic and racial backgrounds of the enrollees.
DR. WYKOFF: Other comments and questions from folks in the back of the room or the sides of the room?
MS. BRASLOW: I would just add that, this summer, I met with several SAMHSA review groups, where we have tried to extend our applicant pool to minority community-based organizations, both our applicant pool as well as our reviewers. In meeting with review groups, one of the things I have continually heard after they have reviewed a set of applications is that we need to provide better training, not only how to collect data, but how to set up an intervention. We ask for GPRA data; we ask for an evaluation. The applicant pool is having a great deal of difficulty in responding to that request.
They suggested the town-gown kind of thing. That's an area that we've talked about in the CDC steering committee for the Congressional Black Caucus. It's just a big problem across the board as we change the demographics of who we give our money to. Unless we provide some technical assistance in how to evaluate stuff, you can set up all the mechanisms you want for collecting the data, and it won't mean anything.
MR. PASSONS: Just some feedback on that notion. For example, I came from a local-level group. There was a grant -- you talk about the notion of providing technical assistance for support around an evaluation. There's sort of the fundamental notion right before that in what drives how the whole program works.
I can remember one grant offhand that was several hundred thousand dollars from one federal agency that had five percent in the budget for evaluation, five percent over a three-year grant of $100,000 per year. It's already a small pool of money, but when you're only talking about five percent, what message are we sending when we don't provide adequate funding allotments for evaluation from the get-go? So there's that sort of precursory issue to deal with.
DR. MASON: It is just appalling, the data: $1.4 trillion health expenditures projected for the year 2000, and you can't even -- we're not willing to invest in evaluating how we're doing. The amount of money we need is such a small proportion of the total amount being spent.
I think what the Council is basically saying is that we feel this is exceedingly important and anything we can do not only to track, but to evaluate methodology and whatever. It's just absolutely critical to the success of what we're doing.
DR. WINDOM: If we can be an advocate in any way, let us know. I think if a community knows where they stand, and they find that they're off base quite a bit, that's a great incentive to go forward and try to really improve it. But if they don't know, and they are sitting there saying, why should I do this, it's not going to get the support we need.
DR. SATCHER: Let me just say that one of the people that we were expecting today, of course, is
Dr. Merlin DuVal. Monte just called to let us know that he's been stuck in the airport in Chicago for the last 14 hours because of weather problems. So he was trying to get here, but didn't make it.
DR. WINDOM: Let's put him on the phone.
DR. SATCHER: Well, he hung up. That would have been good.
MR. NANNIS: Just to make a comment. The work of 2010 has been difficult. It's laborious, time consuming, and it's going to get harder to get it done. I just want to thank all the folks, not just those who are sitting at the table, but all the folks who are sitting around the table. They are the ones who really are doing this work every day, and without their help, we couldn't be here. So just an acknowledgment of all the folks who are helping out around the table.
DR. WINDOM: David, one other thing I want to mention. We talked earlier about the importance of communication and getting down to the grass roots by repetition, showing people what we want to get to.
Maybe if you put together, say, an advisory group of top journalists and op-ed writers to be like science writers are in the press, because they come to science meetings. Get a group of journalists who would come in and listen to you and know what 2010 really means. All these articles they write over time, they could intermittently throw into columns about the importance of this or that issue. A lot of these people would be welcoming your input for that type of thing.
DR. SATCHER: I know we've done that to a limited extent with black and Hispanic journalists, primarily around the HIV/AIDS disparity, but we have not done it more broadly. I think that's a great suggestion. The media is so critical, really can make or break it, locally and nationally.
DR. RICHMOND: David, I just wanted to comment, as we are getting toward the end of the day, that I think it's just enormously impressive, in terms of what you and all of the people sitting around the table and the people in the room and all of their colleagues throughout the Public Health Service and also in the voluntary sector have been doing. It's very easy for us to come in and throw at you a lot of suggestions, but it's enormously impressive to see, since the announcement of the goals in January, in this short period of time, what progress has been made.
I think, in connection with data, but also in connection with trying to initiate new efforts, I'd like to come back -- I don't mean to over-dwell on this, but there's a fresh stream of money that has come into the states through the master settlement agreement. It seems to me it is potentially possible -- people will commit those monies very readily, but the point is, it's not cast in concrete yet in most of the states.
It seems to me that it's potentially possible to acquire funds there to do some of the new things and to provide a lot of the flexibility at the state and the local level that it may not have been possible to do in the past, because there wasn't a new pool of money. So I think it's well to keep that in mind as we think about tailoring this at the state and local level, where we need both more and better data to think that we might find some sources of funds there to initiate some of these things with.
DR. SATCHER: Was it the state of Indiana that set aside $35 million for eliminating disparities? There are a few states that are really doing some exemplary things in this area and in tobacco, too. Also, the idea that was mentioned this morning about speaking to the National Governors Association and the Attorneys General -- we're going to follow through on that. I think there is a real opportunity to impact on it. We have been speaking to state legislatures in different states around the country sporadically, getting them all together.
DR. WINDOM: Talking about tobacco settlement money, which is sometimes difficult to get from the legislature, why not ask tobacco companies today, because they are putting out material to help children not smoke -- they say they are, and they are doing that -- let's ask them to put some money into the program for data collection and see where we stand. Let them put their money where their mouth is.
DR. SATCHER: That's an interesting thought. You would probably have to get somebody else to ask them other than me.
DR. WINDOM: We'll ask them for you.
DR. SATCHER: I've been pretty rough on them.
DR. BRODERICK: I guess I've been impressed today with what can be done through partnerships. I think it's been said by a number of people -- Dr. Akhter pointed out very well that we can't be successful just focusing on one level of government or one partnership, but it clearly takes multiple partnerships.
In looking at these really great examples of these partnerships, one that occurs to me that we didn't talk about today is the practitioner partnership. Is there anything we could do to help with that, to engage the providers? There are clearly decisions made about things that affect Healthy People 2010 every day in practices across the country. To the extent that we could engage the professional organizations or some other part of that constituency, it would occur to me that that perhaps would be an avenue that would be worthy of consideration. Perhaps it has already been done.
DR. SATCHER: I think it's a great suggestion. I'd like Dr. Windom to comment on it, too, because he has been working for a few years now with the American Medical Association. I think the leadership of the AMA is really in tune now with this kind of thing.
There are some other things that have happened. We released the mental health report, and that was an effort. The American Academy of Pediatrics went through an incredible effort to develop clear guidelines for their members for the early diagnosis and treatment of mental illness in children. They have now distributed those to all their members. The American Academy of Family Physicians set aside the whole year of 2000 to make mental health a priority.
When I released the Surgeon General's report on reducing tobacco use, Dr. Randy Smoak, the President of AMA, was there. He made a commitment that they were going to work very hard to work with physicians around the issue of smoking cessation, and what physicians can do. I think, in general, they did have me to come to the meeting this winter to talk about Healthy People 2010, and there was a lot of enthusiasm.
Bob, do you want to say anything?
DR. WINDOM: Yes, there is. In fact, it's so much better than we anticipated that I think, in the future, they will show more benefit. It's like I was saying before -- the aquifer -- down below the physicians are not getting it; it's still up here. So we've got to permeate more. This is something where the effort can be made constantly to keep the information in front of them.
MR. KAMEROW: If I could jump in here -- I'm really in a quandary here, and I'd like to get the advice of the Secretary's Council as well as other people assembled here today. As Dr. Satcher knows and as Dr. Windom knows, the AMA passed in its last House of Delegates meeting in June a resolution saying that they were committing to work with the Department on reducing disparities. We have got to now figure out how to operationalize that.
That's the thing that I think is going to be the tough one to try to come up with, because just as Bob said, it's one thing for the leadership to be committed and interested, and I think they are. The question is -- and in this case, we're talking about physicians -- what is it that you want doctors to do? The doctors are practicing in the hospitals and clinics and their private practices to try to reduce disparities. Are we talking changing the disparities of status in health? Are we talking about access disparities? One might say, maybe not either of those. Maybe it's actually in what's being delivered, that the doctors and others, specifically the doctors, have control over, if there are disparities, and what care is being delivered once the patient hits the examining room.
What can we do? What measurable, or some other kinds of goals -- and preferably those that don't cost anybody any money -- that's the problem, because nobody has got it in their budget to do it. But I've got to go to them -- Randy and I are going to go see the Board members in October, I think, so that when Dr. Satcher goes to the meeting in December of the entire House, he can talk about what kinds of things we can do together. So I really would like some thoughts now or later, or any time, but preferably soon, about what we can tell doctors of America that they can do to make a difference.
DR. SATCHER: Well certainly one, of course, is the smoking cessation. We reported, that if doctors were only to ask their patients if they smoked and then asked them to stop, we would increase smoking cessation rates four-fold in this country. That's over two million more people quitting smoking. If, in addition to doing that, they offer counseling and pharmaceutical intervention, we would increase smoking quit rates 10-fold. That's a lot of lives that we could save. That's just one example.
I think as we go through the objectives -- and even just looking at the Leading Health Indicators -- together, I think we can find some things that are specific and that only physicians and other health professionals can implement in relations with their patients.
DR. MALONE: There is also the part that Dr. Akhter and Dr. Satcher - the partnership. Part of those members coming will be the head of the American Medical Association, the head of the American Nurses Association. The call will actually go out to invite all the other -- and there are many, as you know -- health professional provider associations and organizations to become involved.
I think part of the creativity will be generating what can be done, and not us telling folks what can be done, the organizations actually, the practitioners themselves, coming up with ideas about what can be done differently. It's a from-the-bottoms-up kind of operation that we are going to try to pull off. So I'm hoping, by the time you go, that you will be able to talk about the kind of commitment the professional associations have made to actually eliminating racial and ethnic health disparities.
DR. BRODERICK: To comment on what you said, Doug, about what we should tell doctors, I have an opportunity to talk to doctors in the Indian Health Service all the time. I'm sure we are all aware that there is no shortage of things that they are asked to do, a list of a dozen or two dozen things to check at each visit.
So that request is a fairly common one that I hear: what are the things that we can do within this list of 18 or 20 or 24 things that we need to be looking at at each patient visit, that are going to promote this process? I think these Leading Health Indicators are an excellent place to start, quite frankly. If we could figure out how to convey that message to our practitioners, I think it would be just a tremendous service and a tremendous boost to the system or to the initiative.
DR. SATCHER: I agree. I was in Montana yesterday -- I had never been to Montana before -- to speak to the Montana Public Health Association. There was quite a turnout of Montana Medical Association members, including the President.
Among other things, we talked about the Leading Health Indicators, with a lot of focus on access. They have two major tribes in Montana, but about 50 percent of American Indians don't live in the reservations any longer; they live in the cities and rural areas. They're very interested in developing some strategy for better reaching that population, including those who are uninsured. We're going to be communicating about that.
So I think, if we can work together, we can come up with some things, some ideas, and have them ready to take forward in these various areas.
DR. ROBERTSON: It seems to me that when we are asking physicians to do things -- your point is very well taken, that they get asked to do a lot of things.
We've been piloting a program that I suppose combines the carrot and stick sort of approach, in this Get with the Guidelines program. It's something that is supported with a nationwide program that we piloted in the New England affiliate that provides physicians a discharge planning tool that will ultimately give them ORYX- compatible data that they will have to be providing from their hospital, anyway. It says to a hospital, here is a simple tool that is Web-based, that can have data input into it by your case manager or, through a palm device, by your physicians who are actually seeing patients, that is really easy to use and lets you say, I have complied with the appropriate guidelines in terms of -- we've addressed tobacco, we've got the patient on a beta blocker or an aspirin and an ACE inhibitor, if those are appropriate, or you've ticked that you're not going to do it.
The idea of trying to make it easier for the physician to do it, rather than adding one more thing to the list, I think, is part of the issue. We have the stick, which is that they are going to have to make the report, the reports that people have to make on things that we need them to be indicating. Then we try to find a way to make it easier for them to do it, so they consider it a gift rather than a burden.
Carrying it another step would be to carry that to the out-patient department and out-patient offices and clinics. We think, for example, if we were to put the Get with the Guidelines program in our VA hospitals, which I guess we could do by a simple decision, it would have an enormous impact, because it would affect the population. Secondary prevention is really important, and people could then document that we they're doing all the appropriate -- and make it easier for the physicians at the same time.
DR. SATCHER: Pam?
MS. WITTING: Just a comment. There's another avenue that I think we need to be looking at, too, around getting physicians to be more grass-roots and reducing risk and that sort of thing.
DR. SATCHER: Could I just take a second. Julie, thanks very much for being here and all your hard work.
DR. RICHMOND: I'm sorry, I have to leave.
DR. SATCHER: We appreciate your comments about the work of the people around the room here. They're outstanding people. I want you to know how much it means to us when those of you who are former Assistant Secretaries for Health take your time and spend a whole day with us, giving us the benefit of your experience and wisdom. That's what keeps us going. It really means a lot to us, and I want you to know how important that is.
DR. RICHMOND: Thank you. I can only comment that nothing succeeds like a successor, and all of my successors are here today. (Laughter, applause)
DR. SATCHER: Okay. With that, Pam -- Then I'm going to go to Randy for the summary.
MS. WITTING: Anyway, another of the avenues would be -- employers help drive health plans and what physicians do. So I think another avenue to address physicians is through employers, in designing health plans and what's expected of the health plans, and in turn, what's expected of physicians.
DR. SATCHER: Okay, very good. Again, we hope that today's meeting is the beginning of a new relationship in this area for us.