PODCAST/CONSUMERS/TECH: Interview with MaryAnn Stump CEO, Consumer Aware--HealthFacts.org

This is the transcript of my interview last month with MaryAnn Stump CEO, Consumer Aware. Consumer Aware is the BCBS Minnesota subsidiary that puts out the web site HealthCareFacts.org which ranks and rates hospitals and clinics. Unfortunately I had some technical problems with this podcast recoding, but 95% of what Mary Ann was saying is here—and she said a lot! The original audio podcast is here

Matthew Holt:  This is Matthew Holt with The Health Care Blog, and I'm back with another podcast on the blog. Today I'm very excited that I'm talking with Mary Ann Stump, who is, among her many other titles, the president of Consumer Aware. Which, Mary Ann, you'll explain to us, is a subsidiary of Blue Cross of Minnesota. Tell us a bit more about what you do, and about what else you're doing at Blue Cross of Minnesota.

Mary Ann Stump:  Ok. Well first of all, good to talk with you Matthew. I appreciate the opportunity. About a year and a half or so ago...I've been working with Blue Cross/Blue Shield of Minnesota for about 16 years now. About a year and a half ago, when I had been working diligently in this whole space of consumer information‑‑that became known more formally as "transparency"‑‑our CEO and I were talking one day. I said, "You know, I think we really need a team. Sort of a garage type of situation, a learning laboratory where we can really start devoting‑‑with a particular number of people that have an interest in advancing a whole vision around effective and useful consumer information‑‑ someplace where we can sort of work on this in addition to thinking about the business the way that it is today."

We had an affiliate organization that essentially was doing managed‑care tools. Really as you know, the whole managed‑care movement is not only changing significantly, but I think the kinds of things we were doing historically are not the kinds of things that we're going to need as far as the future is concerned.

What he suggested was: Why don't we take that particular affiliate organization‑‑that I like to think about as a garage so to speak‑‑and say let's set off deliberately to start to look at how we were going to do things differently as far as consumer information is concerned. Based not only on what we know but where we want to start to see people moving. From being the usual recipient approach to health care and really with the consumer at the center, being customers of care. What are the kinds of tools we would develop in that regard? I'd already been working on a couple things, and so essentially we formalized not only the expectations but the opportunity to be able to accelerate that. So Consumer Aware was born.

Matthew: I'm with you. So you're essentially you’re the one who has put out the suggestion and then been told that you had to do it. [laughter]

Mary Ann: Exactly, exactly! What's been really neat about it is that the whole evolution of this, I think...It started off as I think it is in a lot of organizations. That people kind of think‑‑how do you put this out relative to the way that we're doing things today. You sort of tamper around the edges with it as opposed to stepping back and saying: "Gosh, If I could start to think about reinventing this in a different way based on a new view of what success might look like." My background is actually critical‑care nursing, so I really have come from not only the delivery model, but I think the nursing discipline has always really put the consumer at the center of the universe. The chance to be able to suggest‑‑how could you start rethinking this in a way in which the consumer was the center of the universe‑‑was pretty exciting for me. By Golly, it's like be careful what you wish for, because I sure did get it.

Matthew: Right, right. So let's jump to the end with Consumer Aware which now has a website, and you probably have some other materials that you'll tell me about in a moment. I had a good poke around the website, and your working...currently your parent company is a customer as is Blue Cross of Louisiana?

Mary Ann:  Blue Cross of Louisiana, Blue Cross of Nebraska, and Blue Cross of Minnesota. Right.

Matthew: Great. So you got three Blues up on, and at the moment, if I'm a member of one of those plans I can come to Consumer Aware, and essentially what I'm seeing is I think you described it as a sort of nutritional guide to providers.

Mary Ann:  Correct.

Matthew: So, tell me a bit about what it is that the consumer is seeing, what kind of things you're providing. Then we'll get into a discussion about whether those are the right things, and how it's going to evolve.

Mary Ann: Ok. Well first of all, the one clarification that I want to make and I think this is a really good thing, because I think that this is the way that we as consumers think‑‑is that it has nothing to do with whether you're a member of Blue Cross of Minnesota or Blue Cross of Louisiana, or Blue Cross of Nebraska. It actually is available to all consumers.

So the information that goes on there...and we started with large hospitals, starting to describe what large hospitals looked like. It includes all of the information that basically are the attributes of that particular institution. For instance if you look at‑‑one of the metrics we have out there is the nurse-to-patient ratio. That is the nurse‑to‑patient ratio within that institution, not available just to Blue Cross members. I think that's one thing that I think is particularly distinctive about the approach that we're taking even though it's grounded from a health‑plan perspective. The only thing that is actually based on any information that specifically relates to our business at this point is the price, the pricing information when we start drilling down to actual price‑points. That's only available to members. But everything else is available to the general public and it's available through healthcarefacts.org.

Matthew: Let's talk a bit about what the categories are that you have information on. As I said, you've been trying to promote the idea that it looks somewhat like a nutritional food label.

Mary Ann:  Right, right.

Matthew: But what are the categories? We're used to sort of seeing the ingredients, and the percentage of fat, percentage of carbohydrates, percentage of sugar, and that kind of stuff. What are your equivalents?

Mary Ann: Ok. Well, one is around obviously prices, we do have a price‑point there. We also have things like the number of practitioners, or the number of providers, the percentage of charity care, and some general kinds of things that are out there. Then we have categories around accessibility. We have categories around safety and quality. We have categories around services and technology available. Although the framework looks the same‑‑so it looks like a nutrition label‑‑for instance, in a hospital. It also looks like a nutrition label in a primary‑care clinic, but the categories are different and appropriate to that particular site.

Matthew: Most of these are some basic things which the consumer may or may not care about. They may not care about charity care and that kind of stuff. They may care a lot more about parking and what you've said‑‑access. I see you've been through...physical access and can you find the bus line and so on. That kind of stuff‑‑they may care about. I guess the other sort of narrow issues such as some of the measures that have been around for quality and safety and stuff--what are the ones that you think are driving the site? Maybe another way to ask the question is, what are your thoughts when you're putting this together, what do they want to know about?

Mary Ann: First of all they wanted some sort of a frame in which they could actually even make sense of it. We've done quite a lot of consumer research and what we've tried to do is actually listen to what folks had to say and then design around it. One thing they said to us is "Could you make this simple, in a way that's meaningful to me where there's substance. But, by golly I don't want to have a PhD in this stuff, so make it simple." One of the reasons why I was intrigued quite frankly with the idea of using the nutrition label in order to be able to translate this stuff is I thought most of the stuff that's out there not only is boring but it's also pretty intimidating.

You get in there and immediately your eyes glaze over. How I got the idea of actually starting to use the nutrition label as a frame was, I was sitting there, probably around 5:30 one night, around the same time it is right now, and I was drinking a diet Coke and I was eating a candy bar. I was just staring at the nutrition label on the can of diet Coke and I thought to myself you know that's kind of interesting. This is right in front of my face. I see this every day. It's something that even my daughter who had been a figure skater and at eight years old she was looking at things that were on there basically because her figure skating coach told her about it.

So this starts to address some of the issues around framing something that is not going to be intimidating. It's essentially going to be inviting to consumers in a way in which they might even start to take a look at it and have an opportunity to be able to drill down a lot more depending upon what the question might be. So the very first thing we tested with consumers was if they liked the frame. You don't need a class in order to be able to figure out how to use it, which is why we already started looking at even the placement of things like for instance the address and the price always goes in the same place much the same as calories would go in the same place on a nutrition label. So you could start to get some familiarity and comfort with the territory about it. So the very first thing we tested with consumers was if they liked the frame. We had essentially two rules in terms of even developing the prototype. One was, this is page one of the tool. There is no page two. Unless you wanted to drill down but it was always, keep it simple.

The second thing was that we really did cast all of the metrics that we put on, starting with the large hospital and then evolving to the smaller and the community hospital and now the primary care version of it. We tested it with consumers to say, what's important to you and what isn't, so that at the end of the day it was the consumer that was the final arbiter of things that went on it.

So as a result we got some really interesting things like, for instance, it won't surprise you but I think from the standpoint of your background, three years ago things like the number of hospital patients per R.N. Or one of the things that was interesting bubbled to the surface in my view was we had asked about patient satisfaction information. You know healthcare really publishes that out the wazoo! We found that consumers on a day‑to‑day basis don't even use it. What difference does it make to me that you've got 92% patient satisfaction rate with your office waiting time? They said to us, "Gee what I'd really be interested in are things like references. You know you talk to the doc and you say to the doc, "You want to take my gall bladder out? Could I have the names of two people whose gall bladders you took out? I'd like to hear about their experience."".

So we actually introduced some new metrics such as patient references available. Pain management programs' was one that tested really high. None of this information is in one place for consumers but I have a particular interest in and a soapbox approach to it. I really think palliative care and end of life and pain management are significant infrastructure builds that we need to start paying attention to for a number of different reasons as we look at how we evolve and transform health care. Low and behold, pain management programs for pain that's chronic or after surgery or from cancer at end of life tested really, really high. People never are given an option to be able to understand what attributes in a hospital address those sorts of relationship and experience issues, are evident and how are people building them? So we really did get a whole different slant on things just by listening to people.

(Missing piece due to technical problems– read on—

Next Question is about the type of hospital quality indicators)

Mary Ann: Yeah, yeah, Matthew they are. First of all there is the opportunity to be able for instance in the hospital version of it, some of the key procedures with the minimum standards a year. Then what the institution actually does is part of them. So say coronary artery bypass or any kind of abdominal aortic aneurysm repair is another one. Some of the Leapfrog ones are actually in there. First of all the volumes are in there. And the capability to be able to drill down and understand some of the more individual provider procedure issues including things like not just mortality rate, but infection rates. That's also where pain management and the nurse to patient ratio starts to become an ensemble piece relative to that.

Because it's not just the number of procedures or whether you live or die, but it's the number that are done by the particular provider, the numbers that are done by particular institutions. What is the hospital patients per R.N., certainly if you are going to stay overnight or in the I.C.U. that's going to be important as well? So one of the things that we've tried to do and again this is like starting from scratch relative to trying to meet people where they're at around this stuff is that when you click on the particular metric you are also able to see a consumer data definition on each of these and also, frequently a link to other sites that give you that more detailed information as it evolves.


But there is also an element in the consumer data definition construct that also not only what this measure is but also an element that says why should I care? So that it starts to help people understand the why and the what of it as well. But then if you think about again back to the history with the nutrition label, when it started out people didn't know what trans‑fats were, or have any interest in any of that kind of thing. What happened is that as consumers became a lot more sophisticated about not only the role of nutrition but also the implication of it in our day‑to‑day lives, then the nutrition label changed accordingly.

That's exactly what we figure we're going to do as far as health care facts are concerned. I've represented it as this Steamboat Willy. When they started with innovation you had to start one place, but Steamboat Willy seemed like quite a significant innovation at the time in the 1920s but if you look at Shrek today, it looks a lot different, but it couldn't have gotten too weird today of it weren't for the fact that we started with Steamboat Willy. So I sort of think we're the Steamboat Willy.

It absolutely is the first step. The other thing is in some ways it's almost deceptively simple because one of the things that's important is in order to get comparative information, and the fact that you can measure TulaneUniversity Hospital with the Mayo Clinic maybe is illustrative of this. The one thing you've got to start with in collecting the information is making sure everybody counts it the same way. So the devil in the detail in this is really, really significant. So that's why the provider data definition issue is there, to ensure that everybody is counting it in the same way.

We paid a lot of attention in the data description to minimizing the capability of even looking at ambiguity in it. So for instance if you are looking at the number of providers, and you were counting noses on the number of providers, the definition describes that somebody first of all has to be in practice at least 20 hours a week, so half time and that they practice 51% of their time at that particular institution. So say for instance the number of providers that are doing coronary artery bypass, you don't count how many times they are going different places; you count where their home' is. So there is a lot of devil in the details relative to this counting component of it. That's a real important element that you don't find in a lot of situations. It's got to be an attribute around the ability to be able to compare one to another.

I remember a bunch of years ago I did a cardiac centers of excellence type of approach her in Minnesota and we had 13 different sites. And we started out looking at quality measurement and quality improvement so we could start to look at mortality and outcomes information. We were measuring dead three different ways in just these 13 institutions. You think about that. On the surface that seems relatively simple because alive is dead. But we had people that were measuring it only as cardiac related mortality. We had others that were measuring it cardiac related 30 days post‑discharge. It depends on how you define the data element in terms of the meaningfulness and the ability to compare.

So we paid a lot of attention to make sure that there was integrity from the standpoint of everybody entering their data exactly based on the same definition so that there would be confidence that if you were looking at Tulane University Hospital and the University of Minnesota, you were counting it exactly the same way, like the nurse to patient ratio and things like that. I think this is one of the things that folks don't necessarily understand when you start looking at like this work around transparency is phases that you need to pay attention to. One is how do you count? Counting is not necessarily easy if you're going to do it in a way in which there is comparability.


The next generation may be if we are going to move on to phase two, I also think we need to keep in mind that we are counting what counts. That is a harder thing to do because what counts isn't always at least measurable at this time. We have to start thinking about what the proxies are. From the consumer's perspective that's a particularly important element to keep in mind because they're not going to, none of us are going to start looking at stuff if it doesn't mean anything to us. Counting what counts from a consumer lens is a really, really important element of this whole meaningful transparency journey that we're on.

The third generation of questions that I almost even hesitate to talk about, but at least it's on my radar is, when you think about health care at the end of the day it also is about relationship. It's about a lot more complicated things. Is what counts countable another element that we need to be thinking about? But whenever I bring that up it blows people away so I don't say it very often. Hold that one for years from now. OK.

So one of the things that I actually did in designing Health Care Facts from the get‑go on the hospital side was take into account all of the elements of the IOM report. That includes things like saying design from the consumer's perspective. One of the reasons why I have charity care in there quite frankly is the attribute of social equity. So I wanted to be able to quantify that, the teaching element in there because in any given situation if an institution went away and they did a large amount of charity care or they were producing the health professions for the 21st century, we need to somehow reflect that in the value of what it is that's their price point. So I really paid a lot of attention to the IOM report and I think this is one of the reasons why having a health care background and understanding how we create the system for the 21st century, or having a desire to do that was an important element of things.

So then I went out with a prototype and I started talking to CEOs. I got a couple of key institutions within our market to say yeah, this is the kind of stuff my Board is asking me for. These are different than the usual sort of defeatist measures or things like that and there was also an appreciation by several of the CEOs within our market that she's designing something from the consumer perspective in which you were asking us to be part of from the get go. So this gets back to what I think is a real important element to some of the things that need to happen and that is that we really have to garner provider buy in as demonstrated by their collaboration and participation.

Matthew: I was going to ask you, the providers involved in this, what are they going to have to do in terms of data submission. What's the level of pain on them?

Mary Ann: Yes, yes, yes. The answer is yes. But not in different ways. What we did is actually for the first thirteen providers that signed on board, there were sort of two things in addition to being an early adopter of this that we gave them the opportunity to help with the formation of it. One is that we gave them the chance to help us define and come up with the single data definition. So what we did was talk to them at the provider side, how they were counting it. So for instance, we let anything that they were doing that might be consistent with the joint commission approach. We didn't want to duplicate it work but we also said you all have to measure it the same way so that standardization opportunity was one that they had a chance to participate in and quite frankly took advantage of. That was the first thing. The second thing that we gave them the chance to do that I think was also a significant carrot was that not only did they get a chance to look at their own health care stats before it was released that they had a chance to look at everybody else's which was their competitors as well that they never had a chance to look at side by side in a way in which they could actually compare one versus another. So there was significant interest in signing on board with that early on.

The one squeamishness that I got which was kind of an interesting one is that everybody-- although bear in mind this is like three years ago when we started the hospital side--we actually wanted to give a quartile of prices. So either we used a one dollar sign versus a four dollar sign. Now we're going to actual prices that three and four years ago that was a little bit more squeamish type of demon that they would have to deal with. I did frankly get some push back around, "well can't we delay that a bit?" We said well let's wait and see and by the time that we got through the process and we were ready for the 1.0 data release, everybody was fine with their quartiles. So that turned out to be a non‑issue.

Matthew: That's interesting. Let me ask you a bit about the pricing, because obviously Uwe Reinhardt among many others says hospital charge masters were an act of fiction. When you talk about pricing are you talking about the average rate that Blue Cross PPO pays them? When you say pricing is that by procedures?

Mary Ann: It was actually based on our (Blue Cross) contracted price. We also at one point, now this was the initial release, it was also at one point only based on inpatient, not outpatient as well because as you know the way that we do pricing it's very complex. There's lots of moving parts so we try to put some brackets around it.

I got to tell you what was interesting to me at the get go was, now here was the concept: relative to how consumers shop and I'll use another analogy, you know Target, our home town team here, is sort of everyone would say that was, I think that's a one dollar sign. Neiman Marcus is a four‑dollar sign. In our market we knew Mayo was the four‑dollar sign. Even when you started calculating price it wouldn't surprise you that they turned out to be a four‑dollar sign. There were several others, actually many other four‑dollar signs that didn't necessarily stack up in the same way that Mayo did. So it started a conversation around pricing based on just sort of a primitive first step slice, that I think started getting people to access where they were not only to their peers, but also how they could represent value from the standpoint of those conversations.

Matthew:  Are you now when I'm the consumer and I come on the site the moment I see the dollar signs so I get the impression that this is a more expensive versus a less expensive place. But are you going to replace that with something that's more tangible with price per episode, or how does that work out?

Mary Ann: What we're doing right now if you go onto the site with the clinic it doesn't have the dollar sign there but if you're a member, and this is sort of the benefits of membership versus what's available to the general public, in the clinic we've actually started drilling down to, so for instance if you want to know what the price of a new patient might be if you have a cold and you want a work up on that or something like that you can start to see not only what the price of that clinic is but what the range of what that is. So maybe it's eighty‑nine dollars at that clinic and the range of the clinics in the database, which is about 800 in Minnesota right now, the range might be from sixty nine dollars to a hundred and nine dollars. So that's available for Blue Cross members only and we are working right now in a hospital situation to do precisely that. Again it's a benefit of membership as opposed to available to the general public.

Matthew: Now let's talk a bit about how you're going to take this principle. I think what you're doing is very interesting. Of course there’s a lot to be said around if you can or cannot accurately price hospitals. There's also the issue about if you're a member you're getting the Blue Cross rate and is that better or worst than the Aetna rate or the rate they are charging the uninsured. There are a lot of issues around that which we don't have time to get into today. I guess the question is what should you be pricing? Should you be pricing the individual procedures for the office visit or should you be pricing the per month average costs to be a diabetic taken care of by this clinic? There are some other features in there we can go into. But I guess just to tilt this a little bit, if consumer aware and healthcarefacts.org is now for everybody, because you've gone for the market in Minnesota and Louisiana and Nebraska, and one other I've forgotten or is it just Nebraska?

Mary Ann:  No, that's it so far.

Matthew: You've got those markets. Did you happen to have something special in the water in Minnesota -- everyone says there's something special in the water in Minnesota health care. It's a bit of an oddity like California. You've gone to some other places, Louisiana and Nebraska are very different. Has there been a process in each one of those markets to get this up and running? Or is it pretty much now the same now that the outline is established that the health plans know that the Blue plans are basically similar to other groups that you've got to play ball here?

Mary Ann: Oh, none of this has been based on any kind of a mandate or an expectation around which you have to play ball. One thing, that I think is absolutely intriguing, is that we have a Mississippi state link, I think, with Minnesota and Louisiana. But we're polar opposites, and I think this is a good demonstration of how this is not just one of those things that's in the water in Minnesota. And one of the reasons why Louisiana was intrigued by it was the fact that this did not require any sort of a contracting change, what it really did was offer an opportunity to be able to not only to talk to providers, to say, will you join us voluntarily, but that we had also done it in Minnesota and they came up and talked to our hospital association and said, what did you think of this when you started, and why did you sign on‑board with it?

So I think it's just a different way of doing things. And another thing that was fascinating to me in our market was we talked to the VA, I've done some work for their Robert Wood Johnson foundation, and actually, quite frankly, I'm real intrigued by the whole VA model, so I decided early on that I'd go over to the VA here and talk to the head of that, just to get some feedback from them, because you know, they have a great interest in patient safety and all that. And by golly, the VA would participate in‑ they sent us fully filled‑out healthcare facts, they're on the database, and do the updates, even though we don't contract with them. So I think that under certain circumstances, and I think with the right positioning, that there's an appeal and an intrigue about this, from the standpoint of offering an opportunity to providers to describe themselves in ways that which will be relevant to consumers in ways that aren't just relevant to price, or the usual kinds of things that are out there based on claims data.

Matthew: That's pretty interesting, so you've got, it sounds like good response on the hospital side, can you compare that between the three states? And the other question is, I get that big hospitals want to be viewed on something other than price, this may be a big imposition for a physician clinic, what kind of percentages are you getting for the hospitals and physicians, between Louisiana and Minnesota?

Mary Ann: Okay, we've got 100% of the hospitals, 100% of the large hospitals, and 100% of the community hospitals. Now we have not worked on the rural hospitals, for a number of reasons. We've decided that we will go to primary care clinics next, before rural hospitals, but that does not preclude a consumer from taking a blank “healthcarefacts” to a provider, and saying, gee, will you fill this out for me? And then you'd have a chance in which to‑ you know, you've got an existing database in which you can do comparisons, and I think that would be an interesting sort of mobilized consumers' approach, because I know darn well that if a provider has three consumers in that say, will you fill this out, they'll be calling us up and saying, I'd really like to get on this database, since I'm getting bombarded with people asking me to fill out this information. So I think it could catalyze it in that regard‑

Matthew:  If the consumer comes back to the same docs.[laughs]

Mary Ann:  Yes, that's true, that's true. But let's be optimists here.

Matthew:  What's your share inMinnesota now of primary care clinics, give me a sense, not down to a decimal point, but a general idea.

Mary Ann: We have 100% of the primary care clinics for price. We have about 80% of the primary care clinics on the database in the top list of quality and price, and the rest of them are filling them out. We have over 840 clinics on the database, individual primary care clinics on the database. I think that's pretty remarkable.

Matthew:  What share of primary care in Minnesota do you think that is?

Mary Ann: From the standpoint of admissions, I think it's over 90% of the patient visits. And it's rural as well as Metro. Louisiana hasn't started on the clinics yet, only the hospitals, but they're working on the clinics right now. Now, we've only developed the template for the clinics this year. The reason, quite frankly, why we started with hospitals is the interesting thing about the hospital infrastructure is that first of all, they don't have offices of transparency. They've got to find how to bolt this on somewhere. Because as you appropriately identified, just getting this thing filled out and maintained takes some work. And typically in the hospitals, people either went to their quality improvement offices or they went to their patient safety offices, and those were the ones that took the accountability for it. Remember in clinics, if we're going to start designing around hospitals, there's at least typically something that there seemed to be a logical bolt‑on for transparency, and that was usually the patient transparency office, or the quality improvement office. But in clinics for the most part, this is not a function that they even have in there, and especially in smaller clinics, in their infrastructure.

So the reason we really wanted to get started in hospitals was to get the momentum going, figure out how to do it, and then end up starting to work at how we would meet clinics. We actually did some different webcasts, we did a lot of visits to clinics, to let them know what this was, and how to get it going, and what the best approach might be in order to get them not only to fill it out, but also to keep updating it as well. We were pretty pragmatic about wanting to start out at hospitals basically because the likelihood of getting the momentum there was more significant. But I think I can see this as a skilled nursing facility opportunity, a surgical center opportunity, we've got some plans to do some having a baby healthcare facts, or a cardiac healthcare facts, again this is the launch of something that is directionally correct, we just need to evolve and learn as we go.

Matthew: That all makes a lot of sense and seems to be working out for you and let me ask you a few things about your future plans. The first one is, this is‑ you are a subsidiary of the Blue Cross/Blue Shield of Minnesota, but you're an independent organization, considering that at the moment you are funded by the Blue Cross/Blue Shield of Minnesota, but I assume at some point somebody will want to make some money out of this or give you some funding, what do you think the future business model for this is, and how does it compare and contrast to other groups of people who are doing various types of hospital rating and health grades, and what is this noticeable of?

Mary Ann: Folks have called us and wanted to know what we are doing as well. I think a lot of other folks are really focusing more on the business model side of things. Don't get me wrong, that's something we're paying a lot of attention to as well. One of our goals in setting this up as part of the work that we're doing through Blue Cross and Blue Shield of Minnesota even though it's in the consumer aware context is that it wasn't just about making the money. We have a strategic objective about being a catalyst for positive health system transformation. So what role do we play in that?

When I think about the work that I'm doing not only in Minnesota but other places, this is as much of a provider strategy as it is a consumer strategy. We are still evolving what different scenario opportunities there might be around business models. Absolutely we've got to think about revenue models and we've got to think about distribution channels. But we're also focusing on the content as well. And I wish I could answer that definitively for you. I can say that it's what keeps me awake at night as well but it is a work in progress. [Laughs]

(Technical snafu misses question here)

Mary Ann: OK so we've had it up for about the first launch was on the hospital side and it was about three years ago, two and a half years ago. So it's been around for a while. In many ways, what we needed to do was be able to get content up there before letting consumers know it's at this point. I don't know if you followed the Minute Clinic, the quick clinic; they didn't advertise or anything at first. It was word of mouth and then people started using it. It expanded exponentially. So one of the things that we are actually in the process of planning is a lot more publicity. Actually we really appreciate the opportunity to be able to talk to you because of this getting the word out now that we've got all these primary care clinics, now that we're getting momentum and content as far as others are concerned.

We do measure the number of hits on the website. As a matter of fact I've got some recent statistics that actually reflect how many hits we have based on also compared to what's going on. We buy Healthgrades and we buy Subimo. And we are considerably ahead of the number of consumers that are looking at it on MATT. That's a metric that we collect month to month and it averages about 3, 000 to 5, 000 a month which, I think for the fact that we are still the best kept secret I don't think is bad. I'm trying to figure out what are the performance and success metrics that aren't just around the hit on the website. I think the fact that we've got participation by 100% of the large providers including the VA and Mayo who have never participated in public transparency efforts like this, is a success metric.

The fact that we were able to translate this from Minnesota to Louisiana is a success metric -- you know that replicability type of thing. So that gets back to talking about what can you count. We're doing the usual counting relative to hits on the website and the number of health plans that are signing up and what the enrollment of those health plans is and the number of providers.

But also, are we counting what counts? We are trying to figure out what the dashboard looks like in that context as well because in some ways I've likened this to taking a pebble and throwing it into some water. You watch the direction of the water go out in multiple different ways. So this isn't just a consumer strategy. This is a provider change of how they view themselves and how they talk about themselves. This even challenges the issue around is it about price or what is it that we need to learn around what's important to consumers beyond that price in the context of other things. So it's broader than just measuring it linearly.

Can I just mention one other thing though? One of the reasons why we wanted to go with the single page in a nutrition label is that it's supported by a relational database. But I also think and this is a really important concept from my perspective, is that even when everybody changes and we raise the bar we go to Michael Millenson's vision around that, there is still going to be a best fit in whatever circumstance that it's going to be for individual people. I still could imagine people sitting at their dining room table at night and having printed eight different health care facts because they're trying to decide what the best fit might be for a particular procedure or for their mother or dad having a hip surgery or something like that.

Even when we raise the bar relative to providers doing things differently I still do think that the key to the kingdom around meaningful transparency is going to be the opportunity for consumers to be able to choose based on the attributes that are important to them in whatever situation they are looking for, being it a healing relationship, being it technical excellence or whatever. They are going to be able to discriminatingly choose whatever the best fit might be based on the information that ultimately will be available to them. That's what my vision would be.

(technical Snafu) Question is about consumer generated content included in the site

Mary Ann: We're already working on it. We're working on another product called Health Care Stories that is precisely that. So I see them as two sides of the same coin. Know the facts. Know the story. Some people are going to start with stories first. Others are going to start with the facts. And at any given time you flip, because we're quantum! We don't always do things in exactly the same way. We don't fit in neat little boxes. So absolutely, I see that as a dimension of it. Actually think that's a terrific dimension as well. And we're working on that right now.