2012 Meeting of the Subcommittee on Quality Measures for Children's Healthcare
Charles Irwin: Good morning. My name is Charles Irwin. I am the co-chair of the meeting. Charles Gallia on my right is the other co-chair. It is great that you are all here. For those of us on the West Coast, you have two West Coast chairs, so hopefully you are going to have to just keep feeding us caffeine and try to do something to keep us awake because it is 4:45 for us and we have been up for an hour and a half already. Good morning. We are really happy to have Carolyn Clancy and Marsha Lillie-Blanton here, and they are going to give us some opening remarks, and then we will return to the actual process of how we are going to work through the content of the meeting today. Carolyn, I will turn the floor over to you. Thank you so much for being here.
Carolyn Clancy: I think I will just sit right here and will not get 1 millimeter closer. I want to thank all of you for making the time, particularly our West Coast co-chairs. I will remember your service the next time I am on the West Coast instead of dragging around at 6 o'clock at night like I am ready for bed.
I know that you all have been working hard already on this and we are profoundly appreciative, but you are not done yet. This is very important. A lot of times people ask us why those who work in government, why can't you guys just collaborate. And it is kind of like why can't academic departments collaborate or even various entities within State government, but actually sometimes we do. And this collaboration with our colleagues at CMS [Centers for Medicare & Medicaid Services] is just on the hit parade for me like at the top of the list. It has been a pleasure, I think mutually beneficial, and we are just going to have to think of something else to do once we—once quality for children enrolled in CHIP [Children's Health Insurance Program] and Medicaid is absolutely guaranteed, and we have solved that problem.
Now, quality measurement is a big deal at HHS in part because—and I will tell you about this in a moment. The Affordable Care Act requires that the Secretary submit every year a national quality strategy. Now, strategy is not exactly the first word that would pop to mind for quality measurement in the past. Some folks are really, really good at it; there are lots and lots of constituents for various measures. A strategic approach to saying that wouldn't exactly be it. And yet what you are starting to see in this fast-paced approach with many moving parts is more alignment between the public sector and the private sector, which is a great thing because after all most providers are seeing patients from both worlds and many different parts of the private sector. And also, alignment as we evolve into this world where health information technology [IT] is not only universally available, it is easy, it is fun to use. There are no headaches. We are not quite there. But in essence, that is going to be a very powerful enabler, not just of measuring for a report card. It will do that. But actually helping us get it right to begin with.
Over the past several years, the Recovery Act, which is the ARRA [American Recovery and Reinvestment Act of 2009], the roadmap laid out in the CHIP [Children's Health Insurance Program] Reauthorization Act and the Affordable Care Act have provided a fair number of resources. The national strategy—I will talk to you about in a moment. Many components of HHS have measurement councils and are actually working together across the department. Alignment sounds like a great thing. Which measures should we align? Well, stuff that we want to retire in 2 or 3 years. Probably not yet. Let it go. Do what you are doing now, but it will be okay. Other measures that are more important and used by other programs that we would want to align. And the Affordable Care Act has a lot of resources for quality as well.
Alignment, like change, is a really fabulous idea for other people. It is easy to say, rolls right off the tongue. I think all of you should align, for example. It is very hard. What is hard is getting from these spiritual yes, of course, we should all use one harmonized, fantastic set of measures. You mean right now. You mean as we are updating this measure. You mean we are getting into the actual specs and micro-specs. I did not know that was alignment. I would like to go to the bottom of the list and let others go ahead of me.
These are the three broad aims of the National Quality Strategy, which has really been true north for many of our efforts at HHS. I do not want to pretend that we are like totally singing. It is not quite like the Star Spangled Banner or the flag, but it has provided a very important tool for our colleagues at CMS, for us at AHRQ, folks at HRSA, and so forth to begin to think through how do our efforts really—where is the synergy that we can get across multiple programs and so forth.
Three deceptively simple aims. Better care wherever you land—patient-centered, reliable, accessible, and safe. Better health. Now, health care cannot possibly own the better health problem because a lot of that is very much to do with public health, with community resources, with social determinants of health. It is not like we are doing so great in health care, and we have perfected everything we do, and now we can take over community health as well. But the health care system can be a very powerful force for better health. If you think about many hospitals in just a few weeks, in fact, all hospitals paid by Medicare will start to be thinking about readmissions and keeping the rates down. They are already thinking about it to be honest. But the implication there is when the patient gets to the lobby or to the ambulance or other mode of transportation, you are not done. You actually have to keep going. You don't just say have a great trip. Our work is over. No. Now, we are working with others in the community. That is where I think the health care system can be a good force and provide affordable care by getting to more efficient strategies for delivering care, not rationing.
Now, the challenges that you all have. The SNAC is a subcommittee of our national advisory council. The environment is constantly changing. Those of you who come from State Medicaid programs, we very much want your input. On the one hand, the CHIP Reauthorization Act provided a fantastic roadmap and resources and an incredible opportunity. On the other hand, we know how many challenges are facing States. Early on, Cindy Mann at Medicaid said that she thought our work should be aspirational, but grounded. I still think that is a magic phrase. We want to stretch as far as possible, but we do not actually want to kill people, do we? We are aware of the environment changing and very much need your perspective on that. Medicaid programs will begin adopting 26 adult measures. Have they started that yet?
Participant: We are working on it now. We start January 2014.
Carolyn Clancy: I will leave that to the serious expert here, my partner. And we want to keep the core set parsimonious, but comprehensive. And the legislation has something to say about what kinds of measures need to be in there.
Now, the good news is the first SNAC we had—this would be SNAC 2—we had 6 or 8 months. There was sort of a frantic nature. There had to be because we had a very tight timeline. We do not have that now. States are already reporting, and you will be hearing about that from Marsha. We do not expect perfection, and we have more time. And we are very pleased that the Centers of Excellence supported by AHRQ to develop better measures are also hard at work doing precisely that and are part of the mix of measures that you are going to be looking at.
Ultimately, I think—how we think about success at AHRQ is that this becomes a tool for making the right thing the easy thing to do. We are so not there yet. I think on a good day, most clinicians and providers think that quality measurement is invisible. In other words, it does not get in their way. Somebody helps them just jump through the hoops, and it does not give them a headache. But we can do a whole lot better than that.
I am going to really express my profound appreciation for all of you for making the trip here, to folks from the Centers of Excellence, and including the stakeholder groups, testing sites, advisory groups, and so forth. This gives a whole new meaning to team sport as well as State grantees and, perhaps most importantly, our colleagues at CMS. Again, thank you for the time you have put in. I am going to have to leave, but the good news is my team will tell me all about it. I will be following up with them for an immediate debrief. Have a great day.
Marsha Lillie-Blanton: Thank you, Carolyn. And before you leave let me also say how much CMS has valued having this partnership. It has been great for us to have the expertise, the skills, the experience of AHRQ working with us both on identifying of the initial core set of children's quality measures, but also now in improving that core set. I want to thank both you and Denise because Denise has been a very important partner to us in this process.
I also want to welcome all of you here today. I know many of you have already been working very hard on this effort. I want to welcome you. And I also want to thank you for your commitment and your willingness to support us and work with us in this effort. I especially want to thank our two co-chairs, Drs. Irwin and Gallia, because you have already spent countless hours in helping us prepare and guiding us in setting up this meeting, rearranging your lives, your family's lives, and of course being here at this ungodly hour in the morning to help us in this process. I want to thank all of you who have volunteered in this effort.
I want to spend just a little bit of time kind of putting you in the space and mindset of what we live in at CMS because I think that is important as we talk about improving on the core set to understand what we have now with the core set and what want to accomplish. We see the initial core set of measures and the improvement in the initial core set of measures as helping us to drive improvements, both in the quality of care and in the health of our beneficiaries, and that is really important. For us measurement is not about measurement for measurement sake. Measurement is to help us. It is a tool to help us along a pathway of improving care and improving health as Carolyn talked about our aims.
But essential to improving care is having measures that are reliable, having measures that are meaningful, and having measures that States and providers can collect with some confidence and with minimal burden, which is the other thing that Carolyn talked about. I want you to keep that framework and add to that framework the environment that we are now in with Medicaid.
Medicaid is under intense scrutiny for many different reasons, in part because it is now used as one of the vehicles to expand coverage. But as it is being looked to as a vehicle to expand coverage, there are still real concerns about access and quality of care in Medicaid. Providers feel concerned because of payments. Beneficiaries sometimes feel threatened because they cannot find providers. And States are operating in an environment where many of them have legacy systems for data collection. We are trying to move into the 21st century when many of them are still in the 20th century in terms of their data collection, and that varies. There are some States that are front and center at the forefront of electronic data collection systems and are moving forward. But then you have other States that are not. Keep that backdrop in your perspective, in your framework, as you help us improve the core set.
Now, I want to just give one tidbit fact of information about where we are in terms of collecting measures. You will hear a lot about that, both from Denise and Karen. I want to say before I go on to give you that one tidbit. I am looking at Karen Llanos, but I have to acknowledge and thank Karen Llanos because she has actually been the guiding force at CMS around this work. Without her, this could not be where it is today. I want to thank you. But she will be here for the entire day and I will not.
I want to just say one tidbit about where we are. Of the 24 core measures, only 8 of those measures met a threshold that we felt comfortable with in presenting information and findings in our summary report. A threshold in a sense that we had confidence in the measures that we had at least 25 States reporting on those measures. That reflects in part the environment that we are operating in. As you think about improving the core set and you think about the value, what we are trying to do with the core set. Remember where we are now and the challenges that we face and the environment that we are operating in.
With that, let me just end with my charge to the group today. We are asking you to do several things, and I have identified them in three different buckets. One is to draw upon your knowledge and experience in health services research and about Medicaid. Secondly, we ask you to keep in mind the target audience, that we are talking about working with States and with providers. And third, we want you to think about how providers and States can realize value from these measures to both improve care and the health of beneficiaries.
That is a tall order because we already have 24 measures and we are asking you to identify the gaps in the measures, and we are asking you to identify measures currently that have not worked well that we need to improve upon. We do not want to start all over from scratch. We have what we think is a fairly good core set of measures, but we do want you to help us understand the gaps and where we can improve upon them.
Our first 2 years have been learning years, and we very much appreciate and value all of the support and guidance you have given us thus far. We are looking for you to continue to help us and support us in achieving our goals of improving care and improving the health of beneficiaries. I want to thank you. I will be in and out, but here for most of the meeting. I only have two meetings, but I just wanted to give those opening remarks to help guide us in today's meeting.
Charles Irwin: Before we dive in to our charge, we thought it would be helpful if we went around the room so everyone could introduce themselves. The rules of the game are one sentence because we have a lot of people to get through here, and we have a lot of work to do today. Perhaps we can start down here on the right and go around.
Alan Spitzer: Good morning. I am Alan Spitzer. I am neonatologist by training. I am currently senior vice president for research education and quality at MEDNAX Incorporated, which is Pediatrix Medical Group and American Anesthesiology. If you see me slouching all over the furniture here, it is because I had knee surgery last week, and I am trying to keep the swelling down in my knee. Please forgive me for that.
James Duncan: Jim Duncan. I am an interventional radiologist from Washington University at St. Louis Children's Hospital.
Stephen Saunders: Good morning. I am Steve Saunders. I am a pediatrician. I am a former medical director for Illinois Medicaid and chief medical officer for a managed care company, and I'm very pleased to be here. Thank you.
Diane Rowley: Good morning. I am Diane Rowley. I am a pediatrician and professor in the Department of Maternal and Child Health at the University of North Carolina at Chapel Hill.
Laura Pickler: Hi. I am Laura Pickler. I am a family physician by training and geneticist in my real world. I bring the perspective of a provider. I cancelled my clinics to come today, and my patients are not all happy. I also came here via an Indian reservation. I have a perspective of rural America, places where there is not Internet access. My cell phone did not work most of the last 2 days. I am hoping that that will help inform our discussion as well.
Rajendu Srivastava: I am Raj Srivastava. I am a pediatric hospitalist in Salt Lake City.
Carole Stipelman: I am Carole Stipelman. I am a general pediatrician. I work on Medicaid and CHIP enrollment in the community health centers in Utah, and I am medical director of the University Pediatric Clinic.
Clint Koenig: I am Clint Koenig. I am a medical director for a Medicaid managed care organization in Rochester, NY.
Glenn Flores: Hi. I am Glenn Flores, professor and director of the Division of General Pediatrics at UT [University of Texas] Southwestern in Dallas.
Kim Elliott: I am Kim Elliott. I am the administrator of quality for the Medicaid program in Arizona.
Karen Llanos: Hi. Karen Llanos. I am a technical director at CMS, and I work on child and adult program measurement issues.
Francis Chesley: Good morning. Francis Chesley at AHRQ. I direct the Office of Extramural Research, Education, and Priority Populations.
Denise Dougherty: Denise Dougherty. I am at AHRQ also.
Charles Gallia: Charles Gallia. I am with the Oregon Health Authority Medicaid Program.
Charles Irwin: Charlie Irwin. I am head of adolescent medicine at UCSF [University of California, San Francisco].
Marsha Lillie-Blanton: I am Marsha Lillie-Blanton, and I direct the Division of Quality, Evaluation and Health Outcomes, and also I am the chief quality officer for Medicaid and CHIP.
Stephen Downs: I am Steve Downs. I am a pediatrician. I am the director of Children's Health Services Research and General Pediatrics at Indiana University.
Naihua Duan: I am Naihua Duan—a biostatistician by training. I am on the faculty at Columbia University and New York State Psychiatry Institute, and I just retired from my faculty appointment a couple of months ago. I am enjoying my retirement.
Gerard Carrino: Good morning. I am Gerard Carrino from the March of Dimes, senior vice president for Program Resource Development and Evaluation.
Mary Evans: I am Mary Evans. I am a child mental health services researcher from the University of South Florida.
Elizabeth Anderson: Hi. I am Betsy Anderson. Today I am representing the Parent Advisory Group of the American Academy of Pediatrics home care section. For many years, I worked for Family Voices. And I just want to add that for decades now we, as families of kids with disabilities, have been trying to get quality for our kids. We have been hampered in some ways, but the system is so much more transparent. We can be great allies if our ideas are in there, and if we know what is supposed to be happening for our kids. And my own son has been eligible for Medicaid almost since he was born.
Andrea Benin: I am Andrea Benin. I am a pediatrician and a pediatric infectious disease person. I am the senior vice president for Quality and Patient Safety at Connecticut Children's Medical Center in Hartford.
Kirsten Thomsen: Kirsten Thomsen. I am a physician assistant, and my practice area is family medicine. I appreciate, Laura, your comment about the Native American community. I spent many years in New Mexico and presently live in Portland, ME, and I am with University of New England. But considering rural communities and the difficulties that some people have getting health care. I am also a commissioner on the National Commission on Vision and Health.
Feliciano Yu: My name is Pele Yu. I am a pediatrician, a hospitalist at the Washington University School of Medicine. I am also the chief medical information officer at St. Louis Children's.
Edward Lomotan: Good morning. I am Ed Lomotan. I am a pediatrician at AHRQ. I work with Francis and Denise and others on the CHIPRA [Children's Health Insurance Program Reauthorization Act] Pediatric Quality Measurement Program.
Preyanka Makadia: Good morning. I am Preyanka Makadia. I am also at AHRQ.
Maushami Desoto: Good morning. I am Mia DeSoto. I work with Francis and Denise on the CHIPRA program. I am the program officer for the grants and the contract.
Brenda Harding: Good morning. I am Brenda Harding. I am also a member of the AHRQ and CHIPRA team.
Susan Haber: Hi. I am Susan Haber from RTI International, and I am the project director for RTI's contract with AHRQ as the CHIPRA coordinating and technical assistant center.
Stephanie Kissam: Stephanie Kissam. Also with RTI, and we have our two colleagues at this table as well.