July 22, 2009: Morning Session (continued)

Male Voice: [inaudible]

Cindy Mann: Hello everybody. Sorry to be late, but I actually think the order made sense as it turned out to be, but I apologize for being a bit late.

These are our slides from the Centers for Medicare & Medicaid Services (CMS), but actually my colleague, Barbara Dailey, is going to be presenting the substance here. I'm here for the welcome and the fluff. So on behalf of CMS and the Secretary, I really want to welcome you here and to thank you for participating in what is an enormously exciting meeting in my view. Many of us have—and I see many of you around the room—worked long and hard to make this venture happen, and so it is very exciting to be here and actually see it in the concrete.

As Carolyn went through, we are here to begin a process of creating a core set of quality measures for Medicaid and CHIP followed by voluntary measurement by States and then followed by broader pediatric care measures applicable to all payers. We are very excited in this effort to be partnering with our colleagues from AHRQ and working closely as Carolyn talked about with other Federal partners and with our colleagues at the State level and outside of government who have long been leaders in this field.

As you all know, we have been working on these issues for many years. This is a really long overdue and much welcome initiative, and we have this wonderful mix of people to help us through it. So I really want to first thank the co-chairs for their time and their effort and thank all of you on the subcommittee. If you think about, look around the room and see this mix of people, we have incredible researchers who have worked long and hard on this topic. We have many who have operated and are currently operating programs that actually deliver care to kids, and we have people who are doing the delivery of care for kids, so we have a lot of the right people.

And if we think about it, one common thing that binds us besides caring about quality care for kids is that we go to a lot of meetings, right? A lot of meetings. But this I'm happy to say is not just one of those meetings. This really is a seminal opportunity to put all of our work on this issue for the ages that we have been working on, all of our best thinking, all of our aspirations into practice for the kids of America. This is actually the real thing, and it is very exciting.

Today, more than half the kids in the country, 51 percent, get their coverage through the Medicaid or CHIP programs, and if all of the kids who are eligible for those programs but are not enrolled were actually insured—and we are going to get them there the next few years—that number would be far higher. These programs are obviously critical to America's kids, and while the programs have been remarkably successful in many different ways, reducing unmet medical needs, assuring kids have a usual source of care, providing access to care that is generally comparable to what kids get who are covered with private insurance and far better than what we see for kids who lack health insurance coverage, we know we can do better. We can do better in Medicaid and CHIP, and we can do better all around. And that is exactly what this initiative is about, doing better for kids.

Nationwide, among all children, and I hesitate to throw any statistics to this audience because you have either researched them or written them or know them in any event far better than I, but nationally at least by one survey, 52 percent of all children, regardless of their source of coverage—we are not looking just at Medicaid and CHIP but all payers—have no medical home. Nearly one out of three did not have a preventive medical and dental care visit within the year, and as we know, these are national numbers and in some cases, kids fare far worse, and we know that poor kids and kids of color are at a distinct disadvantage in terms of their access to care. We have to do better, and this is our chance.

As you go about making your recommendations, here are my words of wisdom for what they are worth. I would urge you to be aspirational. Why should every child in this country not get the quality care that they need? At the same time, I urge you to be grounded. That does not mean we should set our visions high and our measures low. It means we should think about how to design standards and measures that really can be used and that can actually help shape the care that kids need. That is the good news about this meeting, it feeds into an actual process, and we want to make it work in the real life.

I also urge you to think broadly about quality. Think about coverage. Think about continuity of coverage. Think about access to care. We know without consistent coverage and without gaps in coverage, without access to providers who actually deliver the care, no quality measure can translate into quality care. So if Lisa were here, it would be the first thing she would say is think about continuity of care, think about eliminating gaps in coverage. Think about that access as well. So those are my short words of wisdom.

I wish I could spend the next 2-1/2 days with you, but I cannot. But I really eagerly await your recommendations and our ongoing collaboration. And I just want to underscore what Carolyn just said, which is that this is really our first step. All of us have key roles going forward. The research and advocacy community are critical partners to help us design and effectively execute and evaluate our efforts here. States' health plan providers are obviously key to this effort. They are the ones that are going to make the change happen. And the Federal Government must provide leadership, technical assistance, and financial support for the effort. And I commit to you and on behalf of the Secretary that we are prepared to do just that.

So thank you all for your work. Let me turn it over to Barbara to tell you the real stuff about what is in CHIPRA and how CMS is looking at some of these opportunities. Thank you.

Barbara Dailey: Thank you very much Cindy. Good morning everybody. It is indeed a great pleasure to be here today with all of the quality experts, the health care experts, the academics, State representatives, everyone here with the common goal to improve the quality of care in CHIP and Medicaid.

Comprehensive health reform is essential to the future of our health care system. CMS with our multiple partners is positioning to support that effort. This includes focused efforts to specifically improve access and the quality of care for Medicaid and CHIP programs and beneficiaries. We also continue to improve our efforts to assess eligibility for children for more timely and effective enrollment in those programs for timely service. We must also align our efforts to understand the successes and lessons learned in employer-based coverage that have had a much longer time in terms of practice with quality measures and areas that have demonstrated improvement in quality initiatives such as through accreditation.

We also have an opportunity to further address transitions in care across these different health care settings such as starting with preventive care, then children sometimes need episodic care for trauma, chronic care, long-term care, and as Carolyn has mentioned, even end-of-life care. We have an opportunity to improve coordination of care and access to appropriate services for dual eligibles and to leverage the lessons learned and the successes of Medicare quality improvement efforts that have been learned over the past several years. And we are really looking forward to continuing our partnership with Medicare on current initiatives such as medical home, reducing hospital admissions, and addressing hospital-acquired conditions.

The Department of Health and Human Services' strategic vision really does serve as the foundation for the CMS Medicaid and CHIP quality strategy. A multifaceted approach is important in order for us to be effective. First and foremost is patient-centered care. More focus must be placed on evidence-based care and quality measurement and hence the reason we are here and we are very excited to work with everyone here. CMS is also very much vested to support State efforts in the value-based systems of care, and we must continue to build health IT systems at the Federal level that will be supporting the State systems that are evolving and developing in support of health IT, including electronic health records. We will continue to build upon our partnerships and share information in order to provide States with the most up-to-date expertise and guidance available to them. And of course, we must also continually address the opportunities to address equity in the delivery of care.

The President has significantly invested in the future of our children through signing of CHIPRA. Through CHIPRA, CMS and AHRQ along with various other partners that we had at the Federal, State, and national levels are supporting that investment with a wide range of expertise and experience. This opportunity is unprecedented, and the time has never been more perfect for us to come together as a nation in order to improve the quality of these very important programs.

Now, Title IV, Section 401 of CHIPRA does outline a very comprehensive set of initiatives for States to address quality of care in Medicaid and CHIP. Now, the quality measures program, particularly for purposes of today's meeting, serves as the foundation for quality efforts but is strongly interrelated with all the other activities under CHIPRA. To accelerate consistency across State quality reporting, CHIPRA does call for the core set of measures to be published in January of 2010 for States to adopt for voluntary reporting. Additionally, CHIPRA does call for the development of an electronic health records program specifically focused on pediatrics. There will be an opportunity for States to apply for demonstration grants and for providers to test initiatives for improving health care and also to address health outcomes for children. There is a provision for a demonstration project specific to obesity that is still pending funding, and there will be an Institute of Medicine study on child health and health care quality.

All of these efforts combined will culminate in an initial report to Congress in 2011 but also serve as a great source of information to inform the developing quality measures program that has been discussed and has been mentioned in terms of developing not only from the beginning of the core set of measures in January but including the information from the demonstration programs, from our lessons learned through quality reporting, and through information gained from the Institute of Medicine study.

Now, the aggressive timeline and comprehensiveness of CHIPRA is truly unprecedented for Medicaid and CHIP. Shortly after President Obama signed CHIPRA, AHRQ and CMS came together to strategize the best way that our two agencies could leverage our expertise and experience. AHRQ's technical experience and their resources aligned with quality measurement are evident, and Carolyn addressed many of those. Another example is the recently published 2008 National Healthcare Quality Report.

Additionally, AHRQ's health IT research and development program provides expertise and an infrastructure to support and facilitate efforts for the electronic health records program. Now, CMS also is partnering with entities such as the Office of the National Coordinator to address health IT and electronic health records that also will apply to the Recovery Act (ARRA). We will be working to make sure that the efforts under ARRA do align with the work that we are doing with CHIPRA. So therefore, AHRQ and CMS will partner very closely for the electronic health records program, and we really look forward to that opportunity. Finally, AHRQ's contractual infrastructure does show them very well positioned to support the IOM studies, so they will be taking a lead on that as well.

Now, for CMS, our policy and operational experiences in working with State programs has led to the decision that we will take the lead on the provisions that have direct impact on the States' ability to implement these provisions. Therefore, CMS will lead the voluntary reporting of quality measures, identification and sharing of best practices, coordinating reports to Congress, providing technical assistance to States and providers, coordinating and working with States to assure success in producing the annual State reports on quality, and of course, coordinating the award of the demonstrations and partnering with AHRQ in the evaluation process of those.

Over a 5-year-period, we will learn and assimilate knowledge from all of the provisions to inform the quality measures program. That is why it is really so critical that AHRQ and CMS work in tandem. And we must also take this opportunity to really develop the lessons learned and share best practices from the states' attempts, not only to implement these quality reporting efforts but also what their lessons learned and their challenges and successes are through attempts through the demonstration projects, working on electronic health records, and the annual quality reporting process as well. We really do look forward to partnering with States for their input in terms of developing the quality measures program.

But in collaboration with Federal and other national stakeholders, CMS is in the process of developing a very comprehensive technical assistance plan. And it will not only address the quality measures piece which is statutorily required but technical assistance will be required or will be applied for States across all of the CHIPRA provisions. And because the State's success in demonstrating not only quality improvement in the delivery of care but also in identifying actual improvement in health outcomes, that really is not an option and therefore CMS does take providing technical assistance to the States to be a major priority and will be a major focus for us in this effort.

AHRQ and CMS have established a multifaceted collegial partnership under CHIPRA, and this really is in support of the Department's vision of providing the right care for every person every time. For over the past 5 years, CMS has focused on several initiatives to identify lessons learned, as well as for developing a vision for supporting State efforts to improve Medicaid and CHIP programs. With support from States and various workgroups, we have been developing a national quality framework for both Medicaid and CHIP, and I will describe that in just a moment. CMS also provides individualized support and feedback to States in terms of managed care, external quality reporting efforts, and quality initiatives affiliated with those. CMS has piloted a pediatric measure program specific to CHIP, and I will summarize that in just a moment as well, and we have also developed a quality measures compendium to provide States with a resource of options to consider in looking at quality measures that may apply to supporting their specific State's quality strategies and addressing their populations. Additionally, CMS will continue to build upon our partnerships with Federal and other stakeholders with a specific focus on CHIPRA.

Now, for the quality framework, one of the focuses is to accelerate consistency across State quality reporting but still allow for State flexibility and innovative practices. And so the development of the national framework was really intended to combine the efforts and the successes from the initiatives at the national level with the multiple types of activities that are occurring at the State level. And at the center of the framework is the beneficiary.

Now, the wide range of activities that feed into the delivery of care to beneficiaries, to date we really have not had a unified approach in order to see how all of these efforts make a difference nationally. And so in order for the Secretary to report to Congress on national efforts in the successes and improvement of care, this is the perfect opportunity for us to try to address that. So the ultimate goal in this framework that we are looking to continue to develop is to integrate the successes of both the national and State efforts through the development of a consensus of goals that States can choose from, basically a menu of goals that apply to their particular State's program needs. And then, of course, to measure progress toward these goals, there should be options in terms of how to measure that success in reaching those goals.

The CMS also does look to help the States as much as possible in working with their health IT assessments and planning, to enable them to capture the information in terms of quality measures reporting, as well as for identifying information that can be documented on their interventions and activities that are attempting to actually impact care and evaluate health outcomes. And so, ultimately, having this framework together, having the information available for States to be able to report this in a way that is easy for States to identify successes.

We have had experience as well in piloting the implementation of a quality reporting process through the CHIP program since 2003 on four specific child health measures, and States have really demonstrated quite a variety of experiences and challenges in that effort. The process has shown that success can be demonstrated at the State level and that we can start to see some trends on certain measures, but this has not been without substantial challenges.

Some of the examples of where States have most conveyed their challenges and concerns are—the benefits can vary obviously across different State CHIP programs—consistency in terms of what data should be collected may not always be consistent. Additionally, variants in health IT capabilities have been a challenge. And as has been mentioned in terms of resource issues, obviously limited experience in analytic and quality expertise is sometimes a challenge for States.

Now, quality measurement does strengthen accountability and we know this is the foundation of performance initiatives. You cannot improve something if you really do not know what the baseline of performance is. So to provide States with a reference on options to consider, we have developed this resource, which is a quality measures compendium. The last compendium was released in October of 2007, and we had planned to release volume III this year, but with the signing of CHIPRA and our new wonderful partnership with AHRQ, we have decided to defer that to 2010 so that it will be much more enhanced and much more useful for States.

CMS and AHRQ have a long history of partnering with various organizations and State programs to support quality efforts, but it is really forums like this that further define where we are going to go from here. There are more than 50 separate State Medicaid and CHIP programs, and in order to demonstrate the national impact of these efforts, it is more important than ever that together we try to address a common goal, and of course that is the right care for every person and every time.

We really do wish to acknowledge all of the help of everybody who has worked to bring this meeting together, including the Federal partners quality workgroup that Denise helped to coordinate with Carolyn, and we really appreciated all of the input from that team as well, but particularly, we also want to greatly appreciate the dedication of the subcommittee members convened here today. Your work is so important for identifying opportunities to improve children's health, and it really can be the driver behind health care reform. So we look forward to the discussions on quality measures, including that important public input so that we can assess whether or not every child will receive the right care every time.

Thank you very much, and I do believe we are going to have questions and answers now.

Jeffrey Schiff: Thanks Cindy. I think we will take questions for Carolyn, Barbara, and Cindy. My family tells me that I cannot introduce my wife, my children, and my parents all at the same time without forgetting somebody's name, so you will bear with me here.

Female Voice: Is it at all possible that, once the core set is up in January, there will be more work for this subcommittee, or is that really the end of it and thereafter ARHQ and CMS kind of take over, so to speak?

Carolyn Clancy: So, I will give you an answer. I'm not sure it is the answer you want. In terms of what specifically happens to members of this committee, I think that is a script to be written. The charter has been written through December 31st of this calendar year.

I will say though for at least the past 5 or 6 years, virtually everything that has happened in quality frankly has been through a very strong collaboration between the public and private sectors. Obviously, where it relates to operational responsibilities, I'm speaking of the adult world in particular now where—how would I say it—a powerful motivator has been a link to payment in the form of pay-for-reporting and so forth. That means the buck stops with CMS and the Secretary, but nonetheless, I mean every phase of operations, planning, and so forth has been strongly enriched by public-private collaboration. I frankly do not see any reason why that would change, particularly given all of the work that went into getting this legislation and creating the script and so forth.

Female Voice: The reason I asked in part is that the E-mail that has gone around about additional measures, I think we all get your message that let's go with a true core set that will meet the criteria, but everybody around this table has multiple things we would like to see added in, if you will, the next round or at least considered, and that is why I was wondering whether we might carry on or not.

Carolyn Clancy: Yes. But I think, and I'll let Cindy and/or Barbara speak for themselves, I totally love the framing as aspirational but grounded. I mean that is exactly what the challenge is here today. I do not think there is a thought or thought fragment that we want to miss from anyone in this group. So please, do not leave here if you have not downloaded, and as I said, after you get home, you can send us stuff online and so forth, but I just want us to be very, very focused on the task at hand.

Cindy Mann: Yeah and I would really reinforce that. First of all, in terms of the subcommittee, I think that the script has not been written. That is exactly the right way to word it, so let's—we definitely would value this kind of activity going forward. It's just that government moves in little chunks, so this is the chunk we have moved in so far, but do not be surprised if we continue to be knocking at your door.

And in terms of the core measures, it is not even just what could be in the next iteration in the larger pediatric care measures, but I think the other thing that Carolyn said which I want to emphasize is we can evolve. We can think of a core set of measures that evolve over time as State capacity evolves, as we figure out methods for implementing some of these standards and providing support to States to adopt measures. So I definitely do not want to have the grounded measures be the lowest common denominator. It has to be workable, but workable is in a point of time, and what is workable in January may not be workable later—we might be able to do more things in June or a year from January.

Male Voice: In terms of operational implementation of measures, once we have identified a set of core measures, is it really then up to CMS and the States to figure out how we will use these measures to measure performance?

Barbara Dailey: Yes. CMS is working with AHRQ and other national stakeholders to develop a really good technical assistance plan and determine how we are going to be able to facilitate the States to do that. Also, as part of the CHIPRA provisions, there is the annual quality reporting that is required in trying to decide how that may align with how States may want to voluntarily report these core measures. The core measures are intended to be voluntary but as a baseline, obviously States will have the flexibility if they have other areas of interest or experience that they actually want to continue, to continue that reporting. I do not know if that answered your question, but we are still working on that technical assistance plan.

Cindy Mann: And I would say in general, the world is moving towards, I think, pretty universal acceptance of the nice idea that we ought to have quality measures and reporting on those quality measures and then use them. Use them to direct how we deliver our services, what services we cover. So my hope, my aspiration is that all States will voluntarily report on these measures, but we want to make them measures that every State decides to go forward with, figure out mechanisms to encourage them and to go forward and to make sure that we are using the information in a way that guides us all going forward, both on the design of the benefit package, the design of how we deliver services, and the design of how we pay for the services. So I tend to be very focused on what we can do with this information that will then inform our ability to serve kids better.

Your question seems to me goes to both the question of are we going to get reporting back from States but also what are we going to do with the information once we get it. And I think that is very much part of what your deliberations ought to consider. We want this to be useful. We do not want to have a report that gets put on a shelf as here is what some States reported, a year from now.

Barbara Dailey: If I could just add, the quality demonstrations, one of the categories focuses specifically on States' opportunities to work with those core measures but as Cindy mentioned, we are hoping that States that apply for those grants are working across the board, so that we have a better national understanding in terms of successes and lessons learned in trying to use those measures. But the demonstration is another opportunity for additional areas of experimentation and receiving additional technical assistance.

Carolyn Clancy: The one thought I just wanted to add, and I will recognize this as a personal sort of concern. The end ultimate aspiration here building on what Cindy and Barbara just said is that not only are Medicaid and CHIP using the same measures but that there is a virtual complete overlap with the private sector as well. In fact, if you click on to Hospital Compare today, you do not just see Medicare patients or what is happening for Medicare patients with a couple of exceptions which are all about technical stuff and not about lack of interest from the private sector. It is all grownups, 18 and up. That is what you see, the rates for heart attacks or whatever it is that is being measured. And I think that is exactly the right way to go.

That said, I personally wonder if there are not going to be some measures that at some point in this process we do not want and that States may not want to consider at the statewide level, and I think about this for two reasons. One is that to look at disparities, most of the time you are going to have to get above individual organizations because many organizations are not going to have enough of a sample size to be able to say anything reliable or valid. Even in the adult world, the only way you can really get there for most hospitals is to combine all heart disease together which would give a lot of folks heartburn. We do not have measures for that yet. So, that is one kind of issue.

The other issue is even if you assume that instantly or relatively quickly, everyone agrees we are using the same measures for all pairs, you still have transitional issues with kids transitioning, and it is hard for me to believe that that is not going to be some of the kids at highest risk or poor quality. So I do not want to gum up the works with this, and that may be something that we all conclude as just kind of too much to take on right now, but I do think at some point in this journey, we are going to need to consider whether that is something that is publicly reported or not, but whether it is helpful for States to know for all kids who live here, are we actually moving in the right direction?

Barbara Dailey: Now, one other issue I just wanted to raise and just put on the table to think about is, it is confusing, but it is a real opportunity at the same time that this group is pondering the core measures for Medicaid and that we will, as Carolyn says, ultimately move towards broader pediatric, all pediatric care measures. We have the health IT initiative going on for electronic medical records, which clearly includes the quality component and clearly has Medicaid in it and the Medicare components. And it is our anticipation—we are in the process now of actually developing the initial set of regulations for how those moneys will be used.

But the idea is that we will meet in the middle and that the kind of recommendations that the Secretary will come to based on your deliberations will join up with the considerations of those health IT quality reporting requirements and what it means to have meaningful use for electronic records. So, it is another way of thinking about adding to our ability to get some meaningful reporting and information and sort of move into the '90s a little bit on some of this.

Female Voice: Yes. First of all, thank you all for doing this. This is a long time coming and something that I'm personally very excited about and I know my organization is as well. I have two questions so I'm going to sneak a second one in here with your indulgence. The first is, I just want to confirm what I think I heard from Barbara which is that at the end of the day, what you are looking for is some consistency in reporting across the country so that comparisons can be made and there is some uniformity in the way in which the formats are handled at the State level. Is that right?

Then following on from that, we already have in place as you said also, Barbara—and I think both Carolyn and Cindy mentioned it as well—in the CHIP legislation beginning back in 1997, requirements for quality reporting, and States have set up various mechanisms for doing that, but they are very different one from the other. So there are some transition issues here, and I was wondering if you all would speak to—have you thought ahead about how you would like to handle that, so that we understand here the system into which we are feeding our recommendations?

Cindy Mann: One of the efforts that we are doing in terms of trying to support that effort is we have a number of systems' assessments underway to help inform us in terms of some recommendations and guidance that we want to receive some State input into, so we are still in that analysis phase. We are starting to outline some ideas and some recommendations on how we may want to move forward in terms of that reporting, but we are just not there yet, but we will be looking for input as well.

Female Voice: Would it be helpful to you then if we spoke to the issue of format as we go forward?

Cindy Mann: Absolutely.

Female Voice: And also perhaps thinking ahead about the 2011 cycle, maybe pointing out some areas where we feel there are gaps in either subject matter or procedures that ought to be moved to the top of the queue. Would that be helpful?

Barbara Dailey: That is very important because part of what the Secretary is supposed to report to Congress is not only the successes and the challenges learned but even potentially additional regulation development.

Carolyn Clancy: The one other area, just building on Cindy's comment about health IT, is where format is going to be really very interesting, regardless of the age of a patient, is that we are going to be living in a hybrid world for a while, which is not intended in any way whatsoever to indicate any lack of confidence in Dr. Blumenthal because I think he is terrific, but it is not the case that providers are going to adopt it overnight. So that is going to be a very interesting kind of challenge as well. You do not want to do anything that would discourage or in any way disincentivize adoption of electronic health records and so forth. At the same time, you have to recognize that we are going to be living in a world where some people have and some people do not.

Male Voice:—have a question here.

Rita Mangione-Smith: We apologize, but we have so much to get done today, so we are going to have to stay on the agenda time-wise, so at 11:15 or so we do have to stop the question and answer period, but there will be other opportunities to get questions in, we promise.

Jeffrey Schiff: Okay. The other thing I just wanted to say is we have a public comment period both today and tomorrow. We want to make sure that everyone who wishes to make a public comment has the opportunity to do so, and in order to sort of divide time well, we have a signup sheet at the front desk.

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