July 22, 2009: Afternoon Session (continued)

Jeffrey Schiff: So we are looking for people to speak for, against how they voted for that.

Male Voice: I'll just ask a clarifying question. In the last discussion, the last measure, we will revote again, we can move it then the next time, is that right?

Rita Mangione-Smith: That is right.

Jeffrey Schiff: Yes.

Male Voice: Okay, got it.

Rita Mangione-Smith: You can vote differently.

Jeffrey Schiff: That is actually the sort of the purpose of this is to—

Rita Mangione-Smith:—to inform your next vote.

Female Voice: But we do want a rationale, so that when we write to the Secretary, we can say, "This is why we moved this. This is why this is being suggested," so that is part of why this discussion is happening.

Male Voice: I just want to make a comment because I have voted 6 in the last time for low birth weight, even though it is clearly population management, and I think it is actually an essential measure but because of all these other fuzzy issues about Medicaid. For the population of kids who have insurance, kids who have no care, kids on Medicaid, kids on CHIP, we have to be looking at a single system, but we are not. But I think that is part of where I was confused before I would revote again, and we can include this, the rationale.

Rita Mangione-Smith: Case on initiation of prenatal care?

Jeffrey Schiff: We are moving on to the next measure. Cathy?

Catherine Hess: Was not entirely sure how these were measured, but it is sort of seemed to me hard to talk about frequency of ongoing prenatal care if you had not had a measure of when it first started. But I do not know how the two measures or what their specifications are so I was actually on the valid side for initiating prenatal care. But how often it goes on and so forth is I think is a little iffier, and so I was one of those who voted 6 on that one. But they seem to me to go together in some measurement way.

Female Voice: There is some guidance on the—these are both HEDIS [Health Plan Employer Data and Information Set] measures?

Female Voice: Right.

Female Voice: The guidance on how they are connected is 2A?

Rita Mangione-Smith: If you look at the HEDIS fact sheet, prenatal and postpartum care, timeliness of prenatal care, and then frequency of ongoing prenatal care—that gives you the specification for those measures.

Sarah Hudson Scholle: Do you have any idea if that is the APNCU, or the Adequacy of Prenatal Care Utilization, index that Kotelchuck developed?

Female Voice: No idea.

Sarah Hudson Scholle: Okay. Because I mean obviously how many visits you get depends on how long your pregnancy lasts and when you start getting visits, and so there is this index that adjusts for all of that, which is the Adequacy of Prenatal Care.

Rita Mangione-Smith: So, Sarah, do you know what the correct number is? This frequency says who received the correct number.

Sarah Hudson Scholle: It depends on when you start and then when you deliver that there is a formula that figures that all out. It is very complex, but it is a well-established index.

Male Voice: It is the Kotelchuck index, right?

Sarah Hudson Scholle: Right, the Kotelchuck index. APNCU Kotelchuck index so I have, you know, so I guess that is why—and then I did not know if this is one of those beta blocker post-MI, I mean initiation of prenatal care in and of itself we have sort of been measuring for 25 years. I would rather know that you are getting the right amount of care than just when you started it, so I did not know if that was one of the ones [cross-talking]. I sound heretical just to report, but maybe that is one of the ones we do not want to go and we do not vote, that is what I am saying. Maybe we do not want just initiation.

Rita Mangione-Smith: Right. Right now, we do not get initiation but we do we get frequency, so frequency made it, initiation did not. Okay?

Female Voice: Let me just say that this—for members of Congress and the staff who work with them, one of the things that they are looking at with respect to initiation of prenatal care is how robust the outreach and enrollment process is in a given State. So it is not really about initiating care per se. What it is about is: Are you in fact reaching women who should be enrolling in Medicaid now that they are pregnant?

Male Voice: The HEDIS is very specific. That is the good thing about this indicator. So I am reading right here, it has had to be enrolled in a plan for more than 6 weeks but less than 44 weeks prior to delivery. So I mean it seems like a very reasonable standard, and they give statistics about what proportion of health plan actions meet the benchmark, and then there is pretty good evidence that this is an effective thing to do. So I guess it seems like a no-brainer.

Female Voice: The Compass database, but I just did not have the skills or time to actually go through and see whether this was on there, so can we find out in response to Lisa's question, is this an important measure now? So we are already at 95 percent?

Jeffrey Schiff: Right.

Female Voice: It is focused on [inaudible].

Rita Mangione-Smith: Okay. Paul, do you have a question or a comment? Paul Miles.

Jeffrey Schiff: Okay.

Rita Mangione-Smith: Any other comments on that particular initiation of prenatal care? Okay, we will move down to postpartum care visits overall. So that is another HEDIS measure. So the spec is there. The percentage of deliveries that had a postpartum visit, and I imagine in the detailed specs of the measure they would probably put a timeframe on that, but we do not have that information here. Knowing the National Committee for Quality Assurance (NCQA), there is probably some kind of template around it. Do you want to tell us—or do you know—Sarah, could you share what it is?

Sarah Hudson Scholle: [inaudible] between 21 and 36 days.

Rita Mangione-Smith: Between 21 and 36 days post-delivery, okay, there we have it.

Sarah Hudson Scholle: I mean 56, 21 to 56.

Male Voice: Twenty-one and 56.

Rita Mangione-Smith: Twenty-one and 56 days post-delivery. Okay. So again this was one that does not make it, but there were very few people in the lower four categories. Xavier.

Xavier Sevilla: I have a question about this. I was not sure. Looking at whether the Ob-Gyn is doing the counseling or just the pediatrician, where is this falling into this matter?

Rita Mangione-Smith: Who is responsible, is that right?

Xavier Sevilla: Mm-hmm, and the same thing with the one below.

Rita Mangione-Smith: So it is an interesting question I'll just throw out there in our primary care clinic, the rest of the clinic at the University of Washington, we actually now for the first 2 months of the baby's life, while the mom is awaiting postpartum depression screen and we actually do the referrals if we find a positive screen. So I'm not sure. It is not our responsibility, I do not know. It is an interesting question.

Xavier Sevilla: Yes, the interesting thing is a lot of States do not allow you to bill as a pediatrician for postpartum visits with the mother, and some places still do it anyway but—

Rita Mangione-Smith: Yes, we do not get too comfortable with it.

Male Voice: Yes, yes, so it is an interesting conundrum here.

Rita Mangione-Smith: A social worker goes and talks to them and with the whole nine yards but it is not—

Xavier Sevilla: Well, it brings up a bigger issue of should we be talking about quality criteria for things we actually cannot bill for. Will that put an interesting wrinkle into thinking about this?

Rita Mangione-Smith: So one of the things that we need to think about tomorrow as we talk about importance criteria is the cost that means to factor in to how we would think about this.

Cathy Caldwell: Did the maternal depression screening and treatment pass but the—

Rita Mangione-Smith: They did.

Cathy Caldwell: Okay, so they are—

Rita Mangione-Smith: But the visit did not.

Cathy Caldwell: Right, okay.

Rita Mangione-Smith: The postpartum care visit did not.

Denise Dougherty: The reason those are under there is not because those specific measures are measures in use that we could identify unless somebody could tell us differently. That was actually—and it was not terribly—it is terribly not very well explained. Those are examples of what things could happen in a postpartum visit and the evidence based for those because we do not have an evidence base for postpartum visit, yes or no. So those are listed there to give you a sense of the evidence base for specific things that might happen during a postpartum visit. Now, preferably, we would be measuring those things, but right now the measurement is do you have a postpartum visit, and we do not know whether those things occur but they could occur.

Rita Mangione-Smith: So I think maybe in the next round, though, we have to be very specific that all you are really voting on is postpartum care visit.

Denise Dougherty: That is right.

Female Voice: Denise, are you saying all five of those things are not really specific measures underneath there?

Denise Dougherty: All the ones that we—

Female Voice: All five of those things?

Denise Dougherty: Yes. As far as we know. Now as we said, we do not know what every State is doing in terms of measures. Some States may be measuring the specific [cross-talking].

Rita Mangione-Smith: So maybe our environmental scan will show that some people are using—

Cathy Caldwell: So even though they pass, they were not really measures even that we were supposed to vote on, on those two.

Female Voice: That is true.

Rita Mangione-Smith: That is what it sounded like.

Rita Mangione-Smith: So I think in the next round, we need to be very [cross-talking]. What is that?

Female Voice: The item itself do [inaudible]

Rita Mangione-Smith: That is not true. Every one we are talking about today you are going to see it again whether it passed or not. So all these scores that are 6 and 7 you are going to see again.

Denise Dougherty: But you are not going to see those five underneath the postpartum visit.

Rita Mangione-Smith: You would not see the five underneath the postpartum.

Denise Dougherty: Unless we find out between now and then that some States are actually measuring any one of those or all five.

Rita Mangione-Smith: In any of those that got a 7 and that have nobody—a very few people on the bottom four, you will not be re-ranking. So you will only re-rank the ones that are kind of in this level of disagreement going on that we are discussing today. Does that make sense to people? I see a lot of wrinkled foreheads.

Female Voice: No.

Rita Mangione-Smith: So, okay. So if you put down this list, so let's look at depression prevention during postpartum care even though that is not a real measure. I'm just using it as an example, okay? So that is a 7. If you look in the bottom four categories, two or fewer subcommittee members put it in the bottom four categories, and it has a passing score, so we are not discussing it. It is re-rating it.

Female Voice: But it is not a real measure, and now we have said we want specs for that.

Jeffrey Schiff: No, that is a bad example.

Rita Mangione-Smith: As an example, I'll pick a real measure. How about if I do—

Female Voice: Initiation of treatment.

Rita Mangione-Smith: Okay initiation of—and that is a frequency of ongoing prenatal care. Okay, it is a 7, and it has two or fewer people who rated it in the last bottom four categories, okay? Now if it was a 7, and five or six people were in those bottom four categories, we would be talking about it.

Female Voice: I do not think that is where the confusion is. The confusion is if you take exactly the one you want, depression prevention during postpartum care. We were asked to rank if it is a measure, and now you are saying we do not have a chance to re-look at it now, knowing that it is actually not a measure, now knowing that we said we wanted specs, which is illogical to me.

Rita Mangione-Smith: So it was an error that ended up [cross-talking]

Female Voice: So it should be off that final list.

Rita Mangione-Smith: Yes.

Jeffrey Schiff: Right, okay.

Female Voice: It is not a measure.

Jeffrey Schiff: That is an error.

Female Voice: Okay.

Rita Mangione-Smith: It is an error, okay.

Jeffrey Schiff: Yes. But it will be part of—it will be an example of a postpartum visit.

Rita Mangione-Smith: And it needs to come off of—if it is currently on the list that we are doing importance on tomorrow, it needs to come off.

Jeffrey Schiff: Right.

Rita Mangione-Smith: Denise, are there any others like that?

Denise Dougherty: Yes.

Rita Mangione-Smith: Flag them please.

Denise Dougherty: Yes.

Rita Mangione-Smith: Thank you.

Female Voice: That is too bad.

Rita Mangione-Smith: That is too bad. I thought those were real measures.

Male Voice: So process-wise then, is there a way that if we identify a previously unidentified real measure that there would be an opportunity to—yes, that is this process. So if we had one of those, it was rolled up.

Rita Mangione-Smith: If somebody finds a real measure that is in use that addresses those things, we can add it.

Male Voice: Okay. So we unroll it, find a discrete measure then it goes up there, and it is reconsidered.

Jeffrey Schiff: Right, and then we will discuss, any of those will be scored for feasibility and—

Rita Mangione-Smith: Validity.

Jeffrey Schiff:—validity again, and if they pass that test online, they will be scored for importance online. If they do not pass that test and they are marginal, we will be talking about them in September.

Female Voice: Is that a threat?

Jeffrey Schiff: That is a threat. So vote definitively.

Rita Mangione-Smith: Okay. Back to the ones that are real measures. Sorry.

Male Voice: Okay. Sorry about the confusion.

Rita Mangione-Smith: So checkups after delivery, that did not pass, it has four people in category 4. It has an additional three people in the middle that are in 5 and 6.

Female Voice: Those that appeared from the Centers for Medicare & Medicaid Services (CMS) survey, the CMS-funded survey and the only label we had was checkups after delivery, so I'm not clear whether that is checkup pediatric or mothers or maybe the same as postpartum. It is just we do not have the definition of what that measure is.

Female Voice: There was a survey that CMS had. Maybe you can explain.

Female Voice: I'm checking on it. I do not think we have that available.

Female Voice: No, we do not. And it would not—from what I understand, we have discussed this, okay, to Barbara and John, "Is there not anything more on that survey that could tell us what these labels mean?" And it was one of those surveys where they were asking a lot of questions, and one of the questions was, "What measures are you using?" And that was the label. So there is no more. Even if we had the report, we would not have any more information; that is my understanding.

Rita Mangione-Smith: Okay. So we have no specifications on this measure. We do not really know what it means, whether they are talking about baby checkups or mom checkups.

Male Voice: Well, we get the baby checkups that are done.

Female Voice: I know that we look at it as far as a percentage of women who actually keep a postpartum visit that make—you know, so that we actually do look to try to get some idea on how many women actually make a postpartum visit, okay?

Rita Mangione-Smith: So is that like a [cross-talking]?

Female Voice: And it is about the mother.

Rita Mangione-Smith: So according to the HEDIS specs that postpartum [cross-talking].

Female Voice: And it is basically looking specifically at their claims data, so as far as the specs, I would have to pull it, but it is actually done to identify how many, and we actually had set a goal to try to increase the number that we are getting in for the postpartum visits, so.

Female Voice: Okay.

Male Voice: Yeah. I think it is a point of information. It is a crucial distinction because if it is the first newborn visit—

Rita Mangione-Smith: That is very important.

Male Voice: That is extremely important, and I think that you might get different scores, and if it is the mother's visit, because frankly that is not a pediatric quality indicator, if you think about it, so I think we need—

Rita Mangione-Smith: [Cross-talking] infant checkup after delivery that would have been a 9.

Male Voice: Yes, so maybe before we vote, would it be possible to get a complete clarification on that or—?

Jeffrey Schiff: Right.

Rita Mangione-Smith: Okay. So we will try.

Female Voice: [inaudible] and say, "What are you doing?"

Rita Mangione-Smith: This next one is "personal doctor talked about child's growth and behavior." Is this an item out of CAHPS® [Consumer Assessment of Healthcare Providers & Systems] or is this—?

Female Voice: It is an item on the CAHPS.

Rita Mangione-Smith: Okay. So I think maybe that should not be scored singularly.

Female Voice: Yes.

Rita Mangione-Smith: So let's—

Female Voice: Although it seemed like a very different measure because then the usual CAHPS® experience is a peer measure which is—

Rita Mangione-Smith: Which part of CAHPS® does it come out of? Do we know?

Female Voice: I'm looking—you can move on.

Rita Mangione-Smith: I think it might be the communication composite.

Female Voice: Yeah, might be.

Male Voice: I have a comment on that, actually, not just that one but all the CAHPS® measures. I looked at those, and they all look like something we could really apply to every single child that is taken care of in a medical home. I think to separate them by chronic illness, I mean we could still do that, but we should have the same survey items for children with a chronic illness and without a chronic illness.

Female Voice: Put it on the future list, I think. Yes?

Female Voice: Yeah. I mean CAHPS—I mean 23 or 24 States already report to the National CAHPS® Benchmarking Database, CAHPS® data on their Medicaid enrolled or CHIP enrolled, depending on the State population. And I do not know what percentage of those do enough stratified samples to report special needs versus all kids, but I mean I think we should do it on all kids. These are important metrics on all kids.

Rita Mangione-Smith: Yeah, I think the special needs measures though are—when the survey is administered, my understanding is those only get asked of the kids with chronic illness.

Female Voice: Special needs kids, right.

Rita Mangione-Smith: And I do not know what the logistics—

Female Voice:—which is different in every State.

Female Voice:—would be of getting the survey for chronic—kids with special health care needs being given to all kids. I do not know if that [cross-talking].

Female Voice: No, wait. You could do—I mean [cross-talking] do the screener, exactly. You do a branching logic, you administer the screener so States—and then, you know, kids are—those who screen in for any of the screener then you ask those additional coordination questions. Or those who screen in because they have special services needs, then you ask the service, the coordination needs. I mean that is—

Rita Mangione-Smith: So would you mean that they not do the screener, you would just go ahead and give the full survey to everybody?

Female Voice: No.

Male Voice: The survey—

Female Voice: We do this for our entire Medicaid CHIP population, and the way that it is administered, it is a telephone survey. They start with the screener so if there is a child in the family that is screened just on that then when they go to the supplemental questions, they administer it. So it is done—the screener is on the universe.

Rita Mangione-Smith: Right, but it seems like the suggestion here is that the supplemental questions should be administered to all children.

Collective Response: No.

Rita Mangione-Smith: Okay, then I misunderstood. [Cross-talking]

Female Voice: Yes. That is what he said.

Rita Mangione-Smith: I thought that is what Xavier said.

Female Voice:—talking about communication in respect and all that. Those are not supplemental questions. Those are core path [cross-talking].

Male Voice: Right, exactly.

Female Voice: The special questions are about coordination with parents. If you needed special services, did you doctor help you coordinate it? That is one of the examples.

Xavier Sevilla: No. As far as I know, I mean the CAHPS, the ambulatory child CAHPS® survey has the shared decisionmaking, and that is what I was saying. I was saying those should be done on every child, not just on kids with chronic illnesses, and the way that it was on that table was that the kids who did not have chronic illness would not get assessed for those items.

Rita Mangione-Smith: So actually I'm pretty familiar with the CAHPS® composites, and these shared decisionmaking questions do not get asked with the standard pediatric CAHPS® composites. You get questions for getting needed care, getting care quickly, how well does the doctor communicate and health plan information and customer service. Those are the composites for pediatrics. There is not a shared decisionmaking composite for healthy kids.

Female Voice: The items are listed on your scoring sheets that were given back to you.

Rita Mangione-Smith: So right here [cross-talking] shared decisionmaking; these items that get at shared decisionmaking.

Female Voice: I have two sets of HEDIS CAHPS® survey measures.

Rita Mangione-Smith: Those three items do not get asked of healthy children.

Female Voice: The first one is children without chronic conditions. The second grouping is children with chronic conditions.

Female Voice: Would it help at all in doing our re-rating if we had all of these, say, CAHPS, HEDIS measures somehow listed together because [cross-talking].

Rita Mangione-Smith: So you could check these items?

Female Voice: Well, going from the scoring sheets to all the other information is hard, and if at a minimum, the things that go together were somehow in here together instead of split out, for instance, between chronic and kids without chronic conditions and all, but that is a set of measures.

Rita Mangione-Smith: But it is two different surveys.

Female Voice: Well, so—

Rita Mangione-Smith: So I think we could [cross-talking].

Female Voice: No. I'm hearing it is supplemental questions.

Jeffrey Schiff: I think we need some clarity. Let's get some clarity on this rather than have this debate because it is not—

Female Voice: Because these are all over the lot, and we may or may not recognize them as CAHPS® measures or HEDIS measures.

Female Voice: The only one—there are two that are out of place. In order to see if we had anything to meet the legislative criteria so there is a specific legislative language that says, "Services to promote healthy growth and development." So in order to put a measure in there that is in use, it is part of the CAHPS® survey for children with special health care needs. So I moved it under that. It is also still under the list of all CAHPS® measures for chronic conditions, okay?

Jeffrey Schiff: Got it.

Female Voice: The same thing for under most integrated health care settings, I put a note in here, "See the CAHPS® measures for coordination of care." So that is how things got moved around.

Jeffrey Schiff: That is why they got split.

Female Voice: Okay? That is how they got split.

Jeffrey Schiff: Okay, got it.

Female Voice: Because there are legislative domains that we are trying to fill, so I was going to try to show how they could be filled with the existing measures.

Rita Mangione-Smith: But I do think in the next round, we could format this so it is much clearer that here you are scoring the shared decisionmaking composite, and these are the items that go under that composite that do not score the items individually, just do it as a composite.

Female Voice: It does actually say that. It says shared decisionmaking, score once for all items combined, and—

Rita Mangione-Smith: Yeah, I think it was probably easy to miss that though [cross-talking] scored them all individually.

Female Voice: Right. And in the scoring, we merged the cells so that—but people put the rows back in and scored them separately anyway.

Rita Mangione-Smith: Oh, so they took them out and then—

Female Voice: Yeah.

Rita Mangione-Smith: Oh I see. So it is definitely [cross-talking].

Female Voice: It is separate. It is very difficult. I mean it was difficult to figure out which measures go where, difficult to find out which measures are used.

Rita Mangione-Smith: So maybe just in one row, if you sub-bullet the items and just do not put them into the next row, then nobody can do that—they cannot re-split them.

Jeffrey Schiff: Okay. Is that [cross-talking]? I'm still seeing some quizzical looks. Do people understand?

Rita Mangione-Smith: I do want to come back to Xavier's comment though. So I can pretty much guarantee you the shared decisionmaking composite does not get asked of healthy children because I have seen the full survey. I have a fellow who is doing research with it. You know, and I think your point is important, and I think we will need to think about it, and would we as a group suggest that in this core measurement set, that composite should be asked of all kids, not just kids with special health care needs? That is just something to think about.

Female Voice: I just want to comment that it is a construct of medical home, and since we believe that all children should have medical homes, I would be a very strong advocate to have shared decisionmaking not just for children with special health care needs, but it is a core construct of medical home.

Rita Mangione-Smith: So maybe when we send these out again, Denise, we could put those as options below healthy children and below children with special health care needs.

Denise Dougherty: Sure. Well, I think what we need to do in the next round is be clear about which children are being asked which questions. So here there is a simple label, "Children with chronic conditions." That does not say how that group gets identified so we can—you know what I mean?

Rita Mangione-Smith: Yeah. So then [inaudible]

Denise Dougherty: I do not know how we divide the rating to say, okay, so you have all these measures for children with chronic conditions currently. How do we put a placeholder so people can mark that they want those for all children, not just children with chronic conditions? We have not had a category for which population the measures should be applied to. I think we need to figure out how to do a sheet so that [cross-talking].

Rita Mangione-Smith: That is getting to a pretty refined level. I mean that is something for September where these are measures that make it and are in the core set, then we can make recommendations that include which populations.

Jeffrey Schiff: I think what we are bumping up against is the legislative mandate versus specs because I see that if there is a spec for something to be just for kids with special health care needs, then that is how it lives in its universe, and we have a decision to make about whether we want to recommend or we feel like there is enough validity to expand the spec. That is different than—

Denise Dougherty: Do we want the measure in the concept? Yeah.

Jeffrey Schiff: Right. So okay, I think we have like 25 minutes, and we have to leave some time to talk about coverage, I mean in that.

Rita Mangione-Smith: You mean feasibility.

Jeffrey Schiff: No. I mean the first—very first.

Rita Mangione-Smith: Yeah, and we still have a couple of more—

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