July 23, 2009: Afternoon Session (continued)

Jeffrey Schiff: Yeah, okay.

Female Voice: So, on this rubella there are 12 cases.

Female Voice: I'd rather count giving the immunization.

Jeffrey Schiff: Okay. So noted.

Female Voice: Okay, Chlamydia.

Jeffrey Schiff: We're now—oh you got—?

Rita Mangione-Smith: Yeah. She's got the data on it.

Denise Dougherty: Well, there were three different rates. Ages 10 to 14 overall, and this is not Medicaid, it's 66 per thousand, the rate of 66 per thousand. Ages 15 to 19, it's 1,800 per thousand, 20 to 24 it's 1,900.

Jeffrey Schiff: No, 100—180.

Denise Dougherty: 100,000—sorry—per 100,000, and there's a pretty big racial difference.

Rita Mangione-Smith: Okay, so immunizations for 2-year-olds. You are all very familiar, I think, with these measures and these data. Any comments on importance?

Next is adolescent immunization. Next is influenza vaccination in children.

Denise Dougherty: And this is one where we don't know whether this is an actual child measure or not.

Rita Mangione-Smith: Influenza vaccination in children. So I would suggest that this is one that clearly if it's being done in adults, it will be very, very easy to transform the specifications for children.

Female Voice: Particularly when it becomes mandatory immunizations as opposed to optional.

Female Voice: It would.

Denise Dougherty: Okay, so you are doing it for children. You are doing it for children then? Okay.

Rita Mangione-Smith: So we can take away the question.

Female Voice: Right.

Female Voice: [Cross-talking] with a specific—it's with a specific disease they—which—but we could look at it more across the board and consistent, we need to learn [sounds like], but right now it's focused on diabetes and asthma.

Rita Mangione-Smith: So we are doing it in kids. That's all we need to know.

Denise Dougherty: For some kids.

Rita Mangione-Smith: Yes, any kid. All right.

Denise Dougherty: You really want this one, I could tell.

Rita Mangione-Smith: I do. My true colors are starting to show.

Female Voice: Well, I do need it. I do need to put it [cross-talking].

Rita Mangione-Smith: I'm embarrassed. I've been trying to keep all of my biases under the table.

Female Voice: Rita, I do need to put a thing in there. We are doing it, but we did run into issues with—I didn't find the info and found out that we were really, really low because a lot of the stuff was being done and not being billed for and therefore not capturable. So part of what we had to do, especially with the asthma care coordination, was to put in a survey to try to identify if these children had had the immunizations done. So we're not really able to capture it from claims data, okay?

Jeffrey Schiff: Cathy.

Cathy Hess: And from what I understand with the upcoming flu season and H1N1, there may very well be a big national push with immunizations in the schools and not just—no, we're not going to get that through claims data. I think it would be incredible to be able to count it, but in the current system, I don't think we'll be able to.

Rita Mangione-Smith: Those [cross-talking] some really important feasibility issues that people are raising, so this one did make the cut, the feasibility the first time around.

Jeffrey Schiff: Right.

Rita Mangione-Smith: Okay.

Jeffrey Schiff: And we're also—

Rita Mangione-Smith: But in September, keep this discussion in mind as we're trying to—in the list. Are we ready to move on?

Female Voice: Yes.

Rita Mangione-Smith: Okay. So the next one is—dental, percent of members enrolled for at least 11 of the past 12 months who received any preventive dental service in the past year. Any other comments? Yes, Jim.

James Crall: If you'll indulge me, I want to thank all the members of the subcommittee for recognizing that basically what this and the other five measures that are on here that sort of relate to dental, deal with the most common chronic disease of childhood, deal with the number—most frequent unmet health care need in children and in children with special health care needs and represent 14 to 18 percent of the health care dollars that go for pediatrics. Thank you.

Having said that, there are four measures that I think we need, three of which are one of the six and one of which is not. And this measure to the best of my knowledge, even though it has made this cut, is not collected anywhere. And it's sort of a hybrid HEDIS [Health Plan Employer Data and Information Set]; it's a proposed California sort of hybrid. We're using a HEDIS approach, but it has a specific focus on prevention.

Rita Mangione-Smith: So if I'm remembering correctly, I think all of those other measures were on the cost. Is that correct?

James Crall: I mean the ones that are on here, and I need a little clarification for one of the others, so if you just want to talk about the dental ones all at once, we could probably get this done and up—

Rita Mangione-Smith: Absolutely, we can do that.

James Crall: Okay, because the one that says annual dental visit, is that the HEDIS measure?

Rita Mangione-Smith: Okay, so what we have is—so annual dental visit is HEDIS 2 to 18 years old, so that's the HEDIS measure.

James Crall: Right, that was my question. Okay, all right. So here's my statement that I think that basically, the one measure that I feel that really ought to be on the list that isn't on the list, and it definitely was worded funny—so people may have voted—it's the one that had the months instead of saying the total number of eligibles or whatever, so people might have had a little trouble interpreting that the first [cross-talking].

Rita Mangione-Smith: So that's the—

James Crall: Yeah. Here's my plea. The CM-416 measure for any dental service or any preventive dental service is on this list. I plead with you to keep them on the list, but I also plead with you to put back the third measure which is part of the CM-416 which is percent of kids that get any dental treatment, any treatment beyond a diagnostic and preventive visit, and just leave those as the whole sort of cluster, as Lisa refers to it, which are collected in every Medicaid program in the country right now and reported on.

Rita Mangione-Smith: Can you—so we have on this—on the importance list, we have percent of beneficiaries with at least one dental visit annually. Okay, and then we have annual dental visit HEDIS, then we have receipt of treatment for caries or caries preventive procedure among members enrolled at least 11 of the past 12 months.

James Crall: I don't know anybody that's collecting that but—

Rita Mangione-Smith: So is that the one that is missing that you're concerned about, and is that one—?

James Crall: Absolutely.

Female Voice: So, Jim, are you saying—

Rita Mangione-Smith: Percent and members who received [cross-talking].

James Crall: I could live without that one just fine.

Female Voice: And if this one is the receipt of treatment for caries or caries within a procedure [inaudible].

James Crall: Yeah. So I mean it's a dirty measure. It's got treatment for caries like fillings and things, but it's got a preventive service which you already picked up in the percent of beneficiaries that get a preventive service in a year anyway.

Female Voice: Could you just give us the specific wording if you can find it anywhere?

James Crall: Yeah. It's the one that originally was worded "months who received any dental treatment."

Rita Mangione-Smith: So that one is going to hit round two. That one will be in Delphi round two.

James Crall: I think everybody's comfortable with the rationale for why Jim thinks that should be—

Female Voice: [Inaudible]

Rita Mangione-Smith: If you look under—it says "months who received" and it should be "percentage of eligibles who received any dental treatment other than diagnosis and preventive services in the past year."

Female Voice: I know you're really trying to stay true to the processes of yesterday, today, and the future but I'm going to get real confused when I go home in a month and read this again, and I want to do what needs to be done. Could we have the four that he's talking about put on the sheet, and is there any way to do that?

Female Voice: You actually have about 10 dental measures in here, and I think we're all having a hard time figuring out—

Rita Mangione-Smith: Which ones are the important ones?

James Crall: Important ones?

Female Voice: You have four and about—one, two, three, four, five, six or so—[cross-talking].

James Crall: No. I'm going to give some up. I'm going to give them up.

Female Voice: Six.

Jeffrey Schiff: Okay. So I think we're getting [cross-talking].

Rita Mangione-Smith: Let's stop for a minute because we're getting really bogged down with this, so what I would like to propose is that we continue and finish this process that Jim, for us here, will write down the four. We will make sure they get grouped together, and we will label them as the EPSDT-CM-416 cluster of measures. How about that? Can we do it that way the next round so everybody—because I know all of them are on—some of them made it in already, some of them are on the cast and will get re-voted on. And as long as we know those were the ones that were supposed to go together, then people won't have that in their heads when they do their second round.

Female Voice: And Rita, I think it's also important to note that Jim is okay with us doing away with one that is on the sheet.

James Crall: That's just [cross-talking].

Female Voice: That is his personal opinion. I mean—

Rita Mangione-Smith: To stay true to the process, I'm not going to do that. If you guys come with your hatchets in September, and we're shaving measures, and we decide based on what Jim tells us that that's the one we're going to drop, then that's what we'll do.

Female Voice: Yes, but we're getting ready to vote on importance, so I thought it was important for Jim to say this one is not important to me.

Jeffrey Schiff: We're sort of taking the dental stuff and accelerating it into the process. I guess what Rita is trying to do is say, "Okay, let's not go there right now." So I think we will be—when we bring this up for a revote, we will make it especially clear and may actually make sure you could look at these two to make sure we're—

Rita Mangione-Smith: So this dental measure, this dental percent of members enrolled for at least 11 of the past 12 months who received any preventive dental service in the past year. Jim, do you have anything? This is part of that cluster of measures. It's not so it would fall into the less important area, it sounds like from what you're saying, from your perspective. Okay. All right, any other comments on that, and do we all kind of agree with how we'll move forward with this?

Jeffrey Schiff: Okay. So now we start with child visits.

Rita Mangione-Smith: So well-child care visit rates, first 15 months. Comments about the importance of counting these visits? Variation wise, the States are reporting the range; it's 71 to 90 percent who have five or more well-child care and PC visits in the measure [inaudible]—oh, preventive care.

And I'm going to just actually throw up a comment here. I'm working with a fellow at the University of Washington who has done a really elegant study looking at the Hawaiian, at their main insurer which covers 60 percent of the people. And what he wanted to study was adherence to the AAP well-child care visit schedule and whether it prevented ambulatory care-sensitive hospitalizations. And his study is the first one to look at that and to look at continuity of care to see if there was an independent effect of being adherent to the well-child care schedule.

And what we—and he broke it out. Because he had such a huge population of kids, he was able to look at healthy children, children with asthma, and chronically ill children, and it turns out that continuity of care matters for everybody, okay, it's all three groups, and that adherence to the schedule was quite important for chronically ill children. So it had an odds ratio of 3.0 if they fell into the second to lowest adherence group, which was—they were only—they were making it to less than 50 percent but more than 25 percent of the recommended visits. If they fell in the bottom quartile, less than 25 percent adherence, the odds ratio was 4.0 that they would have an ambulatory care-sensitive hospitalization, controlling for a lot of variables that we know influence those hospitalizations.

So I just want to throw that out there because I know there's very little evidence, and we're in the process of trying to get that published in Archives, so I just shared that because it's out there.

Male Voice: So, Rita, just to recap on that, healthy children, what was the effect on—?

Rita Mangione-Smith: There was no independent effect of adhering to the well-child care schedule in terms of preventing ambulatory care-sensitive hospitalizations in well children. We are in the process of looking at these same variables in the group of healthy kids in the State of Washington so, hopefully, by September, I can give you some information on that.

Female Voice: Rita, what age groups did he look at? Did he look across the spectrum from the 18—?

Rita Mangione-Smith: He did not. We limited ourselves to 5 and under, so we were looking at the kids who have a lot of visits that they're supposed to be going to. Any other—am I turning red again? You probably know the biases.

Female Voice: [Inaudible]

Rita Mangione-Smith: Okay [cross-talking]. Yeah, yeah. Okay, next is adolescent well-child care visits. Comments?

Female Voice: Is this just—?

Rita Mangione-Smith: New York has—New York State is on here, so they have an average of 58 percent, and the range across plans in the State is 45 to 63 percent.

Yeah, and that's at least one preventive care visit in the past year for ages 6 to 17 years old. Why is 6 in the adolescent measure though?

Female Voice: Because of the [inaudible]

Rita Mangione-Smith: Oh, okay.

Female Voice: It's what the State had.

Rita Mangione-Smith: Oh I'm sorry. That's from the [indiscernible]. It looks like the New York measure is just adolescent well-child care visit or preventive visit, and that's probably I would assume annually.

Female Voice: Yes.

Rita Mangione-Smith: Okay. Oh, somebody is shaking their head.

Female Voice: I think it looked at 2-year [cross-talking].

Rita Mangione-Smith: Two every—one visit every 2 years?

Female Voice: If we look at Bright Futures—

Female Voice: Yeah, maybe, but I think HEDIS specs are to—

Female Voice: We weren't able to drill [cross-talking].

Female Voice: Rita, I think if you look at like MEPS (Medical Expenditure Panel Survey) data, it's about 50 percent of insured adolescents have a well-child visit. About 20 or 25 percent of uninsured have one or something like that for national data. Yeah.

Rita Mangione-Smith: Okay. So our next one is comprehensive periodic oral health exams and that more specifically—okay. So this one, Jim, you can help us here. This is comprehensive or periodic oral health examination. It says D0120 and D0150, greater than 3 years old. Is that part of that cluster of measures?

Jim: That would be one of those.

Rita Mangione-Smith: That's one of them. Okay. Any comments? Okay. Moving on to asthma care medication rates.

Female Voice: This is one those where asthma care medication rates was just very brief from the Centers for Medicare & Medicaid Services (CMS) survey, so I don't know if it means the same as the HEDIS measure. There are 25 out of—20 out of 36 managed care organizations are collecting it.

Rita Mangione-Smith: Is that the exact same number that collects the next one down?

Female Voice: Twenty-seven States are reporting valid measures according to the National Committee for Quality Assurance's (NCQA) state of health care.

Female Voice: That's the appropriate medications [cross-talking].

Rita Mangione-Smith: Yeah. It sounds like the asthma care medication rates and asthma appropriate medications for people with asthma are probably the same measure. It's just that's the way it was stated and what you received from CMS.

Male Voice: You really might like to have also the medication possession ratio. It would be integral in whether they ever really had it filled again and then the relationship between rescue meds and chronic meds.

Rita Mangione-Smith: So you'd like more information on—

Male Voice: I think we should group those together and get the right metrics for the level that we want to drill down.

Rita Mangione-Smith: So the specification for the next one down the appropriate medications for people with asthma is a HEDIS spec?

Female Voice: Right. And we have that somewhere in the stack.

Female Voice: And I think the first one with the asthma care medication rates again was from our managed care area that was surveying the States, and I think it's a "SHMEDIS."

Female Voice: And Rita, this is probably the one that our group had the most problems with when we were looking at the measures to actually use, specifically dealing with the measures that we're looking at: rescue and controller use and how to define it. And we ended up with what I call really a complicated way to do it, but they put in tables and had to look for certain things. They wanted to know if how many children that had entered the emergency room or presented—had a hospitalization had the absence of a controller medication, how many used more than two short-acting meds and didn't have a controller medicine. So we ended up with a logic that was really a whole lot more complex than what we had on the national side based on the experts being involved in it.

Female Voice: So they may be different in a way the States [inaudible].

Rita Mangione-Smith: So the way the—just so people are clear. The measured description from NCQA is the percentage of members 5 years and older who are identified as having persistent asthma and who are appropriately prescribed medications, so I'm assuming all of this ED visit, hospitalization to rescues with no controller, was their way with administrative data of determining persistence. That would be my guess.

Female Voice: It was. They didn't have a way to do this [cross-talking].

Rita Mangione-Smith: Sarah, are you here? Yeah. Is that correct? Okay. So I just got the nod from the NCQA people in the audience that is what that was all about. So it doesn't—it sounds like it's really focused on controller medication prescriptions. I might propose to strike the asthma care medication rates because I don't think that's a real measure. I think that's just talking about HEDIS.

Male Voice: It would be a rate with—

Rita Mangione-Smith: But this isn't a real—I think we erroneously—

Female Voice: It's like a title.

Rita Mangione-Smith: Yeah, yeah.

Male Voice: It would be a measure though if you put medication possession ratio.

Rita Mangione-Smith: This should've been a label. Right.

Female Voice: Appropriate use of asthma medication is one of the core measures for the CHIP annual report as well, and I think most CHIP programs do report that.

Rita Mangione-Smith: Okay. Okay, so we've kind of already talked about the next one, which is asthma appropriate medications for people with asthma, and we read—

Male Voice: And just to quickly talk about the importance of that, on one of the tables on the discharges, that was the second or third down after newborn and preterm. So I mean it is a huge preventive hospitalization—preventable, sorry, hospitalization.

Rita Mangione-Smith: And we're not even looking at emergency department use.

Female Voice: Yeah.

Rita Mangione-Smith: Okay. The next one is appropriate treatment of upper respiratory infecton (URI). Any comments? Okay. Next is pharyngitis. It actually should be appropriate testing of pharyngitis. Yeah. The real measure is called appropriate testing for children with pharyngitis, percentage of children 2 to 18 years—I should have this memorized—who are diagnosed with pharyngitis, received an antibiotic, and received a group A strep test, so the denominator is kids with sore throat who got an antibiotic, and the numerator is they got a test.

Any questions, comments? Okay, antibiotic utilization.

Female Voice: This is a HEDIS—

Rita Mangione-Smith: Utilization measure, right? So it's not an effectiveness of care measure. It's defined as, "Summarizes the data on outpatient utilization of antibiotic prescriptions stratified by age and gender."

Female Voice: [Inaudible]

Rita Mangione-Smith: No. Okay. Any comments, discussion?

Male Voice: And it seems like a very nonspecific measure. I wouldn't even know how to interpret it.

Rita Mangione-Smith: Right. Okay. The next one is ADHD care initiation phase. This again is a HEDIS measure and specifically reads "Percentage of members 6 to 12 years with an ambulatory prescription dispensed for ADHD medication who had one followup visit with a practitioner with prescribing authority during the 30-day initiation phase." So you get a script, I assume for the first time, and then they look in the following 30 days to see if there's a followup visit. Any comments, discussion? Go ahead.

Male Voice: Just again on the prevalence of ADHD, a very big prevalence in the pediatric age group, not the best measure. I wish there was something about diagnosis there, but ADHD is huge, and it is the number one mental health issue in kids, and I think one of the top three chronic conditions of childhood.

Rita Mangione-Smith: George?

George Oestreich: The other concern and I don't think it's addressed on any of the criteria. What we've been looking at is the number of kids that would either be receiving psychotherapy for ADHD with no medications or the converse of that with the literature supporting a combination approach. So I'm wondering if—I don't want to spend a lot of time on this now, but should we try to hone them down that if they make it through the cut, the other issue is on ADHD meds, on depression, on what I had mentioned before, the medication possession ratio? Good literature support if you're below adherence that you've got consequences, either hospitalization or additional confounding complications. So how do we deal with that, or should we deal with it?

Rita Mangione-Smith: So it sounds like what you're talking about is there's a potential to develop a better measure around this, but right now the measures that are out there in use; these are them.

George Oestreich: One that speaks to kind of looking at the dynamics of do we use what's there or do we try to make it more meaningful and more—

Rita Mangione-Smith: If we find other measures in all of the submissions people will make between now and the 24th of August, and there's a better measure out there for this.

George Oestreich: Or just an enhancement of this?

Rita Mangione-Smith: I don't know that we can enhance existing measures because that gets into measure development, and we really can't do that as much as we'd like to. Pardon? We need things that are in use now in the private sector and the public sector.

George Oestreich: Okay. So we just put back in as being in use in our area.

Female Voice: If you think it's worse than an empty chair—

Rita Mangione-Smith: Then leave the chair empty.

Female Voice: Leave the chair—yeah.

Rita Mangione-Smith: If you don't think it's worth the trouble of collecting the measure, that's what you really have to ask yourself. If the information you're getting is not worthwhile then on this particular—on what's on the sheet because that's what you have to rank, not what you wish it was, or what you think we could make it, but what it is.

Male Voice: Okay.

Female Voice: I have a question about—and maybe Denise can answer this or Sarah. Since these are both initiation and continuation of both HEDIS measures, and I'm assuming they're both based on the ADHD guideline, whether the evidence report that supported that guideline showed any evidence for either of these processes like a visit after 30 days after initiation or the other one and if there was evidence, if it was stronger for one over the other measure?

Rita Mangione-Smith: So Sarah yesterday was telling us she would try to get us the measure workups for all of these relevant measures, and in those workups is the evidence review for the HEDIS measures, so we should be able to hopefully synthesize that information for our kind of—

Female Voice: I have a bias against a measure that's only about requiring visits, which is the first measure, but the second measure is about actually filling the meds as well as getting a visit. And getting the meds is really important in ADHD if you have the diagnosis, so.

Rita Mangione-Smith: Right.

Female Voice: I think I had a question for Javier as far as your comments. From a clinical perspective, do you like one of these measures better than the other, or would you advocate for both?

Rita Mangione-Smith: Is everybody aware of what the continuation measure is? Would you like me to read it? Okay. So it's presented, "The continuation and maintenance is percentage of members 6 to 12 years with an ambulatory prescription dispensed for ADHD medication who remained on the medication for at least 210 days and who, in addition to the visit and the initiation phase, had at least two followup visits with a practitioner within 270 days—that's 9 months—after the initiation phase ended." So two followup visits in the following 9 months.

Javier Sevilla: I think clinically, the followup is critical for ADHD. I think just like diabetes or asthma, I think close followup is probably the more important one of the two, although as I said the—and what George was saying, I think there are probably better measures out there for ADHD than these. If I had to choose, it'll be hard to—

Rita Mangione-Smith: Well, I'd like to point out that that continuation measure has "and who, in addition to the visit in the initiation phase." So this measure requires that they had the initiation phase visit. Right. So I just want to point that out. Phyllis?

Phyllis Sloyer: This is probably a question for NCQA, but because we're looking at the Medicaid and CHIP population, what kind of sample size do you end up getting with children who may not have continuity of enrollment over 210 days plus 90 after that?

Rita Mangione-Smith: Sarah?

Female Voice: I think you said we could get that this morning. I mean we couldn't get it this morning but—

Sarah Hudson Scholle: We just got it, but I can tell you that this measure does only about half of the health plans that report HEDIS to NCQA actually are able to report this measure for several reasons. One might be the continuous enrollment. The other reason is whether kids—the denominator is different from the initiation because you have to stay on it, so it's a smaller denominator of kids who stay on that long. And the other thing is the child has to have the benefit for both behavioral health and pharmacy, so those contribute to not having that benefit, and the health plan contributes to smaller denominator. That probably is less of a problem if you're looking at a State reporting, but we can get you information on that denominator size if you're interested.

Female Voice: Can I—may I ask a question?

Rita Mangione-Smith: Yes, Doreen?

Doreen Cavanagh: Sarah, I'm also wondering are you finding that—What we've discussed for a long time is that the mental health measures are flat. We're not seeing any change. Are you seeing change in these measures?

Sarah Hudson Scholle: I can tell you the performance rate in this measure is low. It's around 40 percent of children. That's the median performance, so on average 40 percent of children in the denominator actually do it. I have the data on [cross-talking].

Rita Mangione-Smith: We actually have the rate here. The overall rate nationwide was 38.9 percent for the continuation phase, and for the initiation phase nationwide, it was 33.5 percent. The high was in the Northeast at 57 percent. The bottom was in the Middle Atlantic at 26 percent. Non-publicly reporting plans do better by 6.3 percentage points than publicly reporting plans.

Doreen Cavanagh: That wasn't really my point though.

Rita Mangione-Smith: That's counter-intuitive.

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