July 23, 2009: Afternoon Session (continued)

Doreen Cavanagh: My point was that we're not seeing change over time in these measures, and this has been studied for several years, all the mental health measures.

Female Voice: So getting to importance then, if we're not seeing any changes, that means it goes out, or that means it stays in, and more effort should be made? I mean what—how would you think about that?

Female Voice: You have your expert, Len Bickman, and I think he's still in the audience.

Female Voice: But I think also you—the fact of shedding sunshine on these measures, yes we have these numbers in front of us. How many people nationally actually know these numbers and know they're not moving? And how many parents know this? The transparency and accountability for kids not getting appropriate ADHD care I think can move the system.

Rita Mangione-Smith: Yeah. Sarah, has there been no movement on these measures?

Sarah Hudson Scholle: Actually, the mean has risen from 2005—let's see. The initiation measure went from 31 percent to 33 percent, but the 95th percentile went up from 49 to 59, so some people are able to move it. This really has to do—but Doreen is perfectly right, we do not see them, and we have kind of a flat line on our average performance on all the behavioral health measures. To me, that is—likely indicates just a division in how our health care system is set up and the lack of communication across behavioral health. So that's sort of a place to move.

Rita Mangione-Smith: CaroLynn?

CaroLynn Clancy: Sarah, maybe you can answer this. I can't remember, but with the ADHD measure, does that only measure a followup visit with a behavioral health professional? Because—

Sarah Hudson Scholle: It's the prescribing med—it's the prescriber.

CaroLynn Clancy: It's the prescriber who could be a behavioral health professional and, unfortunately, we're not collecting potentially the pediatrician or primary care provider for that child of maybe doing a followup.

Sarah Hudson Scholle: I believe it's a prescriber. We can check out the specs of—yeah. So that's, obviously, I'm sure that was a discussion our measurement advisory panel had and maybe—Charlie is gone. Maybe he'd remember, but we have lots and lots of conversations about who should be counted and how those visits should count, so.

CaroLynn Clancy: That was one of the issues in our State when our State program wanted to look at this and realized—if they still look at it, but they don't put a lot of stock in this particular measure because we have such a shortage of behavioral health providers that oftentimes the prescribers are—the psychiatrist, if you will, and then after that, the care is provided by the pediatrician or the primary care and—

Female Voice: No, thank you.

CaroLynn Clancy: So it's not a real accurate reflection of the followup care that's given to these kids.

Rita Mangione-Smith: Okay. Doreen?

Doreen Cavanagh: I was just wondering if Len had a comment.

Rita Mangione-Smith: There he is.

Len Bickman: One of the biases that creep into everything here is it privileges medical drug treatment over anything else. I think that's something we should be very careful about because it's easier to track against one of those things that is easy to measure, [indiscernible] under the light, we get to measure this. The second thing is, and of course, this is probably the most detailed of all the ones that you've dealt with and it actually causes us more problems because it's not quite detailed enough, I would make the case. So a checkup or a visit is not a visit. We know that. And so is the titration done correctly?

So, just showing up for a checkup is not probably a sufficient measure of quality in some ways. It would need to be more detailed which is very problematic at this level of thinking, but if we get down to the ground level, it has to be at that level. Of course, one of the other ways of dealing with this is to be able to track child progress in ADHD, so you get out of this treatment mess and say, "Is the kid getting better?" That would be my preference actually.

Rita Mangione-Smith: There's a lot of [inaudible]. Cathy? Oh, you're not, okay. Paul Miles was up first. Paul and then Paul.

Paul Miles: Okay. We, meaning the Board of Pediatrics, are in the process of right now in production of an ADHD Web-based module for maintenance certification that requires followup when medications—or when medication is not prescribed using the Vanderbilt, so it's a standardized followup that will be available for general pediatricians and for some specialists who want to use it as well. That should be available within the next 2 months, and it will be one of the options for getting credit for maintenance certification using these measures. And it's based on a very successful published quality improvement project right out of Cincinnati. We developed it with Philip Stein [phonetic] where they actually had not only process but outcomes in terms of decreased scores or improved scores on the Vanderbilt for kids who are treated and followed up appropriately.

Rita Mangione-Smith: Okay. Paul?

Paul Melinkovich: This goes for both the ADHD as well as the mental health measures. But if you look at who most commonly prescribes medication treatment for ADHD or medications for depression, it's primary care practitioners. It's pediatricians and family practitioners. It's probably one of the most common prescriptions outside of—chronic prescriptions that are given to kids. It's probably one of the—these are some of the most significant illnesses that kids have, and it's probably done more poorly than anything else. So I think it's really important to keep in mind that even though this is not a perfect measure, and it doesn't talk about the content of what happens in followup visits, just making sure that kids get a followup visit when they're given one of these medications is exceedingly important. So I argue that it's an important part of what's happening to kids out there that we have very little information about.

Rita Mangione-Smith: Any other? Oh, Paul again.

Paul Miles: Just really quick. The Vanderbilt actually requires screening for comorbidities, which means screening for bipolar core depression, and it's part of how you make the appropriate diagnosis of ADHD. So I think it has some indirect effect on the rest of the mental health issues.

Rita Mangione-Smith: Okay. I'll move us on to our next one, which is followup after hospitalization for mental illness. And do we have specs on this one? It says, "Followup after hospitalization for mental illness data for ages 6 plus."

Female Voice: It's not reported separately for children, for kids.

Rita Mangione-Smith: Oh, it's not reported separately for kids.

Female Voice: And which one are we considering? It looks like there are 2 days, 7 days, and 30 days.

Rita Mangione-Smith: Yeah—7 days and 30 days, data on variation available did not include because not specific to children. Okay.

Female Voice: Maybe Sarah [inaudible].

Rita Mangione-Smith: Let's see. Well, if it's a HEDIS [Health Plan Employer Data and Information Set] measure, I can look at the thing, description. [Cross-talking]

Female Voice: Sick children are included. We just know [cross-talking].

Female Voice: Now, who's the followup with? Is it anybody, or is it a mental health professional?

Rita Mangione-Smith: It says mental—let's see. "The percentage of discharge for members 6 years and older who are hospitalized for treatment of selected mental health disorders and who had an outpatient visit and intensive outpatient encounter or partial hospitalization with a mental health practitioner."

Female Voice: It's going to be mental health, so primary care doesn't count.

Rita Mangione-Smith: Pardon?

Female Voice: Primary care does not count.

Rita Mangione-Smith: Doesn't count, okay. And does it ever get reported out separately for children?

Female Voice: We don't report it out separately. The denominators are small.

Rita Mangione-Smith: So if it were to become part of our core measurement set and—

Female Voice: [Inaudible] okay.

Rita Mangione-Smith:—State Medicaid programs and CHIP programs started reporting it, would it then be reported out separately for children or no?

Female Voice: I think we could go back and ask for it to be reported separately. Yeah, it's just a different reporting mechanism, so I think that would be the kind of change that would be fairly simple to make.

Rita Mangione-Smith: Okay. But I think it's probably important to this group to know that it would be teased out separately. Okay. Paul?

Paul Melinkovich: I mean again from the—if you look at impact on kids' life, well-being and ultimate productivity, I mean these are the kids that get lost and repeatedly are hospitalized and never get ongoing care in a mental health setting. Now, there may be issues around access, but I'm just thinking about importance. I think it's important to keep that in mind.

Rita Mangione-Smith: Paul Miles, do you have something you wanted to say?

Paul Miles: No.

Rita Mangione-Smith: Okay, Cathy?

Female Voice: I agree with Paul. From the data that we've seen, the readmission rate following a mental health inpatient stay for a child—that having these followup visits hugely affects the readmission rate. So I think it's important, very important from that perspective.

Rita Mangione-Smith: Len?

Len Bickman: You take your pick. So far, we could find two empirical studies on those that followup leads to readmission which, take your pick whether readmission is good or bad, but one said—at least one more readmission, the other one says at least one less readmission, so I don't know what the experience is in Alabama, but that's what the literature has so far.

Rita Mangione-Smith: Other comments? Okay. So, our next one is depression management. There's a question mark next to this about whether—was this from the the Centers for Medicare & Medicaid Services (CMS) survey? Okay. So whether it applied to kids or not, do you know, Barbara? You don't, okay. "Had MDD, Major Depression Diagnosis, in the last 12 months and received treatment for depression in the last 12." No, we're thinking this is kids.

Female Voice: It sounds like it's the HEDIS depression measure, which is only for adults. Anti-depressive medication management measure is for adults and at the time—so—

Rita Mangione-Smith: So we should cross that off of our list, please.

Female Voice: If there's—

Female Voice: You might want to look at the specs for NHSDA (National Household Survey on Drug Abuse) before you scratch that one off. It's the huge survey that has been done for like the last 20 or 30 years.

Rita Mangione-Smith: So you know what? I think it's the next one down that we were supposed to cross off—the anti-depression medication management one—but the depression management one maybe we should not be crossing off.

Female Voice: Yeah, [cross-talking] that also has a question mark for kids.

Female Voice: And the quality data of that [cross-talking].

Rita Mangione-Smith: Yeah, both of them do. They both have NHSDA and—

Female Voice: I mean that NHSDA has a sampling frame that lets you get down to regions within States. It doesn't break things out I don't believe by payer insurance or anything but it might be the kind of—since it has been going on forever and presumably will continue to go on forever, it might be the sort of thing that could be recommended to the Secretary that the sampling frame be augmented in some way to get down to even smaller areas or supplemental questions. I mean there's a lot that could be done with NHSDA because it isn't going away as a national survey.

Female Voice: Well, we do actually have the data from this study. It's children who [inaudible] who had a major depressive disorder in the last year and got treatment; it's about 30 percent. We have to go back and look [inaudible].

Female Voice: Major depressive disorder is the big DSM category.

Female Voice: Yeah, right.

Female Voice: So this could be just a small number of kids.

Female Voice: But it would be nice to know what the treatment means.

Rita Mangione-Smith: No, because people already voted it to be valid and feasible, not knowing how it's measured, I'll add. Sorry, it's a learning curve, right?

Female Voice: I put it on the list not knowing whether it had anything to do with kids or not.

Rita Mangione-Smith: Okay. Guilty as charged. Doreen?

Doreen Cavanagh: Does NHSDA—would the NHSDA data be able to separate out children who are just in Medicaid and CHIP?

Female Voice: I don't know the answer to that, but isn't SAMHSA (Substance Abuse and Mental Health Services Administration) one of the—?

Female Voice: Federal workgroup [sounds like].

Female Voice: Yeah. Why not just ask whoever that liaison person is? Because there are specs out there for the NHSDA. It has been—

Female Voice: Well, I'm pretty familiar with NHSDA, and I don't think that it does—would not be able to report out only for certain payers versus—as far as I know.

Female Voice: I think I—yeah. I think that's right, but didn't we say we were still interested in things that were just in use by Medicaid and CHIP?

Rita Mangione-Smith: Yes.

Female Voice: Yes, but there is this line between the abuse and usable line, assuming that [inaudible]—assuming—and we have to go back and talk to CMS and maybe Congress. In the State, in the annual report to Congress, will Congress want Medicaid and CHIP programs and/or the State to be reporting on some items that you can break out by Medicaid? But Medicaid may not be able to attribute to particular plans or claims.

And I think the pediatric quality measures that were discussed here are a perfect example as possible measures because that's—the way that's collected is expected payer. So it depends on who is going to be held accountable because the Medicaid plans may say, "Well, this is just expected payer. That doesn't mean that we actually paid for this person." So there are a lot of issues to be worked out about what is in use or broken or usable by—what does that mean? Does that make any sense?

Rita Mangione-Smith: Okay. I'm going to move us along. The next one is another one of our dental measures. "Receipt of topical fluoride or sealant application among members enrolled for at least 11 of the past 12 months with one-plus fillings in the past year." Jim, can you comment on—?

Jim: The commonly collected measure is one of the four that I would [cross-talking].

Rita Mangione-Smith: And do you have any opinions about it?

Jim: I think it would yield some pretty dirty data and some pushback from States to even figure out how to run the research.

Female Voice: But I think this is one that's actually recommended by the U.S. Preventative Services Task Force [cross-talking].

Rita Mangione-Smith: Is there a procedure code for getting a filling?

Male Voice: Sure.

Rita Mangione-Smith: So probably from admin data, Marlene, you probably just look for kids who had the enrolment—met the enrollment criteria and had CPTs (Current Procedure Terminology codes) for fillings.

Male Voice: The rationale for the measure is, okay, so now you by virtue of assuming that the fact that the kid got a filling, he had actual disease and needed treatment, then you are looking to see whether or not somebody has taken a preventive action once you recognize that the kid's got an actual disease.

Female Voice: Right. I understand that, but I think the recommendation is actually that all children should be getting this regardless of one filling or not, so it's disconnected from Preventative Services' recommendations to me. That's all I'm saying.

Female Voice: Sort of a weird combination. I mean sealant and fluoride treatment are recommended for everybody, so why [indiscernible]? It just seemed a weird combination.

Female Voice: An expert on what the U.S. Preventive Services Task Force actually said since she is a medical officer working with that Task Force.

Female Voice: Hi. Yes, just to clarify. So what the Task Force recommendation deals with as far as the "B" recommendation is recommending that primary care clinicians prescribe oral fluoride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source is deficient in fluoride. And just for point of information, it was the "I" statement about routine risk assessment of preschool children by primary care physicians.

Rita Mangione-Smith: No? Okay. So I'm going to move us along.

Male Voice: Comment?

Rita Mangione-Smith: Oh, I'm sorry. Go ahead.

Male Voice: I still think we're confusing feasibility and validity and importance.

Rita Mangione-Smith: It's really hard because we've been talking about all of them a lot.

Male Voice: Because if you think about importance for children, fluoride varnishes and sealant applications are exceedingly important so [cross-talking].

Rita Mangione-Smith: Well, we clearly all go on down to this measure. I mean it passed, and we all thought it was valid and feasible.

Female Voice: I don't think that my concern is that. It somehow implies to States that it only matters if you have one filling, which is in direct contrast to what the actual recommendations are. That's my problem.

Male Voice: Yeah, it's sort of secondary prevention instead of primary prevention.

Rita Mangione-Smith: Yeah, this is a secondary prevention measure. This is saying you already have kids who've got problems, and they should get fluoride varnish rather than saying kids should get fluoride.

Male Voice: And you've already got another measure that looks at whether they're getting prevention as either primary, secondary, or whatever.

Rita Mangione-Smith: Okay.

Female Voice: There's also another population-based measure that's being reported through HRSA for fluoride and sealants, and it's on all children. So there's a population-based measure for this.

Female Voice: All children?

Female Voice: Yes.

Rita Mangione-Smith: Okay. Hearing services for individuals is the next one.

Female Voice: This is a question mark because we didn't know what the label in the survey done with the States meant.

Female Voice: So this is not like the AAP recommendation for routine hearing screens?

Rita Mangione-Smith: We don't know what this is. This was just from the CMS survey asking, what measures are you doing?

Female Voice: I think you're also going to get some under-reporting because so much of these services, the next two are thinking a lot of those services are provided in schools, and you wouldn't be counting them.

Rita Mangione-Smith: Okay. I want to remind everybody we're talking about importance here, okay, so those criteria that we all agreed on. These can get dropped in September if we decide that for other reasons after we go looking for better specs and better information and everything, we'll have all that for you; that's in September. So we can look a little bit—

Female Voice: So we're supposed to assume the interpretation here and rank that importance?

Rita Mangione-Smith: Pardon?

Female Voice: We're supposed to assume what we think this measure is?

Rita Mangione-Smith: Well, that's what we did when we did the Delphi, right? Okay? We dealt with the amount of information we were provided, so.

Male Voice: So not to belabor it, but let's say you find more information in the interim, and let's say that information is not—

Rita Mangione-Smith: Very supportive?

Male Voice:—a recognized guideline but that it would facilitate the clarification and gathering of the information you thought important for that criteria, what would you do?

Rita Mangione-Smith: I think it's more of what would we do with it, yeah. We'll provide any information we can get to the group.

Male Voice: But could we include it is what I'm saying? Do we have to stay with something that's—how far out does it have to be validated? Does it have to be one State with specificity or multiple States or—?

Rita Mangione-Smith: Some of these validation studies for some of the measures have been done in one population and may not apply to all populations, so—

Male Voice: But it's a value judgment we then make [cross-talking].

Rita Mangione-Smith: That's exactly right. You have to look at what the evidence is and make a value judgment.

Male Voice: Okay. Just trying to make sure I'm staying with the process.

Rita Mangione-Smith: You are. You're on it.

Female Voice: The only evidence we provided in the scoring sheet was about the two U.S Preventive Services Task Force screening recommendations.

Rita Mangione-Smith: And I—that was not specifically about infant screening. Is that correct?

Female Voice: Actually, the hearing screening is newborn hearing screening.

Rita Mangione-Smith: Okay, and what about the vision?

Female Voice: The vision was screening to detect certain disorders, younger—and children younger than age 5.

Rita Mangione-Smith: So they are supported by—doing those are supported. The problem is, we didn't have specifications to give you to tell you exactly what these measures were targeting. We hope we'll get those specifications between now and August 24th. Okay?

Female Voice: A point on the newborn hearing screening, and I'm not quite sure about vision screening at age 3, but again, newborn hearing screening is a population-based universal, reportable figure. It's on the Web, so it's captured.

Female Voice: Right. I mean that's the other—this is another case where most of the screening for newborns is done in the hospital. It's part of the hospital stay before the baby leaves, so you're not going to even—it's a universal thing, you're right, in almost every State, and so you're not going to even see it done by the plans.

Rita Mangione-Smith: Okay, all right. The next one is percent of beneficiaries with at least one dental visit annually. Okay, so it is not among that recommended cluster that you were talking to us about.

Female Voice: I don't know anybody who is collecting. I mean it's pretty hard to imagine how you get a service without having a visit, so it should map pretty closely. It's possible.

Rita Mangione-Smith: Okay. Then the receipt of treatment for caries or caries preventive procedure among members enrolled at least 11 of the past 12 months. That is not part of the CM-416.

Male Voice: That is not.

Rita Mangione-Smith: It is not.

Female Voice: It's reportedly being collected by California is what the information [inaudible].

Rita Mangione-Smith: Okay. On to the HEDIS-CAHPS® [Health Plan Employer Data and Information Set-Consumer Assessment of Healthcare Providers & Systems] survey measures, first for children without chronic conditions. So as you know, that's a whole series of measures where they do an overall assessment of a child's personal doctors, specialists, health care, and health plan. Those are the overall global measures, and then there are the composites: getting needed care composite; getting care quickly composite; composite on communication, which is how well the doctor communicates; and the health plan information and customer service composite.

Female Voice: So since CAHPS® is required, but it doesn't what say what parts of CAHPS. We're kind of more voting in the construct of what parts do we think are the most important parts of CAHPS® to report on. Is that what we're doing?

Rita Mangione-Smith: In this case, we decided we should just kind of globally say do we think this is an important set of measures for kids with chronic illness and without chronic illness. So that's why we only gave you one line for importance.

Female Voice: Got you.

Rita Mangione-Smith: We didn't really want to break it out piece by piece.

Female Voice: Well, there are multiple composites.

Rita Mangione-Smith: There are. There are.

Female Voice: So there are three levels.

Rita Mangione-Smith: Right. And if you would prefer to rank the composites separately, we could, as a group, decide to do that for their importance. I mean if people feel strongly about having the chance to individually look at the composites and rank their importance rather than the whole group of measures, we can do that.

Female Voice: Well, how realistic is it that the States would be collecting part of the whole survey rather than—? I mean, yes, but they might not have to create all the composites and report them. So it's just, you know, I mean just because they have the data, it doesn't mean they're going to report it in the [inaudible].

Female Voice: And I think the other question because it hasn't been determined yet in terms of what will be included in the annual reporting process where it will be required, and that hasn't been determined to what extent that's going to happen yet.

Female Voice: So I guess that leads me to the question, Barbara, of what's most useful to you? Do you want us to score the composites or just say score overall CAHPS?

Barbara Dailey: Well, what would be most useful would be the individual, but I don't know for the purposes of this subcommittee and your need, I don't know if [cross-talking].

Rita Mangione-Smith: Well, I mean if we all feel that certain composites are much more important than others, then maybe we should come forward and say that. That's really up to the group. You guys have to discuss it, and then we have to decide.

Female Voice: Well, the reality is as Barbara just said that the annual reports, CMS will be making decisions about what parts of CAHPS, how to report the CAHPS® information in the annual report.

Rita Mangione-Smith: And I would imagine if we, as this group, recommend certain composites, and we don't recommend others, that may influence what gets decided.

Female Voice: Yeah.

Female Voice: Are we doing another importance round, right? So you could—

Rita Mangione-Smith: In September.

Female Voice:—return to the separate lines. If we just did it now with the two—

Rita Mangione-Smith: Big ones and then break it out for the next time?

Female Voice: And then send the composites for the next round.

Female Voice: And I can add our CHIPRA teams know that that's the plan for September.

Rita Mangione-Smith: Okay. So for now, we'll just do it as a single line with the idea that we'll have a chance to have a second go at it in a more detailed way in September. Paul? I'm sorry. Javier?

Javier Sevilla: I just wanted to again speak for the importance of the CAHPS. One of the six IOM attributes of quality is patient-centered care, and we have to somewhere here capture that, capture the experience of care. I think CAHPS® is not perfect, but it definitely does give you a good idea. So I think it is important.

Rita Mangione-Smith: And do keep in mind, too, that as a group, I heard very strong opinions yesterday about the CAHPS® items that now are currently only collected on children with chronic conditions or special health care needs that those be generalized to a broader—some of those at least be generalized to a broader population, the full population of children. So I think that's another thing that maybe we as a group—Denise, the next time—don't stratify them this way, just put them all—

Denise Dougherty: Well, but that's not a practical way to do it because—I mean we could just say somewhere we want the children with chronic conditions measure collected for all children, but if we group them together, it mixes them up.

Rita Mangione-Smith: Okay. As long as we [cross-talking].

Denise Dougherty: I mean it just wouldn't be the measure.

Rita Mangione-Smith: As long as we can say that in our report or—

Denise Dougherty: Oh yeah, sure. I heard that loud and clear. And in fact, the children with chronic conditions subgroup really varies by State. It's amazing, so it's not comparable anyways.

Rita Mangione-Smith: Paul?

Paul Miles: The American Board of Medical Specialties has adopted CAHPS® as a requirement for physicians as part of the main certification for a physician communication involving patients' decisionmaking, so 600,000 physicians over the next 6 to 10 years will have to do a CAHPS® survey as part of the main certification, but there's talk about doing core counts [sounds like] of 6 to 10 questions out of the 40-some because the cost and the time involvement in—we've talked to Paul Cleary and the crew. They think that's valid to pull out components of this. So I think, overall, CAHPS® is good, and then I think look at this idea of which ones we think are maybe more important and would have some relevance.

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