July 23, 2009: Afternoon Session (continued)

Male Voice: The one comment I'll make is speaking on the other side, working with kids with disabilities, is that I think a number of these are important components and should be measured. I think that there are some of the CAHPS® [Consumer Assessment of Healthcare Providers & Systems] items that are very difficult to tease out, particularly the items related to getting needed care measures. While they may be important, measuring those as a component of care through vis-à-vis or physicians is also impacted by the program, and families might not be aware that they're not getting therapy even though their physician's office has tried to get therapy.

Rita Mangione-Smith: Right. So this is an attribution issue.

Male Voice: Correct.

Rita Mangione-Smith: Where is the system breaking down?

Male Voice: Correct.

Denise Dougherty: And maybe Sarah can help us know whether that's a question at the plan level or at the individual provider level for the CAHPS®, getting needed care.

Rita Mangione-Smith: The composites, those are at the plan level, aren't they? The CAHPS® composites—

Sarah Hudson Scholle: There are several CAHPS® composites, and the composites, the clinician, group CAHPS® survey, and the health plan survey have analogous measures that getting needed care and the getting care quickly composites are similar at the—

Rita Mangione-Smith: Item one?

Sarah Hudson Scholle: But for the plan and for the clinician groups level, the communication composite is also the same. We've tried to be very careful about aligning those but they are—they're not specific to the type of care. So to your point, that is true. It's just—I think it asks about [indiscernible] care, what—urgently or something, but emergency care, but it doesn't talk about the kinds of care that people with disabilities might be needing.

Female Voice: [Inaudible]

Sarah Hudson Scholle: Okay. There may be something in the chronic conditions version that gets at that. It's not in the Clinician and group.

Rita Mangione-Smith: So there's no way to sort out, like if the physician made a referral, and then the referral can't happen for XY or Z reason, so attribution is not—you can't really figure it out.

Denise Dougherty: Just to get to the—the question is thinking about all your health care over the past year or thinking about your visits with your provider, what's the item?

Sarah Hudson Scholle: So for the health plan, it's broader. It's a broad question. For the clinician group, it'd be different because it's asking about your experiences with your personal doctor in the clinician group, so.

Denise Dougherty: So is HEDIS [Health Plan Employer Data and Information Set] collecting both the group and clinician one?

Sarah Hudson Scholle: No.

Denise Dougherty: No, this is the health plan.

Sarah Hudson Scholle: HEDIS is health plan.

Denise Dougherty: So this is not about individual physicians.

Rita Mangione-Smith: Okay. Two more you guys. Hang in there. All right, availability of services, access to primary care practitioners by age and total.

Female Voice: How is it defined? Where? Access, but how's access defined? Is it a [cross-talking] what are the stage [cross-talking]

Rita Mangione-Smith: Oh, yeah, so these are not use of services, right?

Female Voice: It is use of services.

Rita Mangione-Smith: It is use of services. So which one—is it ambulatory?

Denise Dougherty: The access to primary care practitioners—the percentage of members, 12 months to 19 years of age, who had a visit with a primary care practitioner. That's the measurement, and then it's broken out by 12 to 24 months or something like that. We have it.

Female Voice: We know [inaudible] visit to primary care [cross-talking]

Female Voice:—within what time frame?

Rita Mangione-Smith: It would be the last year, wouldn't it, Sarah? Yes, she's nodding. Yes. I'm so glad Sarah's here.

Female Voice: Isn't this a little bit in contrast, though, to the adolescent well-child care visits, though they're every 2 years?

Female Voice: This is different.

Rita Mangione-Smith: Yes, this is just looking at access, so any visit, so do you—?

Female Voice: They're well-child visits.

Rita Mangione-Smith: It's just a marker for you do have access to care.

Female Voice: No, but if you're well, you're going to go once every 2 years.

Sarah Hudson Scholle: Actually, the well-care visits, we looked at the specs in the well-care, the adolescent well-care is 1 year. It does look at what the year. And the difference between the primary care visits spec and the well-child visits spec is that the well-child visit—it's actually very similar on the admin and the admin scoring. The same codes will count for both, but for the well-child visit, if you do—you can do the hybrid option. Go to the chart and you have to document that the well-child things happened at the visit.

Rita Mangione-Smith: This is, yeah, this is an access to care measure. [Group cross-talking] Cathy.

Cathy Hess: Sarah, but for the well-child it also would be looking—in claims data—it's going to be looking only for those well-child visit codes correctly and the other one would just be looking at any visit to a primary care practitioner.

Sarah Hudson Scholle: But some of the same—most of the same codes are in the spec. They're very close.

Cathy Hess: Okay. And I can understand [cross-talking]

Sarah Hudson Scholle: Our policy people have recommended that they're—say they're very close. They're essentially similar.

Cathy Hess: But wouldn't the well-child be a little bit more narrowly defined though than the primary care one? In our numbers for the primary care, one we get a much greater percent than well, and so it is useful from a State perspective because it casts a broader net, and it gets us beyond some of those specific coding issues.

Sarah Hudson Scholle: It gets to some of the sicker visits.

Cathy Hess: Pardon me?

Sarah Hudson Scholle: It gets you to sick visits and well visits—

Cathy Hess: Yes.

Sarah Hudson Scholle:—and primary care.

Rita Mangione-Smith: Xavier?

Xavier Sevilla: Yeah, I just wanted to speak about this particular measure. I mean just to have a visit for—having a visit I don't think really addresses any of the importance criteria. I think we're really looking at well-child, check somewhere else where we are looking at a visit for a purpose. This really—people could be coming in for a cold or anything like that for just urgent things and never going to preventive care, and this would still count there, so I don't think this measure's very important.

Rita Mangione-Smith: Lynnn?

Lynnn Olson: I may be losing brainpower at this point, but I'm confused. These last two, how are they different in terms of how they're operationalized?

Rita Mangione-Smith: So, I think one thing that's important to keep in mind with the HEDIS measures, some are of effectiveness of care measures, some are utilization measures, and some are access measures. So this one that we're looking at now is an access measure, where I believe—isn't well-child care visits under effectiveness of care?

Female Voice: Well, it's not [inaudible].

Lynnn Olson: It is not?

Female Voice: It's not.

Rita Mangione-Smith: It's not, okay. So it's considered an access availability of care measure, so they are both access to care measures. The ambulatory care measure is a use of services measure and it's described as: summarizes utilization of ambulatory care for outpatient visits, ED visits, ambulatory surgery procedures, observation room stays, so it's a utilization measure.

Lynn Olson: So it could be an office visit, or it could it be an ED [cross-talking]

Rita Mangione-Smith:—ED, hospitalization, surgery—

Female Voice: And that's the ambulatory one?

Rita Mangione-Smith: I'm sorry, not inpatient. It's outpatient ED visits, ambulatory surgery and procedures and observation room stay, so any ambulatory service—outpatient service.

Female Voice: Will that count as [inaudible]?

Rita Mangione-Smith: Yup, utilization, right. Xavier, did you have—no? Tim, did you—no? Mary?

Mary McIntyre: I just wanted to ask, is there anywhere any kind of—and this goes I think more to looking at what measures and whether there's something that exists like the children that have chronic problems as far as access to care availability.

Female Voice: That was going to be [cross-talking].

Mary McIntyre: Because that's one of the things I think that we really—that's one of the things we've been trying to struggle with to try to get the information that we have children with problems. In the end, just like we're pooling the information with the diabetes and the asthma, identifying kids who we see that haven't been in for a visit, so that the focus became to try to at least establish—to get them in twice a year or something for care because they had documented problems. So is there anything on a national side—and this I guess goes to identification of additional measures beneath. If we're looking at access, then maybe we need to try to find something that's going to identify those kids that would actually really benefit from having those additional services or visits.

Female Voice: Yeah. I think the MEPS will have that because they've asked people if they had a visit and then it can—MEPS is the AHRQ's Medical Expenditure Panel Survey. So this is nationally representative data on—it can be, "Did you have a visit in the last year?" There are various descriptions of what a visit is, and then the information can be categorized by whether the child has a special health care need or not.

I don't know—I know that CAHPS® measures actually have to start out with, "Did you have a visit?" If you didn't have a visit then the rest of the questions don't get addressed is my understanding. Is that right, Sarah?

Sarah Hudson-Scholle: Perhaps, actually, it doesn't require that you have a visit for CAHPS® generally, okay? It's for eligible members. The CAHPS® for children with chronic conditions does have an entry of—that requires that you have a diagnosis, and then there's a confirmation in the survey. So you should be able to create the measure that Mary wants by using the children with chronic conditions definition from the CAHPS® that we use to identify the sample for the CAHPS® and then applying one of the access to primary care measures, of the well-child visit measures to that denominator. But right now, we don't report data that way.

Rita Mangione-Smith: But it sounds like you have all that data that [cross-talking]

Sarah Hudson-Scholle: That would be a spec that would be easy to write based on the existing denominator and numerator data, but right now those data aren't separated out that way.

Rita Mangione-Smith: I think we're done talking about these—oops, we're not? Phyllis?

Phyllis Sloyer: I guess I thought availability, and I got a little bit confused. Equal capacity, is there anywhere—and I thought the legislation talked about capacity because you're not going to get—obviously, you're not even going to have a use measure if you don't have the capacity in the system.

Denise Dougherty: Okay. This is a labelling issue that—the National Committee for Quality Assurance (NCQA) was wonderful, just as Sarah has been today and yesterday, giving us information. So they labelled their utilization measures as availability. They said "access/availability" and that's so—and that's the closest we have now to availability. So it's—

Male Voice: So this is sort of one of these "a-ha" moments for me that I came 5 hours later than everyone else had it. But on the scale of cost and burden, analyzing existing population-based surveys is a whole lot easier than chart review by a few orders of magnitude and—

Female Voice:—or service.

Male Voice: Right. And so I am wondering, having again missed yesterday, but thinking about in some of the undeveloped areas like duration of coverage, we—you need some administrative data. It would be great to have administrative data. You could do something like that with population data that we talked about.

Similarly, I think on capacity and availability of services, there are measures of provider participation. And some of our national surveys, we know with appropriate analytic overlay can be disaggregated by a coverage type with reasonably high levels of accuracy, and it moves us in a completely different model than a plan-based—but it also fills in a gap, which is that not everything is plan-based.

So I don't know where this fits in, but it seems to me, if we're talking about core measures that really go way beyond what we're used to measuring at plan level, a more focused effort to figure out what could be drawn from the already existing. And we've done it in a couple of places, but it just seems like we ought to expand that line of inquiry given timelines and resources.

Denise Dougherty: Yeah. And part of the report that you're going give us, your organization, is on what the Medicaid directors perceive as the availability or lack of availability. Then I will have you talk to Karen Kuhlthau who's going to look for more availability measures. And so it sounds like you know some things and—about their validity, so that would be very helpful.

Rita Mangione-Smith: Yes?

Male Voice: I don't know how broadly the investigation is going to be, but I know that at least in the area of dental services, the General Accounting Office (GAO) has also been charged to look into availability, capacity, and things like that. So I don't know how broad the charge is, but they've contacted me about the first part of it—the dental.

Rita Mangione-Smith: So I'm going to ask you what our school teachers all asked us to do, which is to put your name on the top of your paper please, because if you're interested in the next round in knowing what your scores were this round, if you don't give us your names, we can't do that, okay? And then, before—if you're willing to sit down and do your scoring now, that'll be wonderful because our person who can tabulate all the data has to leave in a while, and we'd like to get it done before.

Thank you to the four people who have written down evaluation-type comments. We would love to get input from all of you on how this went, so send them to Denise and Padmini. Okay, so for the last bit of time we have together, one of the things that we wanted to do because a lot of questions have come up about what is the role of this group after we meet in September and—so we'll share that with you to start out, and I'm going to let Jeff do that.

Jeffrey Schiff: Okay, we're done with that. No. I think we were just talking about that. I think this is—remember, we're advisory, this group will make the recommendations, and I think, actually, our work will pretty much be officially done after our meeting in September, so most of our work—and I think there's—I think we obviously have identified is there's a ton of it, will need to be done between now and September. Because I suspect in September we will—these conversations we've had about importance and inclusion will become intense.

But I think that it will—I think it will be because that's actually where this will then get done, turned over to staff to write up the recommendations from our work, so just to be clear. I think what we're asking a little bit of Barb and Denise was: What's the internal process after this? And I guess they said a couple of things. One, is the NAC doesn't meet again until November, so even though this is officially a recommendation to the NAC, and it will be—it will really be up to—

Denise Dougherty: After that, we are taking all these things that you have wonderfully done here and quickly writing a draft report to the Secretary that will have to go through AHRQ and the Centers for Medicare & Medicaid Services (CMS) and all that kind of stuff. But after we send something to the Secretary or through the clearance process, we really can't send it to all of you. But we may be asking you -- during the clearance process, a whole bunch of agencies get to ask questions, maybe suggest more measures. So we may be calling on you for additional help with some things.

Rita Mangione-Smith: So when are you sending it in to clearance? I think that's a bit of a mystery. Is that happening [cross-talking]

Denise Dougherty: As soon as possible after September 18th, because Congress set a deadline, and it can take awhile to go through clearance in the department—we have mentioned through CMS.

Female Voice: Yeah. There are several different types of clearance processes, one for AHRQ, one for CMS, and then with the multiagency clearance process. We're going to need at least 60 days. And then if the Secretary wants changes, it'll have to go back again. So we need to allow for that in the timeline in order for this to be published. So we're targeting to have a final decision by the Secretary by the beginning of December with holidays. So, as Denise said, we need to get it in clearance as soon as possible.

Female Voice: This is thinking way down the road, but is there any possibility that before you go public with it but after it's gone through clearance and all ready to go, that you could make available to members of this group an embargoed copy? So that some of the people sitting around the room could be ready to comment to the press, to their State folks, and so on favourably, hopefully, about what this is—what this all means.

Denise Dougherty: It's going to depend on the newsworthiness of this and—but we'd have to work that out with Public Affairs and [cross-talking]

Marina Weiss: I was going to say we should go through the Office of the General Counsel (OGC), too. Because this is work of the subcommittee, I just need to confirm legally what we're allowed to share once it gets into the clearance process.

Denise Dougherty: But when you're advisory to the NAC, which is advisory to CaroLynn, so the work product that comes out will not be a product of this subcommittee. But your enthusiasm about it, so we need to—that's a great suggestion, Marina. I think we need to work that out, especially if the Secretary wants to make a big deal out of, "Look at this. We have an initial core set, and we want public comments," and that kind of thing, so I think that would be helpful.

Female Voice: My question's about the dozen or so papers that you've commissioned. Will we get those in early September and read them madly in that first 2 weeks or—what's the process?

Denise Dougherty: Yeah. And somebody just asked me—an author just asked if we want the authors to come to the September meeting and, yes, you will get the papers. There'll be drafts of the final reports, not the final, final, final because—so you will—we will share those with you. That will help with the decisionmaking process. It's going to depend on when I get them from the authors.

Female Voice: Would it be possible to ask all your authors to prepare a one- to three-page summary because I don't think in 2 weeks or thereabouts before the September meeting we're going to absorb 50-page reports in times of 10 or whatever.

Denise Dougherty: In fact, that is the deliverable, in government terms, that it's tables with bullet points. Okay, is that—?

Rita Mangione-Smith: And I'm sure I speak for all of us when I say that as soon as you get anything, please send it our way because it is going to be so much to digest in a very short period of time. Paul?

Paul Melinkovich: I think a little apprehension, maybe other people share it, is that the work product of this committee has been all of this thinking and the rationale behind what we're doing, not just a set of measures. And how much of that will be captured in not necessarily the report but in the release at the time that these measures get released—kind of the thinking behind it.

And secondly, that next critical process, if we put forward say, 30 measures, and then the Secretary decides to go down to 10, or we give 50 and they decide to release all 50, the rationale behind that, will that be explicit from the Secretary of how those decisions were made that necessarily we're—we weren't necessarily a part of?

Denise Dougherty: I think in order to have a meaningful public comment period, we need to—this could be the longest Federal Register notice ever, though I doubt it. We need to provide all of that information and take the input of the subcommittee and all of that. We're not just going to stick out as—who knows? I'm not the Secretary and I'm not the OGC, so—and I'm not the Federal Register people so—but my preference would be to have a very fleshed out discussion of how we got to the list. And then how the—what the internal decisions about the [cross-talking]

Paul Melinkovich: And especially this point that our number one thing that this is a journey that this—yeah.

Female Voice: And the transcript from the subcommittee meetings from yesterday and today is going to be posted on the AHRQ website, so it'll be publicly available.

Denise Dougherty: We can give you all an opportunity.

Female Voice: Do we get a shot at editing the transcript?

Denise Dougherty: It would—you'd have to do it within 3 to 5 days.

Female Voice: I can do that.

Female Voice: We might have great [Group cross-talking] to do that.

Denise Dougherty: Me, too. I didn't mean everything I said. [Group cross-talking]

Male Voice: I guess my question is an addendum to Paul's, which is that I think that one of richness of things that has come out of this and will continue to come out, particularly after September, is we need more measures about this. We need government agencies to have better interagency collaboration both federally and at a State level, et cetera, et cetera.

And separate from the report and the list of measures, is there, for lack of a better term, advice that this committee can provide to the Secretary about what may be next steps because this is obviously an iterative process over many years? And why should some of the discussions that we've had be recreating—of what we see as barriers and/or needs be recreated?

Jeffrey Schiff: I think that's a really good point. And I'm hoping that if we have committed to that second point as our highest votes which is really something of the process; exactly, that would be captured in the report because I think this is really, I guess, our advice to the staff here is that the will of this group is that we catalogue our list of measures and things that need to be developed in that way. So that would be the advice, I believe.

Denise Dougherty: Here's one issue, and we haven't worked out the OGC part of it. One of the reasons that we are not formally asking this group for a set of priorities is that we want people in this group to be able to apply for the next round, so we have to have a priority-setting process. We don't know; we haven't clarified, and we probably never will, whether in fact if we ask you to give us a formal set of priorities for measure development, you wouldn't be able to apply for those grants or contracts or whatever they are.

So that's one reason we're ending it December 31st, we're not asking you for a formal priority-setting. We may find out that it's—just like the NAC, you can apply for grants even if you're on the NAC. But we haven't nailed that down, and so we wanted to be very careful because we have great talent around this room, and it would be a shame if you all didn't actually apply for some of the pediatric measure development stuff. So we are taking it in, but we don't want to make it a formal priority list, okay? But I think what Marina has suggested over there though is a way to get those priorities in place without having a formal priority-setting recommendation process, okay? That's part of our thinking.

Female Voice: Could you explain a bit more about how the IOM report fits into all this?

Denise Dougherty: Well, the IOM, there has been—

Female Voice: Not the comparative effectiveness one, but the one that has to do with this, yeah.

Denise Dougherty: No, I know. We're having a meeting—and Barbara, I need to get you on the calendar for that—to talk to them. They haven't been able to work on it yet. And so [cross-talking]

So we have to sit down with them and share what we're all doing, what you're doing, and figure out what they can do that would be useful. Now, that could mean nothing because they're appointing a committee and that committee makes its own decision about what they think would be useful, so just—

Female Voice: Have they picked a committee? I mean I'm wondering whether you want to suggest to them that there are some great minds in this group that might make a nice connection or liaison if they were asked to serve on that committee.

Denise Dougherty: Yeah. I don't know what they've been allowed. I know that they started asking about who would make a good committee member. And now, we have even more suggestions, so—as you know, IOM does its own thing. We read—can suggest.

Rita Mangione-Smith: So we're going to move on to the very last piece of what we would like your help with, and that is what your ideas are about, what we should include in our report out tomorrow to the National Advisory Council. We have some ideas about what we're going to present in terms of letting them know what our process was, what our pre-work process was, what our process was during these 2 days or what it allowed us to accomplish. And then when Arielle finishes back there, we'll show them at least preliminarily these are measures that have made it through all three stages with the caveat that they may not make it in the end because we're not done. We've realized there's a lot of extra work to do. So those were kind of our global ideas, if there are some specific things that you think we should be sure to include, we'd love to hear from you about that.

Female Voice: Well, certainly, emphasizing the breadth of the inputs you got from the subcommittee members I think will be important because there are so many constituencies represented on the NAC, and you need to try to convey that we probably covered them all just to allay their concerns. And I guess I'd have thought that they would like to know about some of the conceptual framework stuff, and this idea of their trajectory and the three columns kind of thing I think might appeal.

And if there's anything then to be said to the NAC about not so much, if you will, column A and column B, but the measure development stuff that will need to be done, and how might the NAC for instance be helpful to AHRQ in thinking through support for that kind of activity down the road, because that's a 2-, 3-, 5-, maybe 10-year research agenda kind of thing, and get people thinking about it.

I know there will be some substantial interest in mental health because David Shern is on the NAC, and he'll be very interested in that, yeah. But there won't be as much about—there won't—there's nobody there who represents the dental community, so I think maybe just briefly trying to convey that that actually is part of what we have really tried to grapple with. And that it didn't get short shrift might be an interesting little footnote for them that that was really included as part of a very broad conceptual framework for child quality of care.

Female Voice:—different groups but we are on it. That's why we're here. I mean they wanted a couple of people, but it's representatives of disease advocacy groups and consumer patient advocacy groups.

Female Voice: Oh, yeah. And professionals and researchers and somebody from the Chamber of Commerce and health plans are represented, that kind of thing—that person, I guess, I should say, not thing.

Female Voice: That there are no child—people except [cross-talking]

Female Voice: Tim is our only child [cross-talking]

Male Voice: Well, and Cathy's experience in pediatric research. But I think a foundational piece really needs to be a brief discussion of the CHIPRA legislation. I think that there—they may have been focused on health care as a general conceptual—and, certainly, in the NAC meeting, previously, there was a lot of discussion on comparative effectiveness. But I think that they need to know that this legislation has passed and what the—some of the components, key component items were because there are not many members who are pediatric-focused on the NAC right now. There may be some new members appointed who are, but at least right now there are not many.

Female Voice: And could I, just to add to that. Building both on what Tim said and also what Paul said, that this is a multiyear effort. This is phase one of what's going to be a much longer and more—and broader process. And that for those people who are thinking of themselves, well, I've been paying attention—at least somewhat—to health reform and don't all the bills contemplate that CHIP would not be reauthorized beyond 2013 when it expires—this current authorization expires?

I think the point really needs to be made that one of the reasons for which these quality provisions apply to Medicaid had to do with communicating to everybody that this is a long-term venture. That it is not CHIP-specific.

Male Voice: I think they might want to hear that there was a focus on outcomes for kids. That really was the primary driving force, but I think they might also want to hear about the focus on action that this is clearly about measures, but it's about measures that can be used to make a difference as quickly as possible.

Rita Mangione-Smith: Alan.

Alan Weil: At the risk of being a little self-serving, I'm reminded by other comments that stepping back is going to be really important. This is not a group that focuses on this issue every day. And I think it would be helpful not just to give them background on the process we've adopted but on how much has been done in this area despite the fact that there is still a lot to be done, and that we are drawing on the somewhat fitful but still quite substantial efforts made in many instances in an uncoordinated way, and some of them quite organized by a lot of actors in the system.

And I just think that kind of a sense of—we have a trajectory here, but we're not at the beginning of it. We're trying to corral a lot of energy that people have put in. And I think one of the consistent messages we've gotten is people are looking for this kind of leadership to get us to the next phase. So this is not just about development. It's about taking, harnessing interest in a topic and experimentation in it and moving it in a direction. That feels like an important part of it.

Female Voice: And the State.

Alan Weil: Yeah, the State—I mean, yes, the States are certainly asking for it and—I mean providers are asking for it, too. But, certainly, the States are eager to see this fulfilled.

Rita Mangione-Smith: These are all wonderful suggestions.

Jeffrey Schiff: I think just as co-chair, I think we want to thank everybody here for all their hard work and dedication. It's been a pleasure.

Rita Mangione-Smith: Amazing report but—

Female Voice: And I think we can all thank you for your leadership.

Jeffrey Schiff: I think we also need to give a special thanks to Denise and her staff for [cross-talking]. Are we adjourned?

Rita Mangione-Smith: I think we're adjourned.

[End of transcript]

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