The following is a transcript of the Second Meeting of the Subcommittee on Quality Measures
for Children in Medicaid and Children's Health Insurance Programs (CHIP), held on September 17-18, 2009.
September 17, 2009
Afternoon Session Resumed
September 18, 2009
Morning Session Resumed
September 17, 2009
Jeffrey Schiff: My name is Jeff Schiff. I'm one of the co-chairs of the SNAC, the Subcommittee of the National Advisory Council on Child Healthcare Quality Measures for Medicaid and CHIP Programs, and we have a busy day and a half here. I think we'll go around the room and introduce ourselves. Most of us bonded last time, but we'll have the opportunity also to introduce folks who couldn't be here last time.
Rita Mangione-Smith: So I want to second, just thanks for being brave enough to come back for the second round. I think it's going to be a long and very difficult day and a half, but I'm sure we're all up to the task. I'm Rita Mangione-Smith and the other co-chair of the SNAC. And I'm looking forward to what we're going to be doing over the next day and a half.
Denise Dougherty: I'm Denise Dougherty, the senior advisor for Child Health and Quality Improvement at the Agency for Healthcare Research and Quality.
Carolyn Clancy: Carolyn Clancy, director of AHRQ. I'm really glad to be here.
Timothy Brei: Timothy Brei, I'm a member of the National Advisory Council for AHRQ and a pediatrician in Indianapolis.
Victoria Warren-Mears: Good morning. My name is Victoria Warren-Mears. I'm the director of the Tribal Epidemiology Center at the Northwest Portland Area Indian Health Board.
Xavier Sevilla: I'm Xavier Sevilla. I'm the chair of the Steering Committee on Quality Improvement of the American Academy of Pediatrics.
Alan Weil: I'm Alan Weil, the executive director of the National Academy for State Health Policy.
Ann Page: Ann Page, director of Health Care Accountability for the District of Columbia Department of Healthcare Finance.
Phyllis Sloyer: I'm Phyllis Sloyer. I'm from Florida. I wear several hats. I'm here as Title 5, and I'm also the president of the Association of Maternal and Child Health Programs and running CHIP and the Medicaid program for children with special health care needs.
Mary McIntyre: Hi, I'm Mary McIntyre and I'm medical director of the Office of Clinical Standards and Quality for the Alabama Medicaid Agency.
Ann Kohler: Hi, I'm Ann Kohler. I'm the executive director of the National Association of State Medicaid Directors.
Robert St. Peter: Bob St. Peter from the Kansas Health Institute.
Cathy Caldwell: I'm Cathy Caldwell with the Alabama Department of Public Health. I'm the director of Alabama's CHIP program.
Carroll Carlson: Carroll Carlson, I'm the Director of Government Programs for Group Health Cooperative of Eau Claire in Wisconsin, and I'm also on the board of Medicaid Health Plans of America.
Doreen Cavanaugh: I'm Doreen Cavanaugh. I'm research associate professor at Georgetown University, professor of mental health policy focusing on behavioral health care.
Marlene Miller: I'm Marlene Miller. I'm vice chair of Quality and Safety at the Johns Hopkins Children's Center, and I'm also vice president of Quality Transmission at the National Association of Children's Hospitals.
James Crall: I'm Jim Crall. I'm chair of pediatric dentistry at UCLA.
Paul Melinkovich: I'm Paul Melinkovich. I wear a couple of hats. I'm a pediatrician in Denver directing a network of community and school-based health centers, and I'm also the chair of the board of the National Assembly for School-Based Health Care.
Jonathan Klein: Good morning. I'm Jonathan Klein. I'm sorry I couldn't be here at the first meeting. Then I was still a professor of pediatrics at the University of Rochester where I was associate chair for Community and Government Affairs, but now I am associate executive director at the American Academy of Pediatrics.
Kathleen Lohr: I'm Kathy Lohr from RTI International down in North Carolina. I'm a member of the AHRQ National Advisory Council as well and a distinguished fellow doing a certain amount of health services research and health policy research at RTI.
Linda Lindeke: Good morning. I'm Linda Lindeke. I'm the immediate past president of the National Association of Pediatric Nurse Practitioners called NAPNAP.
Barbara Dailey: Good morning. I'm Barbara Dailey, director of the Division of Quality, Evaluation, and Health Outcomes at CMS (Centers for Medicare & Medicaid Services), and I'm a pediatric nurse.
Cindy Mann: Good morning. I'm Cindy Mann, director of the Centers for Medicaid and State Operations (CMSO).
Jeffrey Schiff: Thanks everyone. We have a couple of members who are joining us by phone.
Just a little bit of housekeeping before I turn this over to Cindy for her opening remarks and to Carolyn. You'll see that we are decidedly higher tech than we were last time, and as this is a Federal initiative, this is being broadcast on a WebEx right now. You'll notice that we've asked folks to bring their computers to get into our own WebEx site if they need to. We have these devices which are electronic voting.
With that, I want to turn this over to Cindy for some opening remarks. I want to just say by way of introduction that those of us who are in State programs have noticed a high degree of collaboration occurring now, both between the States and the Federal folks and inside the Federal agencies around Medicare and the Office of the National Coordinator. And so we're delighted for you to be here and welcome.
Cindy Mann: Music to my ears, thank you for saying that. We're working on it.
So good morning everybody. I'm going to do another one of my hits and runs which is to give you my thoughts and then run to other meetings, so I apologize for that. I wanted to be here this morning and to say good morning and to welcome all of you to the second meeting of the National Advisory Council subcommittee on quality measures and I want to really thank you for continuing to commit so much of your time and certainly your expertise to help us identify these core measures that will constitute what we really see as a way of turning our ship as you might say.
This effort is really central to building a national quality system for children. And I don't say that lightly. We are literally trying to turn the corner on how we do business. I think as a nation, the discussion in health reform makes it clear that we're no longer satisfied nor should we be with simply paying the health care bills, and we know we need to be focused on quality care and on results. It's not just a nice thing to do, we used to have like—we did our business and then, "Oh yes, there was quality over there on the side." But we are increasingly trying to build our system so that it is based on quality, and it's not just this thing over there on the side.
Quality should design our view of how the benefit package should look. Quality should guide our view of what cost sharing should look like. It should guide our contracting policies. It should guide our payment policies, and we also, of course, like to think that if we focus more on quality, we will also be making our health care system more efficient and effective.
So there's lots of pieces to the puzzle, contracting, rates, data systems; all those things really need to be realigned. And there are the new health information technology efforts which are a newer piece to the puzzle. And they, like our data systems and our rates, are another key tool to driving toward better quality. So not to put too much pressure on you, but we see these core measures truly as central to the effort of changing our health care system. So take a deep breath and do a lot of good work in the next day and a half.
So I really don't say that simply to get you to feel good about all the time you're committing to this effort because of the importance of the work. But you should feel good about all the time that you're spending. I do that really so that we continually challenge each other to think about the core measures as needing to work, as needing to serve as a driver in that broader system.
First and foremost, we need to make sure that the measures are something we can use. Measures that all the stakeholders will feel, tell them something meaningful about these programs. Reporting from the States, as you know, is voluntary. And if we don't want measures that'll sit on the shelf, measures that even if reported still won't provide us a useful window on the quality of care that children are receiving and give us tools for improving that quality, then we've not met the challenge of the day. It will take work to convert our systems to use these new measures, and the value of using them has to be self-evident.
Also central to the effort—to these measures is that they need to be susceptible to being reported through electronic health records because that's indeed the direction that we're going, and it's indeed the direction that we need to go. As you know, there's an electronic health records initiative inside CHIPRA that we're working on that this will feed into, and of course, there's a major health information technology (health IT) initiative within the department to move forward in this area.
So the exciting news is that we're anticipating that these measures that we're discussing in the next day and a half and over the next period of time will be folded into that emerging effort. So the platform for using these new measures is being built. And that's exciting because again, it gives us a way to drive these measures into our system and not have them sit on the side, sit on that shelf as we would, as we might think about it. But we also need to be conscious that the new platform and the measures have to work well together. We can't design new fuel for the car and then the car doesn't take the fuel or something like that.
So finally, I'd say the core measures need to be, as the term suggests, "core" measures that give us strong grounding in this unfolding adventure and set the stage for more to come, and I think we've talked about that at the last meeting as well.
So we did say, I think I said at the last meeting that they need to be aspirational and yet grounded, and I know that's easy to say, so I'm saying it yet again, and it's really hard to do. But I think it's a good marker for where we need to be, and I know that you're all really making progress on that. So we are excited, really eagerly anticipating your recommendations. We're also very eager to share the recommendations not only with the full committee but also with the public and with other stakeholders and interest groups to get their comments and to build something that's really rich and robust. We really think this is the unique opportunity to turn the corner on our health care systems and particularly for the health care that we give to kids. So thank you all for your efforts. We really appreciate it and even though I'm going to be drifting out after a little while, I am paying close attention to all of the work and really eagerly anticipating what you produce, so thank you all.
Jeffrey Schiff: Carolyn, I think you're up next.
Carolyn Clancy: Thank you. And Jeff, I think you said it right when you'd already noticed a shifting of how things are doing. We're very, very excited by the new leadership at CMSO, and I could go on and on but I won't. I did want to tell you a funny story though and ask you a question.
So we did some town halls on quality a few years ago and used these little clickers to gauge public opinion and so forth. Of course, what we found out was that most people who go to these town halls already know about quality so it wasn't exactly like getting people on the street. But the test question was to ask people, "What do you think is the national park that gets the most visitors every year?" So the choices were Yellowstone, the Grand Canyon, the Great Smokies, and one more. Any of you have an idea what that is? Cathy?
Carolyn Clancy: Yes. You would be the only person I've ever asked that question in a group who actually knew the answer.
Male Voice: [Inaudible].
Carolyn Clancy: Yes, of course. Usually, results were split very evenly between Yellowstone and Grand Canyon. So on that little anecdotal note, we'll see if this comes up. I just want to compliment what Cindy had to say, and I have to say that she really inspired us again last week when she talked about making sure these worked for States. This was just in a call between AHRQ and CMS folks, and she of course, not surprisingly, had a lot of ideas about how we might engage States and make sure that they buy in and make sure that these become really the foundational step in getting to a place where quality is the design principle for health care.
We've been incredibly excited to work with CMS, and what I've just listed here are the specific components of this roadmap for quality for CHIP and Medicaid that we will be directly involved with, and you'll be hearing more about this later. I'm not going to list it over. We're talking about children's health care quality today, and I've had a number of colleagues who've observed that the entire quality enterprise on many days is not unlike 6-year-olds playing soccer. Everyone is really, really busy, but it's really kind of hard to know if there are any rules of the road and so forth. And I think the legislation and frankly, the work that you've all done together today, thus far, is a striking contrast. That doesn't mean we're not trying hard in other areas, but this really stands out.
The charge that you have is very, very focused. You remember that to recommend an initial core health quality measurement set, and I think that aspirational but grounded is a phrase I find myself using a lot in other areas as well. I think that's precisely it. It is incredibly important to keep in mind the timeframe that we've got and also keep in mind that the endgame here is actually getting people to use these measures.
So the specific charges you have are providing guidance and criteria, guidance on a strategy for identifying additional measures and use because after all, this road map that we have actually allows us to build out on the future which is very exciting thus far in every other area of quality I can think of. I think we've had that aspiration but absolutely no map and no clear expectation of resources to do that. And then the third task, of course, is to review and apply these criteria to a compilation of measures currently in use by Medicaid and CHIP.
So this is just the timeline, no surprise to any of you, but in case any of you are feeling a little breathless and if Rita and Jeff aren't, there's something actually wrong with them so I won't be asking them. This is a lot of work in a very short timeframe. Partly getting back to the 6-year-olds playing soccer because I don't think we've ever given policymakers any kind of reasonable expectations about what a timeline might look like. On the other hand, there is some value to speed right? If this was going to take a few years, there might be some tweaks that we would love, but people would forget the urgency, and this actually sets it up very, very nicely to be totally aligned with health reform and the strong focus on quality measurement and reporting in the current drafts of legislation. I can't vouch for the Baucus bill. I have not digested the 200 and whatever pages yet.
So this is intended to just be a roadmap, and again, measures are not the endgame in reporting. It's really about how does this whole effort promote improvements in care and systems that will make the right thing the easy thing to do. How do we actually get to better measures in the future and frankly, another missing piece of the current quality enterprise is knowing, "Does this make a difference?" We're pretty sure it does. There have been selected studies for adults that look at fairly narrow slices of care that kind of make us scratch our heads. They're not dramatic.
Now, my guess is that's a combination of short timeframe and some other challenges, but I think we owe it to all the people who are going to be actually doing this to make that kind of commitment to make sure that we know that reporting on these measures and then putting changes in place to improve care actually have the desired effect. So that will require a lot of leadership and coordination, and I cannot think of a better human on the planet than Cindy Mann.
So you've had your public meeting in July. The next 2 days, I think, will be very, very busy; energizing, I hope, as well as exhausting and potentially exhilarating. Questions at any time, you can send by E-mail. You have to be careful though. Denise and her colleagues respond so rapidly that you may be taken off guard thinking you'll get a response back in a few days.
So I just want to close with some thanks here. I don't think I have language to express the appropriate appreciation for Rita and Jeff's work. They have worked tirelessly and very, very hard, and you're not done yet of course. As well as to all of you.
We very, very much appreciate the work, and I think it will be worth it without question. I want to thank the paper authors and also the Medicaid Medical Directors Learning Network. This is something that we started working with at AHRQ a few years ago. Well, do you know how energetic and thoughtful Jeff is? That kind of leadership? Well, it turns out there are a whole lot of people like Jeff. And they have created a network and they've become very vital partners to AHRQ as a principal means of sharing some of the tools and information that we have that we think they can use. And frankly, for giving us feedback to say, "I don't know if this works. You might need to fix it this way which is probably at least as invaluable as actually using it," and also to people who made public comments. So I'll stop here. I'm not quite doing hit and run but kind of close. I'll be here to about mid-morning because I actually want to hear the beginning of the conversation, and this morning I have the flexibility to do that. But this is exciting stuff, thanks.
Rita Mangione-Smith: So I think we're going to open it up to questions for Cindy and Carolyn for a few minutes. And if there aren't any, we'll file forward.
Female Voice: Is there other—the public—?
Rita Mangione-Smith: Oh and public comment and questions.
Female Voice: I just wanted to thank AHRQ on behalf of the medical directors—and we're now working with the dental directors—for all the support that they have given to the Medicaid agencies. Thank you.
Jeffrey Schiff: I have one question or comment and I'd love for Carolyn or Cindy to comment—Carolyn said at the NAC meeting which followed our other meeting that this was probably one of the most exciting pieces of legislation because of the quality that was written into this bill. Are quality provisions like this written in any other bills, or is there a plan to do so?
Carolyn Clancy: You know, there is, now, for the various pieces of health reform legislation. I am told that it's—there's some language in the Baucus bill. I just haven't looked at it yet. I don't think it's as thoughtful as what was in CHIPRA partly because there was actually time for the language and thought for CHIPRA to mature right when they started 2 years ago in the CHAMP Act (Children's Health and Medicare Protection Act of 2007), and you all know the history there. Anyway—and partly because I think they were really great people thinking ahead who understood States and so forth. I think one of the challenges for the rest of the quality enterprise is that there is no consensus on how data will be collected or what I would call a national strategy. For some aspects of care like hospital care, you know, when you click on Hospital Compare and look at all this stuff. There is a sort of centralized repository where all the information flows. There are other efforts like the NCQA (National Committee for Quality Assurance) and so forth that take a more distributed or federated approach, where NCQA puts out the specs, and they supervise the vendors, and they certify that they can do the work. But there is no centralized database anywhere, and I don't think anyone really knows what the right answer is. So none of the bill is actually presumed to prescribe one, which is probably a good thing, but I just think this was very tightly organized. I'll leave it at that.
Female Voice: I just wonder, either Cindy or Carolyn, when these go up in the Federal Register for public comment and so forth, is there a timeline in mind for what happens after that? In other words, are they up for 30 days or 60 days and what happens? I mean there'll be responses to public comment and so forth, but somewhere down the line, there presumably is a decision and some implementation, and I just wondered if you have any feel for what that timeline looks like?
Cindy Mann: Yes, absolutely. There's a decision made by the Secretary to adopt core measures by January 2010. So that's the tight timeline that we're on here to bring this to fruition, make sure we get robust public comment and make them the best that we can be and then—and then we go out on the street, but as Carolyn had—what I've already talked about and I think we want to start when we're not wearing you out on the measures, start engaging the community. At the same time, we're now moving that process through is how to think about implementation, how to make sure that people are thinking about that now, working closely with States, bringing them in. I know we obviously have lots of mechanisms for doing that, since many of you in this SNAC are members of State organizations.
But I think we want to—once we have recommended a set of core measures, we want to—we have some listening sessions planned to both get some more feedback on the measures, but then also begin to have some working sessions on implementation. And again, this is going along side by side with the work on electronic health records—a provision that was in CHIPRA—and the health IT work which also begins to take off. And we have a quality demonstration project also in CHIPRA (Children's Health Insurance Program Reauthorization Act), and we're going to put out a request for proposals and reporting on these measures will be—no surprise to anybody—a precondition of joining that demonstration project.
So I think we have lots of different vehicles but lots of work to do, and that's I think what we were talking about is, again, we don't want these to be on the shelf. We want these to be useful, so part of being useful is making sure as we go through designing the measures they're useful, and part of it is really engaging stakeholders and States in particular on how we can make sure that they work for them.
Carolyn Clancy: So I think the aspiration here is just that when this core set is released by the Secretary, that the States are not at all surprised, and in fact, they've already begun thinking how do we get up to speed doing this. I will tell you having been on the receiving end or distributing end of many public comment requests for the national quality reporting for a variety of other organizations, usually the comments can be summed up by one word: more. Almost no one says, "Don't do something, but we want more measures."
Now, sometimes, that's actually good input for future measures development. Oftentimes, it tells you a lot about what a particular group is very passionate about. Sometimes it's, frankly, an indictment of the science that we have or don’t have in terms that you can't really create a measure derived from scientific evidence if there isn't any evidence, for example, about many aspects of childbirth and so forth because we just haven't made those investments. But usually, those are the most common public comments, and they vary from 10 pages of eloquence to almost postcard stuff that says dental or mental health or whatever the person's topic is.
Jeffrey Schiff: I want to thank both Cindy and Carolyn for giving us this charge because it's wonderful to start with both of you because it certainly frames this. We're going to go on now and talk a little bit about how we envision the next day and a half running and a little bit of where we got to last time.
I think when we put together the slide set for the NAC and then put this out on the Web, this is what really struck me as being most significant, and that's that 48 percent of America's children under age 19 are affected by the work we're doing here, and I think that's very significant. And then if one is to look at this in terms of total spending on children—and about 70 percent of the health care spending on children comes through the Federal Government—so our work is very important.
I didn't go through the whole set that we used at the NAC that looks at the legislation but I will tell you that over the course of the last 6 weeks or so, this is what is kind of burned into my cortex and that's that taken together, this set will be used to estimate the overall national quality of health care for children and this is a direct quote out of the legislation so everyone knows that.
Anyhow, to remind you that this is—and I think Cindy and Carolyn also both spoke to this. We decided last time, and I think in a very important discussion, that we're working on getting to a grounded set of between 10 and 25 measures, and we'll get to the number over the course of these 2 days that are currently feasible and aspirational in that they will stretch folks' workload. And that—I won't say stretch people's workload; that's the wrong term. Stretch people to work to move the system forward and—but that the measures already exist, and that is part of our charge is within that group.
We also talked about having an intermediate group of measures that have good specifications that some States are already using but didn't make our cut. And then aspirational, which are measures that we know need to be developed, and I give Marina full credit for coming up with this framework, but we have used it as we've talked about this.
So that's where—if we get to a point where there's a lot of I'd say a head steam around making sure that we don't forget about something that we really want to get developed or we really want to recommend, we'll write it down so we don't lose that thought, and we'll hopefully get to that at the end if we have time, but our charge is really to get to that grounded core set.
I'm going to turn this over to Rita now. We're going to talk a little bit about where we've gotten to, and then I'll take it back, and we'll actually talk about our process for the next day and a half.
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