July 22, 2009: Afternoon Session (continued)

Jeffrey Schiff: I know we do, yes, so—

Rita Mangione-Smith: So I want to make a suggestion. Maybe the first thing tomorrow, I know that importance is important. We will spend much time talking about it tomorrow, but maybe we can just eke out like maybe 45 minutes at the beginning to talk about feasibility of these measures because I do not know that we are going to get through feasibility today.

Jeffrey Schiff: Okay.

Denise Dougherty: Could I say something about the duration of coverage that may help?

Jeffrey Schiff: Do we want to—I do think—okay.

Denise Dougherty: I mean we are going to hear tomorrow how Jenny Kenney has started conceptualizing this issue. I think since the definition is not clear, we do not even know how this could be a quality measure, you know it seems—

Rita Mangione-Smith: It seems like it is kind of off the table. There is no measure here for us to really assess.

Denise Dougherty: Yeah. We will have more information hopefully by September.

Rita Mangione-Smith: And then we could rate it as more information.

Denise Dougherty: Yeah, exactly.

Male Voice: The other thing that might be helpful is as we relook at these as much discussion as we have had, we might also indicate what we think the origin or the domain of the information is because I think clearly from at least my Medicaid experience, lots of this is not going to come from Medicaid. It is out there, it has validity, it is desirable, but its origin is not going to be from our record set. It might be a requirement that we would make on a managed care organization (MCO) that is providing services, so it would not be an indirect report.

But when I was looking at those, I was trying to think, okay, do I have the data anywhere in my shop that I could do this? And the answer to many of them, they are desirable, but it is not there. And then the question was, do I have the leverage to make certain that I acquire that data in order to report it? And again, there is a decision process. So if we could somehow distinguish the expectation of the domain from where that would come, I think it might be more useful in us grading the relative value of the data and the applicability of it.

Denise Dougherty: I think you are getting us into the feasibility.

Rita Mangione-Smith: Into the feasibility piece, yeah. That is definitely what we have to tackle when we talk about that.

So we have about four more to get through. Lead screening rates was one that passes that you can see there is a fair amount of variation and scoring. We have four people who put it down in the bottom four categories; we have an additional three people who also did not put it in the passing grade, so 7. Xavier?

Xavier Sevilla: Okay. First of all, on the lead screening, I think everybody understands that lead screening is a worthwhile exercise. I think the issue is to do it universally on everybody, and the U.S. Preventive Services Task Force (USPSTF) actually concluded that they really did not see enough evidence to do it universally on all kids. And actually looking at some of the scientific evidence since then, since 2008, there are a few studies that support that and actually what they said is that it is still a problem. However, the way to universally test—which is to do it on every single person at 1 and at 2 years of age, which is what Medicaid does—is probably not the best way to do it. There are other risk factors that can be identified. That will make it a lot more specific and more sensitive for lead screening. So I actually scored it low; so that is what I did.

Rita Mangione-Smith: Cathy?

Cathy Hess: I had scored this one low, too, and it was largely because of that "D" recommendation from the U.S. Preventive Services Task Force. The fact that there are some studies out there, it does not necessarily tell us they are decent studies that might overturn a "D" recommendation. So if this is one that could be split into high risk or pull out the average kids and focus on high risk where I just mean there is insufficient evidence, but it is not a "D," that might be worth scoring just that one, and then you and I will probably be on the same page.

Rita Mangione-Smith: Glenn?

Glenn Flores: I guess I'm confused because we already have a risk population which is Medicaid, which is low income, and we know that that is associated with higher lead levels and mean—in terms of the mean—and on top of that, there is recent evidence that we are probably using the wrong cutoff level in terms of some of the outcomes that 10 is not even that sensitive, and you need to go down lower. So I'm concerned that we are sort of de-listing something that has pretty good evidence about the efficacy of screening in a low-income population that is largely minority.

Xavier Sevilla: If I can just mention that, in some of the recent literature, they actually showed that there are specific risk factors that are not—you know Medicaid itself is not the risk factor. There are specific risk factors that you can pick on kids that will make them high risk and definitely worth screening. However, to universal we say, all Medicaid kids need to be screened. I think that is where there is just not enough evidence that it is a worthwhile exercise to do.

Rita Mangione-Smith: Cathy?

Cathy Caldwell: And certainly CHIP, most of these kids are not really low income. In my State, CHIP is more middle income, and we look like a private insurance, so lead screening is not done routinely like it is in Medicaid. So if it is a core measure, there are different issues there, Medicaid versus CHIP. Just put that out there.

Glenn Flores: I guess that brings up the question of what is a high enough prevalence of a specific condition to say it is worth screening for. And my understanding is whether or not you talk about risk factors, and sure, living in an urban area and living in older buildings we know about that, but if the overall prevalence within a population reaches a certain threshold, and I cannot recall offhand what it is for having a lead level above 10 among those below the Federal poverty level (FPL), even those who are 20 percent FPL, I think it is still at least 1 percent if not slightly higher.

And my criterion for a screen for something is if it gets to a 1 percent level, even the 0.1 percent level, if you think about newborn screening we are going into the decimal points, that if it is worthwhile for those conditions, and we know that lead toxicity has a number of severe outcomes, sometimes permanent morbidity, occasional mortality, then I would think twice as a pediatrician about whether we should be screening a high-risk population, again, using that as low income or poor. So I disagree respectfully.

Female Voice: Maybe part of it turns on the extent to which this committee would recommend essentially something that the Preventive Services Task Force has said "no" to. That is maybe a tricky kind of quasi-political issue of taking on the USPSTF. On the average, overall, high risk is perhaps another matter. And I suppose if you want to argue that Medicaid equals high risk, that is a rationale you could use for keeping it, but I would think it hard to make a strong case for going against a D recommendation from the Task Force.

Jeffrey Schiff: Yes, except that we know that there is very little evidence in general for when you look at Task Force issues for kids. So I felt one of the things we sort of were having consensus around is there may be some issues where there may not be Preventive Task Force recommendations that we agree with or even evidence, but in terms of a group of experts, we might say it is time to actually think about that as a quality measure at least.

Rita Mangione-Smith: So some of this will get shaken out in our importance discussion although for this one, it would not be until the next round of importance discussion because it is one of our slightly controversial measures, so we will go through [cross-talking].

Male Voice: Slightly.

Rita Mangione-Smith:—re-grading for validity and feasibility. So you heard the arguments on both sides of the table, and you can vote whatever you think is appropriate based on what you have heard.

Female Voice: Is this one that in the next round you can split the two parts? Because we only just got lead screening, and can we split it.

Rita Mangione-Smith: So it is a HEDIS [Health Plan Employer Data and Information Set] measure, and HEDIS, a percentage of 2-year-old members who had one or more appropriate lead blood test or lead poisoning by their second birthday, and I think it is only applied to health plans that are Medicaid health plans. That was used as the high-risk population for that measure definition.

Female Voice: But all Medicaid programs report this on the CMS-416 that was mentioned earlier. It is a requirement that all States report this to the Centers for Medicare & Medicaid Services (CMS), so it has already been collected, at least for Medicaid and not for SCHIP, but all the Medicaid States report all their kids, not just kids in plans in this measure.

Female Voice: Right. They are a CHIP Medicaid expansion.

Rita Mangione-Smith: So that—in Medicaid is already doing this—all of Medicaid is already doing this. Yes? So it is a question of whether we as a committee would suggest it be a core measure and then recommend it for voluntary reporting for kids in CHIP.

Male Voice: I just looked up at the [cross-talking]. I'm sorry.

Rita Mangione-Smith: Right. But these were—also the measures that we suggest will also go to CHIP.

Male Voice: Cathy, do you want to—?

Cathy Caldwell: I have a question. Does the American Academy of Pediatrics (AAP) recommend lead screening for all children?

Rita Mangione-Smith: Glenn?

Glenn Flores: [inaudible]

Rita Mangione-Smith: I think they say the [cross-talking].

Glenn Flores: I think it is the screen. You screen it with a questionnaire, verbally. So I think that the AAP recommends the screening part, and I would have to get back to you on exactly the language of that, but I know that the test, the actual blood test, is what I think we are talking about here, right? Or is it screening as in—?

Male Voice: It is a measure; it is the blood.

Glenn Flores: It is the HEDIS measure, it is a blood test.

Jeffrey Schiff: So just stats from the GAO report that I just pulled up. One Medicaid child in every 12 has an elevated blood lead level, and that is three times higher than the non-Medicaid population, so I think that is a pretty good risk factor.

Rita Mangione-Smith: Okay, I am going to move us on because we have another big issue to deal with which is obesity-related—sorry, I'm getting tired. Okay—weight assessment and counseling for nutrition and physical activity for children and adolescents. Denise, before you leave the room, I just want to confirm this is an actual measure, yes?

Denise Dougherty: It is a HEDIS measure.

Rita Mangione-Smith: Okay, thank you.

Denise Dougherty: [inaudible]

Rita Mangione-Smith: Good. So this is a HEDIS measure, so we have specification. It got a validity rating of 6, so currently it would not make it, and there are four members of the subcommittee who put it in the bottom four; an additional six who put it in the uncertain validity range.

Female Voice: I'll be a bit of a champion or passionate about this one. Again, it is a HEDIS measure now, and Sarah is not here but—I mean Sarah [indiscernible], but Sarah Scholle is.

Rita Mangione-Smith: She is right back there.

Female Voice: Yeah. Anyway, it includes both a documentation of the body mass index (BMI) percentile with the date in it, so it is just getting docs to measure the percentile, and then documentation of obesity, some kind of nutritional obesity counseling. And the baseline measures meant that they did when they presented the State data at Academy Health last year is somewhere under 2 percent of charts had obesity, BMI percentile documented with a date. They did much better on nutrition; it was around 60 some percent in public and commercial.

And then in terms of link to outcome, the other criterion we raised, we do not know yet, but as the documentation said the Task Force is reconsidering the evidence, and there has been a lot of work in this area, and I think we are going to see something more positive coming out of the U.S. Preventive Services Task Force about the value of having providers identify and counsel.

Female Voice: I also just want to make a notation that in terms of the overall CHIP provisions, there is the focus demonstration on obesity, so it is high on the administration's priority list.

Female Voice: And in terms of disparities, depending on the State, the prevalence of overweight or obesity is between 1.5 and 2.0 times greater or sometimes 3.0 times greater among publicly insured children than privately insured, so it is a big issue for the Medicaid CHIP population.

Female Voice: Can I ask a related question in terms of hypertension among kids with obesity and how we are tracking that if we are tracking that? We are not.

Rita Mangione-Smith: We are not, but we failed pretty uniformly on it when we looked at it with the RAND study. We do not track hypertension in adolescents very well at all. We do not know how to be internists; that is our problem.

Female Voice: It is an issue.

Rita Mangione-Smith: It is an issue because we need to start learning to be—

Male Voice: I actually ranked this more in the middle because I'm unaware of any evidence that there is outcome related to doing this. I agree that it is an important issue, but unless somebody can inform me, I'm still not aware of anything that says my doing this [cross-talking] has any impact on changing that trajectory of the child's weight.

Female Voice: But there is growing evidence that it is sort of—I do not want to misspeak here. I do not know if Charlie is in the room or others, but I think we are seeing the evidence move towards just like with smoking counseling and cessation that having the doc talk about it can help those who have exhibited a readiness to change, not all patients, and that is why many providers do readiness to change scales, that does get them more engaged in some kind of nutritional program and/or more physical activity. So I think the evidence is moving in that direction. I do not want to make people think it is high-level evidence, but I think it is starting to move in that direction.

Jeffrey Schiff: Yeah. I think you bring up a good point too which is—I think you are making this point—that the assessment and the counseling are also different issues, and there are interesting questions about the efficacy of, for example, counseling, we do not know it. And even the weight assessment, there are some State experiments. Joe Thompson is doing in Arkansas where all the schools require BMI, but on the other hand, there is no evidence I think strongly suggesting that that has an impact; sometimes, it angers parents actually. But I think that is another interesting question here, should we be separating out BMI assessment? As you mentioned, there are some great studies now suggesting that doctors do not do that often enough, and then if they receive counseling or treatment, because those are different quality indicators—I do not know if we can separate them out—

Female Voice: Maybe we could ask Sarah with the logic, for instance, if you combine those two was because they had a—

Rita Mangione-Smith: Sarah, you did not know you were going to get into policy, did you?

Sarah Hudson Scholle: I should have brought my HEDIS manual with me, but I'm just downloading it as we speak. So it is actually three indicators under one measure, so it is three separate rates that we will be reporting; one for BMI percentile documentation, one for counseling for nutrition, and then the third for counseling on physical activity. So they are different.

Rita Mangione-Smith: So Denise, when we redo the score, could we break it out to those three?

Denise Dougherty: Okay.

Rita Mangione-Smith: This is the obesity one, breaking it out to—there are apparently three separate indicators; one is for weight assessment, one is for counseling on nutrition, and one is for counseling on physical activity.

Sarah Hudson Scholle: And we would be happy to provide measure workups for the measures that you are considering, or if you would like them, we have actually got detailed measure workups in the materials we submit to NQF for those measures. That might be helpful to the committee.

Rita Mangione-Smith: I have seen those. Please send them. It will be very helpful.

Male Voice: Okay.

Rita Mangione-Smith: Okay, Paul?

Male Voice: Even if there is no evidence for this measure, I think it is absolutely essential in terms of laying a foundation going forward. Any improvement efforts or any changes we make, we have to have the baseline data. So this is one I think laying the foundation now is critical for going forward.

Rita Mangione-Smith: I agree. So I'm going to move us on to our last two and maybe we can kind of talk about them together. They ranked out about the same. Although it says nonspecific measure, since we put out the call for additional measures, we got a bunch at New York State Medicaid is using, and they do actually have a measure that looks at screening for alcohol and illicit drug use in adolescents and screening for depression in adolescents. So there are actually measures out there in use, so I think it is legitimate to talk about these as individual measures, not just an adolescent or child care visit overall. Those were initially put in just to give you something to think about in terms of what might happen at those visits, but they are actual measures.

They are shaded in pink because again, very few people put themselves in the bottom four categories, but as you can see, very few people scored these because I think it said not a specific measure, and in that case, people got it and said, "Oh, they are just giving us examples of what might happen in an adolescent visit." So in the second round, maybe we should not spend too much time talking about this because the committee is so underrepresented on these measures. So let's put them back up for the next round and we will see what happens with that.

Female Voice: [inaudible]

Rita Mangione-Smith: We will take that up because it is a measure that exists in both cases. Do we want to discuss this at all or kind of table it because some people rated them? Table it?

Jeffrey Schiff: Okay.

Female Voice: I'm all for that.

Male Voice: All right.

Rita Mangione-Smith: Because we have 3 minutes before public comments, right?

Jeffrey Schiff: Okay, so just a little bit of process here. I have one person for public comment, Dr. Hagenbruch. Are there other public comments back here before we do that because I guess what I'm going to suggest is that we take a little break for 5 or 10 minutes, if that is okay, and then we come back, and if we can take that public comment, maybe we can actually finish up doing the feasibility now since we have the time. I know we are all tired, but we have a busy day tomorrow as well.

Denise Dougherty: But with the public—sorry, this is Federal speak here. At 4 o'clock, we said we will have public comments, so we need to have public comments at 4:00, and then we can move on.

Female Voice: Okay. [inaudible]

Jeffrey Schiff: Okay, so Denise, does that mean that now that it is 4 o'clock, that we have the public comment right now?

Denise Dougherty: Yes.

Jeffrey Schiff: Okay, public comment is—

Denise Dougherty: So there is one person who signed up?

Jeffrey Schiff: From the American—

Female Voice: American Dental Association?

Denise Dougherty: Okay. Let's see it.

Jeffrey Schiff: Okay. We will do this. We will have our break. We will come back. We will do feasibility.

Rita Mangione-Smith: We have to do one more validity.

Jeffrey Schiff: And one more validity thing. Thanks. You were tough up there. Thank you.

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Public Comments

Joseph F. Hagenbruch: Thank you, Mr. Chairman. I'm going to read this so I do not make any mistakes. I'm Joe Hagenbruch; I'm the current chair of the American Dental Association's (ADA) Council on Dental Benefit Programs. Including myself, there are three other individuals here today representing the American Dental Association as observers at the invitation of Dr. Conan Davis, who as you all know is the dental chief director for Health and Human Services, CMS. We have Dr. Chris Smiley; he is a member of the council; Dr. David Preble who is the council director; and Dr. Robert Burns who is from the ADA Office here in Washington.

We applaud the efforts being put forth here today and tomorrow, and we are pleased to inform all of you that the ADA has already begun plans to implement a Dental Quality Alliance (DQA) for the dental profession. This meeting here happens to be very timely for us as the American Dental Association; just today, we sent out invitations to prospective DQA steering committee participants from various parties of influence within the dental profession. We are especially proud and appreciate Dr. Jim Crall's efforts on behalf of the dental profession as he works with the AHRQ on behalf of the dental profession and the patients we serve. And I thank you for this opportunity.

Female Voice: Thank you. Okay?

Jeffrey Schiff: Do we have any other public comments? It is not registered. Okay. Seeing none—I have 3:01. Let's come back promptly at 4:15, okay?

[End of Public Comments]

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Afternoon Session Resumed

Rita Mangione-Smith: Okay, so we have another dental measure to tackle, and then Jim and I were talking during the break, and he made a very astute observation about the HEDIS/CAHPS® dental measure, so we may just take a peek at that, but I'm going to have him talk to you all about it first, okay, and then we can decide as a group how to move forward.

So the measure we need to look at right now is 120-day dental assessment. It should be under preventive health promotion and preventive care and just above treatment and management of acute and chronic.

Okay, so it reads, "120-day dental assessment," and that is further defined as the percent of children 1 to 18 continually enrolled at least 4 months who had an initial visit within the first 4 months. This is a measure that is used in the State of California, I believe. Proposed to be used in the State of California, and it got a 6. There is quite a bit of spread in how people ranked it. Only four people put it in the absolute pass range. There were a lot of uncertains. As you can see, 10 people in the uncertain range and in the bottom four categories, we have six people ranking it in the bottom four for validity.

James Crall: Rita, I'll just make a comment. I mean I think this is basically the point that Lisa made earlier. I mean this is simply any dental service within X period of time, and this is setting the period of time at 4 months, so it is simply an example of that issue that surfaced earlier about whether you are 11 months of eligibility and you are looking for a service or any month of eligibility and looking for a service, and this just by some rationale, picked 4 months.

Rita Mangione-Smith: Right. And there are a couple of—I will point out in the measures that we will be assessing importance on tomorrow, annual dental visit made the cut for that, and there are two other dental visits. If you want to look at that importance sheet, you can see what they are. So a couple of them have already made it in but this is one that was a little bit more on the edge. Xavier?

Xavier Sevilla: I have a couple of comments from a practicing pediatrician's standpoint. I think there is a measure at least in Florida that looks at this, that a pediatrician has to make a referral to a dentist and has to have a visit by a certain time, very similar to this measure. And two things come to mind. First of all, I think throughout the United States, there is a big problem with access for kids having a dental home, and that kind of impacts this measure. The other thing that I would like to just get some information, maybe somebody from the subcommittee, is if this measure has been measured for a while, and I suspect that probably the numbers that they are getting are probably low because of this issue of access, what has changed? How is this measure helping us to get more resources or get better access? So what is really the purpose of having this measure out there?

Rita Mangione-Smith: Go ahead.

James Crall: I'll respond not particularly around this measure but around the measure—because as far as I know, there is no longstanding data around this measure. I was part of a group in California within the last year that came up with some recommendations to the California [indiscernible] SCHIP program and the Medicaid people about additional measures that could be put in place. As far as I know, there is no history on this. There is a relatively long history on the CMS-416 measures that look at what percent of kids got these services within a 12-month period. And if you ask how that is used, I mean people from CMS can jump in here, but in the last year, CMS went out to 16 or 17 States and conducted site visits for States that had utilization of any dental services below 30 percent of the kids enrolled in Medicaid. So I think it has been used in the sort of program and policy arena, the CMS-416 measure.

Female Voice: And just to add to that, we had our first national dental health town hall forum in April of this year, and we had three different State representatives come out and present the initiatives that as a result of their low rates actually pulled together resources through different collaboratives, legislative changes that actually began funding initiatives, demonstrating the need particularly when there was a result of a death in one State.

Female Voice: This one kind of confused me because I thought about the ages of children and the frequency of dental visits, and the 4 months just did not make any sense as opposed to if they are enrolled, are they getting their dental visit based on the recommended schedule? So 4 months really did not do anything for me.

Rita Mangione-Smith: And just so everybody knows, the annual dental visit is a HEDIS measure. That is the one that people ranked as being valid and feasible and in the site, you will be ranking importance on, so take these measures as they are. Some of them have been more used than others, so that is fine. Are there any other comments on this particular measure?

Jeffrey Schiff: Glenn, do you have a comment?

Glenn Flores: I had the same sort of quandary, which is I did not understand why that 4-month number was the magic number and what if a child that had a dental visit before on another—maybe they were privately insured and now they are on Medicaid—so would they need a second visit within a 1-year period? So that number just did not make a lot of sense to me compared to the other measures which I thought were all pretty powerful.

Rita Mangione-Smith: Okay. So Jim, I'm going to give you the floor to talk a bit.

Male Voice: This is the CAHPS® [Consumer Assessment of Healthcare Providers & Systems] dental measure.

James Crall: I asked Rita to speak on this one because I think actually it is a 6, so I think it is sort of a median, so it deserves some—I think Carolyn had the comment this morning that there is no measure that does not have an advocate. Well, I'll do the disclaimer here. I have been involved in the development of that dental CAHPS® survey, but I thought just looking at the distribution, a couple of pieces of information just for the group, looking at how it was ranked in the spread.

First of all, we are talking here about validity, and I would not pretend to be credible on that regard, but I have had my colleague Ron Hays involved, and there is a paper published in Medical Care that speaks to the psychometric properties of this particular instrument, and basically, I think, concludes that it meets reasonable psychometric standards for a classic test theory, and only Ron and Kathleen probably know what that really involves. I do not even—I do not pretend to go there.

Female Voice: [Cross-talking] also used to be [indiscernible].

James Crall: Yeah. The second point I would make is the State of California CHIP program, the Healthy Families Program, has used this instrument every other year for three cycles now, and there are reports that are available. I would be happy, Denise, to feed both the Medical Care paper and the reports to the group for when it gets around to the next round of voting or whatever. For consideration, you can look and see how the results shook out by plans operating the CHIP program in the State of California.

Rita Mangione-Smith: So I'm going to add this for [inaudible]. Does that sound fine to everybody?

Male Voice: Good.

Rita Mangione-Smith: Okay. So that concludes the validity part of our discussion. We could [indiscernible] look at these same measures we all just went through, and now you have to change gears and think about feasibility, okay?

So will the States on average have the data they need just for the measures? Are there detailed specifications, or do we believe we can get detailed specifications by the end of September for the measure? And can that measure be measured reliably? So for scale-type measures, more sort of reliability that Jim was just talking about and/or the process measures, the reproducibility piece. So if I go from one plan to the next using these specifications, am I going to be able to say I'm making a valid comparison between those two States, those two plans, those two clinics, whichever level you want to think about? Okay?

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