The Subcommittee on Population-Specific Issues of the National Committee on Vital and Health Statistics was convened on Tuesday, June 24 in the Hubert H. Humphrey Building in Washington, D.C. The meeting was open to the public. Present:
Subcommittee members
Lisa Iezzoni, M.D., Chair
Hortensia Amaro, Ph.D.
Richard Harding, M.D.
Vincent Mor, Ph.D.
George Van Amburg
Elizabeth Ward
Staff
Olivia Carter-Pokras, Ph.D.
Patricia Golden
Ronald Manderscheid, Ph.D.
Carolyn Rimes
Others
Lynnette Araki, National Center for Health Statistics
Steve Clauser, Health Care Financing Administration (HCFA)
Liz Mauser, HCFA
The NCVHS Subcommittee on Population-Specific Issues met briefly in advance of the June 24-25 meeting of the National Committee. After reviewing their work plan, they were briefed on the Medicare Outcome and Assessment Standardized Information Set (OASIS) by two Health Care Financing Administration (HCFA) representatives. Following this, they discussed their responses to the presentations and agreed on the content of a letter to HCFA, which they asked Dr. Mor to draft for submission to the Committee the following day.
Dr. Iezzoni recalled the Subcommittee's decision to ask Dr. Amaro and Dr. Carter-Pokras to draft the Subcommittee's response to proposed revisions to OMB Directive 15. It will be circulated to the Subcommittee and then submitted to the full Committee.
She also announced that the Subcommittee has authorized full payment for the core data elements document prepared by Dr. Mor, asking him to redraft it based on comments that will be supplied to him. In this area, the Subcommittee plans to keep track of coding for long-term care, looking at ICIDH and the ways the Census Bureau and Social Security Administration are thinking about disability.
The group was reminded of its decision to hold a one-day information gathering session on the Territories and islands in the fall. They will come up with a date.
Dr. Iezzoni described the main issue of this meeting as typical of those to which the Subcommittee needs to respond with nimbleness. She then introduced the first speaker, Steve Clauser from HCFA's Office of Research and Demonstrations (ORD).
The ORD sponsored Peter Shaunessy's work on performance measures and other work on quality improvement system for home health, both of which are the basis for OASIS. Mr. Clauser focused on the policy context and history of the information set. Home health became a policy focus in 1994 when Bruce Vladek initiated the interagency Home Health Working Group. That group spawned the Home Health Initiative, which sought input from a range of sources on the home health benefit and advice on policy directions in this area. Quality assurance was one arm of the initiative, something the industry supported provided it was done with a core assessment instrument rather than an extensive instrument such as the MDS.
HCFA followed up by convening a group of experts in clinical assessment who also suggested a core instrument and recommended one developed by a research initiative with the University of Colorado. It is the basis of the current national demonstration project with OASIS for home care. The notice of proposed rule making was published on March 10, proposing to require agencies to collect OASIS data as a condition of Medicare participation. The comment period has closed; only 140-150 comments were received, a small number considering the import of the notice. HCFA hopes to move to a final rule and to implement the system based on these comments. Mr. Clauser stressed that the OASIS instrument is expected to evolve over time.
Liz Mauser, from the same HCFA office, is Project Officer on the OASIS demonstration. She briefed the group on the development of the instrument, which started with companion studies sponsored by HCFA and the Robert Wood Johnson Foundation which developed and tested outcome-based measures or indicators of quality for Medicare home health services. The HCFA study ended in 1994, and included an extensive effort to get the perspective of clinical care home health providers. Several iterations of the quality indicators (referring to attributes of care or of a patient) were developed, followed by a feasibility stage using surveys to look at burden, possible sources of data, and other factors. The criteria for choosing outcomes to measure included their being measurable, simple, and "not very gamable." The empirical phase of development focused on refining the measures, developing risk adjustment methods, and doing further reliability testing.
Asked how gaming was evaluated, Ms. Mauser said she would find out and let the Subcommittee know. The tool is administered by a home health nurse or physical therapist. She explained that the current notice requires agencies to begin to collect OASIS data but not initially to report them to HCFA, to give them time to learn how to collect the data and to integrate them into their assessments. Regarding the concern about gaming, she said HCFA will audit the surveys once reporting begins.
Dr. Amaro asked about provisions for interacting with clients in their own languages, and was told that the instrument is in English only. Ms. Mauser did not know what is planned regarding translating the instrument. Subcommittee members agreed to flag this as a concern, along with the one about gaming.
Mr. Clauser assured the Subcommittee that HCFA will welcome their comments despite the official closure of the comment period. Dr. Iezzoni expressed regret that the Committee was not informed sooner so it could have provided more timely input.
Ms. Mauser then described the demonstration that has begun, the purpose of which is to have agencies integrate the OASIS into their clinical records, replacing their own assessment items. She acknowledged that the instrument was developed for outcome measurement although it is being promoted as an assessment instrument.
The demonstration will look at whether agencies have trouble incorporating it into their assessment process. It will also refine Medicare's approach to outcome-based quality improvement, with an outcome analysis stage followed by a second stage to develop plans of action to improve care or reinforce good practices.
Dr. Iezzoni returned to the gaming issue, expressing her strong concern about an instrument that evaluates providers on the basis of information that they themselves report. Related issues are code creep and the subtle changes in interpretations of functional status that are simply a matter of human nature. She noted that the demonstration is a research enterprise and will not necessarily pick up such behavior. Furthermore, it is burdensome on patients to have people come back and examine them and talk to them in the auditing process. She questioned the possibility of getting meaningful data in the presence of these factors. Mr. Clauser agreed that these are "generic problems," and he and Ms. Mauser encouraged the Subcommittee to send HCFA their comments.
Dr. Iezzoni observed that the demonstration seems contrary to the administrative simplification effort, and Mr. Clauser said HCFA is optimistic that the OASIS does not impose a significant burden on the agencies, which have expressed strong support for it.
Returning to her report, Ms. Mauser said that 50 agencies were phased into a 3-year demonstration in January 1996. This group is "a leadership sample" chosen from 300 applicants for their administrative stability and flexibility. At this stage of the demonstration, they are focusing on the outcomes to reinforce or the care behaviors to change. Reducing re-hospitalization rates is a major focus. 26 states are represented in the demonstration. The participants indicate that incorporating the OASIS has helped them make their assessment process more precise and improve care planning.
500 agencies were involved in the OASIS research, and hundreds are currently collecting either all or part of it. It has widespread industry support.
Ms. Ward commented that from her state agency perspective, HCFA is perfecting in the OASIS "a plane that will fly at 5,000 feet" when she needs one that will fly at 10,000 feet. These planes may collide, or they may have to use different airports. Specifically, she needs something that measures patients not just in "the home care box" but across care settings. Mr. Clauser said a group is looking at post-acute care data sets as one approach to this problem. Subcommittee members agreed that they would like to talk with the post-acute work group. Asked about the decision-making process, he said an interagency work group will review all the comments. The hope is to have agencies reporting OASIS data to HCFA by October 1, 1999.
Dr. Mor observed that the bulk of agencies with limited resources will not be able to change software frequently as the OASIS evolves. He urged HCFA to recognize "the little guys." Ms. Mauser said the Federal Register notice encourages providers to look for flexible vendors. Following on Dr. Mor's point, Dr. Iezzoni pointed out that well-endowed "lead agencies" constitute a skewed population in the home health care field and should not be regarded as typical.
Dr. Mor observed that HCFA's various instruments -- e.g., the Uniform Needs Assessment instrument, the FIM, OASIS, and the MDS -- do not mesh. Ms. Mauser said the agency has started working on this problem and figuring out what data items are needed across all settings. Finally, the Subcommittee asked her to raise with her colleagues the question about language. She also will pass on a suggestion to look at WHO's quality of life assessment, which has been developed for multiple languages and cultures. Dr. Iezzoni thanked the speakers for meeting with the Subcommittee.
Members agreed to send a letter commenting on the matters discussed above. They highlighted the following concerns:
· questions about the interpretation and use of the data
· the gaming issue
· questions about why the agency is moving on the rule before the demonstration project is completed, and at a time when the health care field is in considerable flux
· the mistaken assumption that one tool exists that can be used by everyone
· the language issue
· cultural issues
· validity questions
· concerns about the burden of audits on patients
· subjectivity/bias issues
Dr. Mor agreed to draft a letter in consultation with Dr. Iezzoni and other members, with the aim of having the Committee act on it at the forthcoming meeting.
The group reviewed proposed revisions of the report by the former Subcommittee on State and Community Health Statistics. They approved the changes. The final report will be presented to the full Committee.
Members agreed to meet July 21 to develop plans for their project on Medicaid managed care and to develop a scope of work for a contractor.
Dr. Amaro briefed the group on her correspondence and conversations with Dr. Sondik about plans and ideas for race and ethnicity data. He has asked to pursue this discussion with the Subcommittee as soon as possible. They agreed to invite him to join them in the mid-afternoon on July 21.
Dr. Iezzoni then adjourned the meeting.
I hereby certify that, to the best of my knowledge, the
foregoing summary of minutes is accurate and complete.
/s/ Lisa I. Iezzoni November 7, 1997
Lisa I. Iezzoni, M.D., M.S., ChairDate