MEDICAID MANAGED CARE: WORK PLAN DEVELOPMENT AND PRESENTATIONS
PARTICIPANTS:
Subcommittee:
Lisa I. Iezzoni, M.D., M.S., Chair
Hortensia Amaro, Ph.D.
George H.
Van Amburg
M. Elizabeth Ward
Staff:
Carolyn M. Rimes, Key Staff
Olivia Carter-Pokras, Ph.D.
Patricia
Golden
Ronald Manderscheid, Ph.D.
Committee Deliberations:
DR. IEZZONI: I'd like to get started. Today is the second day of our subcommittee meeting. For folks in the audience, welcome, but what we are going to be doing today, and we don't mean to exclude you, but we have some work that we need to do with each other. So we have organized the table so we will be basically having a dialogue.
Our feelings wouldn't be hurt if you left or if you stay. Whatever you want to do. At one point I guess we'll see whether there are any suggestions that you might have, but this is going to be basically very much of a working session, so I apologize if people's backs are to you. That's kind of rude, having your back to some people.
What we need to have by the end of this morning, whenever that is -- it could be in an hour, it could be in three -- is we need to have a sense of three things. The first is what we want to come out of this nine month effort that we have been spending looking at Medicaid managed care.
Who our contractors will be for work that we are apparently able to contract for. We have a little budget for this project, and so the subcommittee should have received a list of the potential contractors that we can choose from.
Then finally, just kind of a preliminary sense of what we want to do with our site visits.
We had hoped to start this morning with a presentation from Pat Golden, however, on what she has learned on the islands and territories meeting that we had tentatively schedule for December. Pat will hopefully be coming. She has probably had some delays in travel.
For those who aren't aware of this, this will be Pat's last day with us. She will be moving on to other places, and so Marjorie and Jim are going to be thinking with me about how to staff that particular function. It may or may not be feasible for us to have the territories meeting in December. We are going to aim for that.
For a variety of logistical reasons, it still would be a good schedule for us to do that, especially if we hire a contractor to do some stuff for Medicaid managed care. It would be nice to give them a few months time to do that work before we meet again about it.
Marjorie and Jim will be working with me on that staffing issue.
So are there any questions about that comment?
MS. GREENBERG: Just maybe a confirmation that folks are basically comfortable with the --
DR. IEZZONI: I didn't send that around to everybody. I sent to Hortensia, because we were going to talk about that with Pat today. That was a memo to the staff.
MS. GREENBERG: That was just kind of laying out the meeting.
DR. IEZZONI: I was just kind of laying out what I wanted Pat to do basically. Let's talk about that. Let me just ask you guys who are on the subcommittee what you would prefer. I often will go back home after these meetings and just the next day or within a week or so write a memo to the staff about issues that we raised during that particular meeting and things that we need to follow up one.
Respectful of the overwhelming burden of paper and messages that people get associated with this committee, me being on the receiving end, I only send it to people that I think really kind of would be interested in seeing this, or have been very intimately involved with it. I'm happy to send all of these memos to everybody if they would like them. I didn't think so.
DR. AMARO: We were just sending a memo, because I gave you some input about content, and then you were just checking with me. It would be good at some point to get input from everyone, and get everybody thinking.
MS. GREENBERG: Lisa, I would say that your pulling things together after the meeting is very helpful to staff.
DR. IEZZONI: Actually, some of you might have received yesterday in your materials, and IOM report about disability. This was a loose end after the meeting the first week in September. You might remember that -- Pat Golden is held up in traffic because of a major traffic accident, but she will be here to do a presentation. I gather in Washington, D.C. that major traffic accidents can delay things for hours.
[Discussion regarding people moving to the table.]
DR. IEZZONI: Jason Goldwater, who is a presidential management intern. He will be kind of helping with the Medicaid managed care project.
Basically just to finish on this, this was a follow up from the meeting that we the first week in September. You might recall that we had a presentation on the Social Security Administration's disability survey that they are planning, and we had some serious concerns about the methods. Like from the moment that the poor man opened his mouth we were just shaking our heads.
He said that the IOM had actually given them feedback on their methods. So what this is the IOM feedback. So we can look at this. We didn't get enough of a presentation to really have a sense of it, but we can at least read this and see whether we want to follow up on that issue briefly at one of the subcommittee breakout sessions or whatever.
Let's not do the territories discussion until Pat Golden comes, because although she has only worked on it a little bit, she has some interesting insights and some interesting observations that I think can inform some of that discussion. So let's hold that off.
So about the homework that we were kind of all assigned to think about what we want as the product from this endeavor, George, Hortensia, Elizabeth, what are your thoughts based on yesterday's discussion and what we did in July?
MS. GREENBERG: This is what Stanley provided me with. It is Section 4753.A1F. "Effective for claims filed on or after January 1, 1999, provide for electronic transmission of claims data in the format specified by the secretary, and consistent with the Medicaid statistical information system, MSIS, including detailed individual enrollee encounter data, and other information that the secretary may find necessary."
DR. IEZZONI: That is being interpreted according to HCFA as?
MS. GREENBERG: The enrollee encounter data I guess, up until then it sounds pretty claims to me.
DR. IEZZONI: Pat, why don't we give you five minutes to catch your breath, and then we'll get started on that. Basically, George it sounds like the language that Marjorie read to you is the language that we have. The guy from HCFA yesterday said that they were interpreting that as meaning that there are going to be encounter data reported.
We're not going to solve this, unfortunately, right now, unless Jim, there is a higher authority that you would know that somebody could go to right now?
MR. SCANLON: No, I think they are sorting through, Lisa. There are a lot of provisions in the Balanced Budget Act for HCFA, and they are just sorting through -- on the assumption that it will at least provide for some authority for reporting, what leverage or what advice the committee might want to give.
MS. RIMES: My old boss worked on the balanced budget thing in HCFA. I'll give him a call too.
MR. SCANLON: On the assumption that they now view it as authority either report to the state or report to HHS in some standardized way, I think we should at least think of how the committee might want to lay in there. It doesn't mean it will happen.
DR. IEZZONI: I heard very clearly yesterday that people suggested that we take a step back and say, what do people want to know first about quality and access, is that I would propose we focus on. Do people feel differently?
DR. AMARO: As opposed to cost?
DR. IEZZONI: Yes. I think biting it all off will be just too much for us. Quality and access is a lot. We could maybe do access. Access I think is maybe the clearest and most obvious concern. I was thinking also just saying access.
DR. AMARO: It seemed to me that a lot of what we heard yesterday was regarding just the lack of standards, the lack of requirements, all the way from any kind of national standards through what are tracking, through contract language, to problems with the data systems if you were to do this with the political and turf issues and all that.
It seemed that one of the contributions we could make is really contribute to highlighting the need for starting to provide some forum for the discussion of the issues, and for the development of standards, performance goals, issues around requirements of including this kind of language in contracts. That if you did that about collection of data, it could, I assume, be about all those issues -- access, quality and cost.
If you are talking about not us doing some definitive study of what the answer is to the questions we started out with at our last meeting, but rather with trying to develop a set of standards or guidelines for setting up systems that will eventually yield the data over time.
I'm willing to hear the other side, but it seemed that setting up the data systems is what we heard most people saying was really critical. Once we take that on, it would be important to have the data systems include cost, otherwise I think we will find ourselves down the road instead of being part of the question.
DR. IEZZONI: I agree. I just thought doing all of it was going to be overwhelming. So I thought data systems around the question of access was one way to focus it.
MS. WARD: I guess I can't image we -- asking a performance question and getting an answer to it. Some states believe that access to care is the quality measure they are interested. Some states are already trying to answer those questions. I'm not in a position to ask an analytic question, and think we're going to get an answer to it.
Where I'm sitting is more where Hortensia was, that as an advisor to the secretary, I see some process issues about how different federal agencies are trying to do performance measurement, and what requirements they are or are not requesting of the people who are reporting. I want that chaos to look less chaotic.
I'm very concerned that we heard a lot of work going on with CDC around performance measures that could not have been any more in opposition to some of the Medicaid contractors we heard from. That is what concerns me, because I'm sitting here thinking about what that chaos is doing to the providers of health plans and the state agencies.
They are working in many states with researchers in those different states. Almost all the states have some academic affiliations. There was testimony that talked about states are doing quality measurement for which they are not prepared. The states I know are working very closely with renowned quality outcome people who are situated at academic settings, and they are much closer to what CDC was saying in terms of there is no researcher who has said this is the way, and the only way to do quality measurement. It doesn't exist. The science isn't there.
So that's what I went home thinking; what could we contribute to our oversight of what is being done that could help remind the secretary that we got some rather conflicting processes.
DR. IEZZONI: That was a really eloquent statement. When I hear you say that, I say, sure, that's what we should focus on.
Out of respect for Pat's time, why don't we keep these thoughts in mind, and Hortensia and Elizabeth, we'll come right back to them as soon as we can.
Pat, I have already told the committee that this will be your last time with us, that you will be moving on to other things, but that you have been thinking about this issue of the study that we want to do, the brief study on the territories, and that this morning you were going to spend some time giving us some of your insights.
MS. GOLDEN: I had hoped to be here in time to assemble these materials for you, so I apologize, but I will just pass them, and you can just take one and continue to pass them on somewhat in the order that I am giving them to you.
I think probably in the interest of time I'll just read quickly from my notes.
In looking at the charge, what I thought I needed to do, and perhaps we're also interested in is just what areas were we actually talking about. I know that we have used the term "territory." I have also heard insular areas, Pacific territories and other outlying areas, territories and possessions, outlying areas and possession, Caribbean and Pacific Islands, U.S. flag territories, and truly associated states.
As I tried to talk to various people, I realized there really is no consensus necessarily as to which is the more appropriate term. All of these rubrics cover the same entities, and convey their geographic location, as well as some notion of their political relationship to the United States embodied in the constitution, treaty, compact or some other mechanism.
As a result of the manner in which these relationships are codified, the relationships with the U.S. are varied, but also share some commonalities. In general, we seem to be speaking about the following type of relationships: a U.S. commonwealth or territory, which is a permanent part of the United States; a freely associated state, which is a sovereign nation, whose security is provided by the United States; or a U.N. trust territory, which is temporarily administered as a territory of the United States.
Moreover, different agencies use various of the rubrics out of custom, or in an attempt to capture their own particular relationship to the areas and/or in an attempt to capture their sense of the politics of the area, or for some other unknown reason.
For example, as discussed below, Health United States provides data on cases of AIDS for U.S. dependencies and possessions and independent nations in free association with the United States. I think you have a handout that says "Technical Notes," and that discusses what we get from the AIDS surveillance system.
You also have prior to that, a write up is about as accurate as I could determine, of what those areas are. It's the second handout. I think it follows the map.
The relationship of these Pacific and Caribbean areas to the United States has changed over time, and holds the possibility of continued change. For example, Puerto Rico, a U.S. possession since 1898, became a commonwealth in 1952. Since then, Puerto Ricans have considered three different political status options: statehood, enhanced commonwealth, and independence.
A somewhat more purist understanding and codification can perhaps be based on information from the Department of the Interior Office of Insular Affairs. That is what is shown in the handout that says, "United States Insular Areas and Freely Associated States." I pulled some of that information from materials I obtained from the Interior Department Office of Insular Affairs.
This office uses the term United States insular areas and freely associated states. The office lists 14 U.S. insular areas, and they are listed on that handout. The office mentioned that territories are addressed in the U.S. Constitution, and the term "territories and possessions" is still appropriate for some of these areas. Some of these areas have very small populations, and some are uninhabited. On the handout I have asterisks those areas that I think would be of some interest to this particular body.
The Office of Insular Affairs lists also three freely associated states: the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau. All three are in the Pacific. As mentioned, these freely associated states are self-governing, however, the U.S. has various compacts of free association with these entities.
Additionally, the Department of the Interior Office of Insular Affairs recognizes several formally disputed islands in the Pacific, but I do not feel that we'll probably have any concern about those areas.
The mission of the Office of Insular Affairs is to manage, coordinate, and implement federal policy in the islands under its jurisdiction. The Commonwealth of Puerto Rico does not come under the jurisdiction of this office, and few other of the islands come under jurisdiction, such as various arms of the Department of Defense and the U.S. Fish and Wildlife Service, however, nothing precludes arms of the federal government from working directly with the islands, except perhaps those under jurisdiction of the Defense Department.
Various programs of the Department of Health and Human Services already work with and have presence in some of these areas.
A couple of other terms that are mentioned on there which may or may not concern us, but some of the islands are unincorporated, and that means that not all of the provisions of the U.S. Constitution apply. Some are unorganized, and that means that Congress has not provided the territory with what is called an Organic Act, which organizes the government much like a constitution would.
In sum, the political status of these islands in reference to the United States varies quite a bit. In terms of what would be of further concern to us, these islands are multi-ethnic and multicultural. On some of the islands both English and another language are considered the official languages of the area. There is also diversity among them and within them with respect to the organization of health care delivery, and with respect to other government and social institutions.
Some additional information that I have uncovered is as follows. First, it appears that the U.S. Department of Health and Human Services works with these areas on three levels. One, through grant programs, block grants, formula grants, and also discretionary grants, through out stationing of PHS staff, and through various work groups such as ours, who look for opportunities for involvement relevant to their various missions.
In 1994, the Department of Health and Human Services began an initiative to enhance its current programs in the Pacific Basin, and established an intra-departmental working group, chaired by the Office of Public Health and Science. The purpose was to facilitate communication and coordination around Pacific issues. Additionally, each agency was asked to establish their own internal work group to address the Pacific Basin.
CDC has such a group, and I have been in touch with Bud Nicola(?) at the CDC on the work of the group. He is the person that sent in the handouts that described the output of one of the meetings. Lynnette, you are also on that work group. Of particular note to us is the fact the CDC funds an epidemiologist in the area.
It also appears that these departmental work groups have assembled quite a bit of data on the health status of the various islands. For example, the fiscal year 1996 HRSA on the HRSA Pacific Basin Initiative included a health profile of each island. You have an abstract of their report. In the back, I think on the last page, perhaps page 3, there is a particular note on the source on the quality and the data, however, that the report encompassed.
I spoke with Howard Lerner at HRSA, who is quite knowledgeable about the workings of the HRSA group, and also knowledgeable about a number of other activities in the area. Howard was also able to talk a bit about an IOM study funded by HRSA. This is a five year study which should come out in December, and has three main objectives, one, to evaluate the medical office's training program in the area, and this is a special program that trains people post-high school, to deliver health services.
I think it was probably very much a project of Sen. Inouye. What is happening is that after this training, there is some concern about how the continued medical education of these particular people will be sustained. So one purpose of the IOM study is to evaluate that precis.
Another purpose is to evaluate the status of the health care delivery system in the Pacific Basin. The third of course would be to recommend some feasible action steps to improve the health status in the area.
The Department also has an Office of Pacific Health and Human Services in the Office of the Regional Health Administrator of Region 9, the purpose of which is to facilitate operational coordination among agencies, and to triage requests from the jurisdiction to the appropriate program contact.
There are several other departmental initiatives that would probably be of interest to this group in coordinating its work around these territories. One of course is the Healthy People 2010 Initiative, the Healthy Communities Initiative, the Asian and Pacific Islander Health Initiative, the Hispanic Agenda for Action, and perhaps some others. The Office of Minority Health appears to have quite a bit of involvement in these initiatives.
There are several data initiatives that I would like to bring to your attention, and one of which is the NCHS vital and health statistics activity. We collect and publish data for Guam, Puerto Rico and the Virgin Islands. You have a handout that I prepared for the Healthy People 2000 review for the Asian- Pacific Islanders. In there I do discuss data from Guam which was pertinent to that particular activity, but it is illustrative of what we are doing in Puerto Rico and also the Virgin Islands.
In addition, Health United States provides data on cases of AIDS for U.S. dependencies and possessions and independent nations in free association with the United States. That is the rubric under which these data are published, and I have referred to that earlier, and you have the handout that describes some information from their technical appendices.
I have also spoken with people at Census, which collects decennial census data in Puerto Rico and the Pacific Islands. Census also conducts the Current Population Survey, and it makes estimates and projections. These estimates and projections are now done under the International Office at Census, however, they are certified by the Estimates Branch at Census. These individuals work very closely with individuals in the various territories.
I also was able to come across a report funded under a HCFA grant. That particular report discusses a project that was designed to analyze the structure of the health care delivery system in Puerto Rico, and to assess the applicability of U.S. health policies on the island.
This project was carried out several years ago, with the goal of gathering information to provide health policy makers in the U.S. and Puerto Rico with a detailed framework of the Puerto Rico health care delivery system, which would then result in coordinated efforts in the implementation of health care reform. Nevertheless, as I read the report, I thought it contained information that would be very useful to this group.
The first stage of the project consisted of gathering and analyzing data on the health status of the population of Puerto Rico. The report used Medicaid/Medicare data, vital statistics data, Census data, and data from local sources.
For all of the information that I have mentioned, there are a number of people that I have identified as contacts, and a number of whom I have asked to mark their calendars for a December 9th meeting.
As we continue to plan for this project and define its rationale, several other issues came to mind, one of which was the population that we addressed at minorities on the mainland, we need not be reminded are for the most part, not minority in the islands that we are addressing. There are other populations that tend to be minorities on those islands.
Second, some of the health and health status issues are more closely aligned to those of Third World countries than to the health status issues that we discuss here in the U.S.
Third, when we have attempted to have projects even in the area of data collection, I have found through my discussions that the logistics and lack of infrastructure have proven extremely problematic to the success of these efforts.
For the most part, government-to-government relationships with these areas are under the purview of the State Department, while other aspects of the U.S. relationship to these areas are under the jurisdiction of the Department of the Interior, part of whose mission is to manage and coordinate the implementation of policies and programs dealing with these areas. With respect to the Department of Interior, these areas deal principally with programs that give monetary and technical assistance to the territories.
Also in talking with a number of people, I was very much reminded of many political nuances that come to play as we work with these territories.
So those would be some guiding background factors as we plan to carry this project forward. I have a list of contacts that I have made, as I have mentioned. I have a long list of participants who were at the Voices Conference which was sponsored by the Asian-Pacific Islander Health Forum, which preceded the Healthy People 2000 review process. I think that a number of those participants would be very useful to the group also.
DR. IEZZONI: Thank you. Are there any questions for Pat?
DR. AMARO: That's very helpful to have all this background. Thank you.
MS. GOLDEN: Now I guess in terms of how to proceed?
DR. IEZZONI: Right. Why don't we just kind of talk as a committee briefly about what we want the outcome of this to be? Hortensia was the instigator of this interesting activity. It is one, however, that is not as big as our Medicaid managed care program. So the idea was that we would have a one day kind of meeting, with a lot of pre-meeting background paper thing, and then have a second half day meeting where the committee would kind of decide what recommendations we might have based on what we heard the prior day.
So Hortensia very helpfully made a list of the kind of things that she might like to hear about as background. I kind of expanded some. That is what you see on this memo that I wrote to Pat and other subcommittee staff.
Poor Marjorie said that when she looked at this she said, "Oh, my God, this looks like a lot." I said, Marjorie, you had to look for the word "brief" in there.
MS. GREENBERG: I really am not knowledgeable about this area at all, so that was probably partly my reaction.
DR. IEZZONI: This looks like a lot, but I think actually a lot of what Pat has already done gets us quite far along some of these issues here. So I guess do other subcommittee members agree with how Hortensia and I were kind of framing this? That it would be a one day meeting where we hear this, and think about the issues listed in this memo that Hortensia and I came up?
Then hopefully what we would do is have staff help us write a 10 page kind of summary paper that would have recommendations. That would kind of be what the output of this would be.
MS. GOLDEN: As I talked to various individuals, I listened fairly attentively to see who I thought might be able to be most contributory to the process. So I guess my plan was to identify those individuals, and give you a brief blurb on what I thought their contribution would be as speakers. Of course I would expect the OMH and others would maybe want to add to that.
Also, I had planned to be quite involved in at least still executing this through, if that is appropriate, and to certainly be involved in writing the report.
DR. IEZZONI: Oh, okay, great. Well, what I would like to do is just say with the committee's approval that we will at this point, move forward on this plan. Hortensia, is that okay with this date? And we will celebrate your birthday. The first day is Hortensia's birthday, and we'll make a special point to celebrate that, because that is truly a great sacrifice to come to Washington and be here at the Humphrey Building on your birthday.
DR. AMARO: Well, it's not the fiftieth quite yet. If it was, I wouldn't be here.
MS. GOLDEN: Are we running into a holiday of some sort during that period. Howard Lerner mentioned a Jewish holiday, but he didn't have his calendar handy.
DR. IEZZONI: No. I think the dates are still good. We all have them on our calendar, thank goodness. We're not going to move the dates.
So what I would like to do at this point is just anoint staff. I would like to ask staff to kind of talk among themselves about what people's time availability is. Olivia I know that you have a lot of contacts, especially in the Atlantic. You know Puerto Rico.
DR. CARTER-POKRAS: [Remarks off mike.]
MS. GOLDEN: What I have is that also, and in there I have already identified -- in throughout my little write up, there was no need to read names et cetera -- but I have the state data center in Puerto Rico. We don't have one in Guam. We don't have one in the Virgin Islands, but I do have the contact for that person.
We also have Census data people in these islands, and I have a list of those names; just a host of people, but I didn't think that was appropriate to give you that list at this point.
DR. IEZZONI: It might be that we don't need people to actually make presentations, but there might be people from like Census who get us some of the data; one is background stuff. That is day going to be very full, and so to the extent that we can have written background materials before, that would be great, and it would also facilitate writing the report.
Why don't I just ask staff if you would coordinate among yourselves people's time availability, the respective roles that people want to play, and get back to us, kind of organized maybe around the framework that Hortensia and I put up in the memo.
MS. GOLDEN: We'll give you this. I probably have some of the same materials.
DR. IEZZONI: Actually, can I leave this.
MR. SCANLON: I think what we may do is prepare a binder for you.
DR. CARTER-POKRAS: Some of it we actually received from other people. There is the latest vital statistics report that we received from Puerto Rico that we received when we were planning the Hispanic progress review. So I only have one copy of that in the office. That is our office copy.
MS. RIMES: I'm not suggesting that we need to distribute it right away. I was suggesting maybe I could take a look at it.
MS. GOLDEN: Why don't you take it then, because I'm sure that we have the same report.
DR. CARTER-POKRAS: Some of the summaries that we did in- house about the available data for the Virgin Islands or the Pacific Territories -- the Pacific Territories summary is in the Healthy People 2000 progress review, and also for Puerto Rico. So we have already done some of the gathering of information.
MR. SCANLON: The overall objective -- let's be clear -- is a fact finding analytical effort so that we could end up with some potential assessment of weaknesses or limitations in any and all of the territories, and possibly make some recommendations.
DR. AMARO: To make a recommendation or a number of recommendations to the secretary that would be informed by all this fact finding about how we might improve data systems, where it might be sort of easier to start, where challenges might be overwhelming. To assess the situation and make recommendations about what might be feasible and appropriate based on what we find on everything, all the dimensions that have been mentioned, including the political nuance as you put it, of the different territories and islands.
I think that my recommendation initially on this comes from the perspective that we have assumed -- our government -- some level of pretty serious responsibilities that impact the lives of the people who live in these areas, including the development and maintenance of a public health system and health care. Yet, we have had very little systems to kind of look at and to track in fact what are the health problems.
We should start thinking a little bit more broadly about the U.S. also includes -- and kind of bring them into our awareness, so we can evaluate and move toward inclusion of them in appropriate ways in our data systems. That is really my goal, and I think the rest of it will evolve from what we learn.
MS. GOLDEN: As I mentioned, some of the people that have been involved in some data efforts out there, I think those would be the more appropriate people to bring in. The rest of it would be background information. So I have made notes throughout my discussions with them, people that I thought would be best able to contribute to that particular part of the process.
DR. IEZZONI: That is excellent. You know let me just make a statement, and I think Hortensia, you will second me on this. We are realists. We don't want this to be an enormous effort. We want people to rely for the background material on things that are readily available.
DR. AMARO: Right. I think my interest is not in out of this coming some huge structure of events, but rather to start to set in motion a number of steps that will continue through the department. That this will really be sort of the stimulus and the impetus for a lot more work on this, where some of these recommendations can be further evaluated and implemented, et cetera.
DR. IEZZONI: I think a consciousness raising activity, because I think a lot of us had no clue about the kind of issues, Pat, that you were talking about in terms of relationships with different geographic locales. I don't even know what to call them now, given what you have described.
Okay, so that's helpful. If you one of you, Carolyn, Joan or Marjorie can get back to me, to just give me a sense of how you might think about organizing this, working with Pat and Olivia, to the extent that you have time. We need to make sure that mental health is at the table on this one, because I think that SAMHSA are some of the block grants.
MS. GOLDEN: I didn't call Manderscheid, but I do know that SAMHSA participates with the HRSA group.
DR. IEZZONI: There might CDC.
MR. SCANLON: I assume that the territories report.
MS. GOLDEN: The epidemiologist that is in the island is funded by CDC. He is out there this year, and CDC had agreed to be one of the presenters if we can't get the epidemiologist himself.
MS. WARD: I'm just trying to keep in focus what the point of all this activity is, and that has been helpful to remind me why we are doing all this, and what we do want to have be the outcome. So if we could keep that in front of anyone who presents, so we don't just get an historical, the beds per 1,000 for Puerto Rico, that is meaningless to me.
What I want them to say to us is if you could have someone in the secretary's office tell you to do something different that would go somewhere, much like we did yesterday with what would be your recommendation to improve what you think is going on in terms of information systems, data collection, monitoring of the health status so that they have that question in front of them, and we don't get buried under data about the health of these people, because that is not going to get us anywhere.
DR. IEZZONI: I think that that is essential background, because I think that that informs some of the data issues, frankly. If endemic infectious diseases are a big problem, that's a very different data issue than if they are not.
But I think that you are absolutely right, we want that day of meetings to focus on information systems about health, what the barriers are to getting more information about health, and how we might think about improving it. So the rest of it is background, and we want it to be brief, because we only want a 10 page report to come out of it. We want a distillation.
MR. SCANLON: We'll probably have a binder.
Is this going to be held in Washington?
DR. IEZZONI: No, this will definitely be held in Washington.
MS. GOLDEN: The last comment, and I hope you might remember that I had asked one or two people if they thought they could be present to submit to us some of the presentations that I heard in San Francisco. One of them I thought was particularly relevant, because it talked about health status indicators. They had a list that was more reflective of the needs of the island, than as I mentioned, was mainland-concerned.
They were interested in the educational system. They were interested in housing, running water, sanitation issues. That is relevant to the point that I said that many of the health issues are really more Third World oriented.
So I think still that this is very appropriate, because the needs assessment might be somewhat different at that level, than what we might anticipate as we followed a traditional Healthy People 2000 model.
DR. IEZZONI: Absolutely. Okay, great. This has been a productive discussion.
DR. CARTER-POKRAS: Earlier I had raised the question about travel costs. If I do need to go back to the head of my office and ask for travel costs to help support this, do we have an idea how many people we would be bringing in from outside, or whether there are additional funds available from the National Committee?
DR. IEZZONI: There won't be additional funds available from the National Committee. We don't have funds allocated to this particular function.
We need to make sure that the people we bring in are on target with this issue of data and collecting information on health. I don't know how many that would be, Olivia. I can't preconceive that, but I think maybe as you all start talking among yourselves about who you have identified as the best candidates, maybe you could let us know who you are thinking might be people that you would like to invite, and we can see what the travel implications are in that.
DR. AMARO: Can I make a suggestion about establishing a criteria for who we invite versus background information? I think that there are a lot of people that you know and that you have mentioned who can get background information, data runs and all that.
I think the people who should be invited are the ones who are in a position because of their knowledge or the public health system and data needs to actually say to us, here is what would really be helpful. Here is the next step that we are ready for, and the rest is background and we can read. The discussion and any invited guests should be people who are really well positioned to do that.
DR. CARTER-POKRAS: One message that we have heard in talking to folks in Puerto Rico is that they felt very much left out of the granting mechanism because of the fact that they weren't able to establish that they had this problem. For instance, if you look at the HIV and AIDS rate in Puerto Rico, it is extremely high. Tuberculosis tends to go hand-in-hand with HIV/AIDS.
Well, when Congress identified the 10 geographical areas that had the highest rates of tuberculosis, Puerto Rico was left out of that. So I called up and I asked the Tuberculosis Division director at CDC about that. He said the reason why was because they only had one laboratory on the island that could do the tests that were required to collect the data to actually show that they had high rates of tuberculosis.
DR. AMARO: What year was that?
DR. CARTER-POKRAS: This was certainly during the last five years. This has again become an issue, because there was a letter that was directed to the secretary again about CDC grant funds; Puerto Rico was left out. This is what I know about Puerto Rico, but it is probably a similar issue for the Virgin Islands and Pacific Islands.
DR. AMARO: So that's an example.
MR. SCANLON: Perhaps the regional health administrator from Region 2 would be New York, and then the Virgin Islands and Puerto Rico would be 9. We might bring the regional administrators in. They would be knowledgeable about these issues.
MS. GOLDEN: I think what we need to do also is get a sense, as I have attempted to do, is to see who is on first with these agencies with this. Then from there we can decide who would be, because we only have one day. I think that the person that is closest to understanding the data on a broad scale would give us the best mileage out of the time that we have.
DR. IEZZONI: Okay, perfect. So you guys will get back to us then? Okay, great. Is everybody okay with that?
Thank you very much, Pat, for braving all the traffic and coming in.
Yesterday actually was a very productive day, I think. I hope other people felt the same way, in hearing about Medicaid managed care. So we have a proposal on the table from Elizabeth as to what might the focus. Hortensia, you were going to comment on that. Can you recreate what your thoughts were?
DR. AMARO: Well, Elizabeth put it a lot more eloquently than I did. I do think from everything we heard yesterday, we are really not in the position to answer a lot of the questions that we identified in our original meeting, because it seems like the data sets are spotty. There have been specific studies, but we certainly don't seem to have the data systems that kind of track these issues over time.
I think the most valuable contribution we could make is to really push toward the development of an infrastructure and capacity building at the states, and at the national level that would allow us to eventually have those data over time, really to sort of put the building blocks in place.
So I guess the product that I'm envisioning is not an answer to does managed care improve access.
DR. IEZZONI: Actually, that isn't what I was proposing either. I was proposing an information system to address that issue. What I was proposing is taking a subset of what you were talking about, just focusing it around how would you begin to look at the issue of access. Do we have the data? I hear exactly what you are saying, that we might want to be a little bit broader about it.
MS. WARD: I think what we can say is what we have heard from all the testimony, is that the capacity is not there for any quality measurement, regardless of what the question is related to Medicaid managed care. What we have to have in place is a capacity if we ever want to get to the point where we can answer those questions.
DR. IEZZONI: I just want to clarify. I don't think that we should ask a question is Medicaid managed care doing a good job? What is the access problem. I think our mandate is to look at data systems and data infrastructures. In the context of what I'm saying, that where my head was, was data systems infrastructure.
Are you suggesting, Elizabeth, that we should focus our data systems infrastructure on quality, or do you think that it should be opened up to everything reporting?
MS. WARD: I don't think we can say today what every state is going to want. There is a national health insurance system that is today, managed by states.
MR. VAN AMBURG: And significantly funded by states.
MS. WARD: And significantly funded by states. We heard yesterday state-by-state will have some of its own questions about their form of Medicaid managed care and things that they want. It may be that HCFA comes out with three questions it wants from every state, to require to report. We might encourage them to be small and consistent about some kind of national question that they want to insist on that would allow them to compare every state to each other for their national purposes.
I think what we are saying is that they are going to have to do -- I think we ought to be able to oversee how they are doing that, so that it is reasonable that we can have perhaps consistent questions that they want, that the capacity for states who are pouring billions of their own dollars into what their particular measurement questions are.
DR. IEZZONI: That is another thing that I heard yesterday, is what do states want to know? So one of the things that we could do is serve as the convener to find out what states want to know about Medicaid managed care. We could also ask what CDC wants to know about it; what HCFA wants to know about it.
Then ask are the information systems there to be able to answer those questions, and what are the various kind of requirements that places like CDC and HCFA are placing on states in terms of reporting information, and as Elizabeth was saying earlier, the inherent contradictions and impositions of that.
MS. WARD: That's getting closer. I think we have to refine sort of what we see as a general problem to something that is more manageable.
DR. IEZZONI: That's why I suggested focusing on quality and access, because if we broaden it and then say what do states want to know, what does HCFA want to know, what does CDC want to know, I suspect that a lot of people are going to want to know what the costs are. That is obviously important, as everyone agreed yesterday afternoon. That's the reason all of this is happening.
If we focus on costs, it is going to take us in a very different direction and very different people that we would be talking to, rather than if we focused also on quality and access.
MS. RIMES: I'd like to make a slight plea too, if we do discuss those terms, as I am finding out listening to things like performance measurement, which is a nice general term also, there is very little consistency when you talk to different groups about what the possibly could mean. I am having to say from just the Medicaid, which is granted, staid and a little more controllable, this is the terminology I am using o define performance measures. Does this comply with what you guys are working with?
So I just recommend structuring it in terms of like what we might mean by things too, because there does seem to be a huge variation.
DR. IEZZONI: George?
MR. VAN AMBURG: I have a different opinion.
DR. IEZZONI: What is your suggestion?
MR. VAN AMBURG: Well, you are talking about having an information system for Medicaid for managed care. I'm not sure that is the issue. We have had an information system for fee-for-service for 20-some years, and how many of you have ever tried to get any information out of it? You can't do it. It's impossible.
I think that when I was working with our Medicaid on the managed care part the issue was what is the legislation going to ask? What questions are they going to ask, and how are we going to answer them, and how are we going to be sure we have information to do that? That may or may not involve an encounter-based data system. That may involve other issues as well, and how are we going to compare that to fee-for-service?
Sue Dodds' comments yesterday is everybody used the UB-92 and the HCFA 1500 for encounters, which makes no sense whatsoever, because we can't get any information on that now on the fee-for-service side that does anything about access or quality.
So I think the issue of us looking at what questions need to be answered by the various parties, whether it happens to be CDC, HCFA, the states is the place to start, but not to assume that we are going to require a large information system on every encounter that is going to forward to the states or the federal government.
DR. IEZZONI: I don't think there is that assumption.
MR. VAN AMBURG: That's what it sounds like when you talk about information systems.
DR. IEZZONI: No, what I meant is, is the information available to answer the questions. That would be a system, but it doesn't have to be a system.
MR. VAN AMBURG: That's right. There are a lot of ways to do this.
DR. IEZZONI: That's what would be very interesting to hear.
MS. WARD: Hortensia and I were using the word "capacity," because I don't know what the capacity is going to be yet. I can't say today what I think that capacity is. That's why I'm saying I think it is still for me, very global. What we know is that billions of pieces of data have been collected for years about Medicaid recipients, and most of it is garbage.
MR. VAN AMBURG: That's right.
MS. WARD: So when I talk about capacity, I mean something that will in fact answer questions. I agree with you, George.
DR. IEZZONI: Now I actually think that we are all in agreement on that. Absolutely. I don't have any preconceived notion either that it should be a universal encounter system. I can say that I have gotten 79 million Part B claims from Medicare to do research on, and so I don't think that it's fair to say that you can't get any information --
MR. VAN AMBURG: That's Medicare.
MS. GREENBERG: What is it about Medicaid, although in the area of quality in particular I would say it probably the 1500 and the UB-92 certainly aren't your gold standard, but that in the Medicare data system, which those are the two bulwarks of, there is the capacity to look at some of these issues.
DR. IEZZONI: The difference in Medicaid is denominator, Marjorie.
MS. GREENBERG: I'm sort of asking a rhetorical question. What are the differences? Denominator, state run, there are a number of different issues. What types of actions could maybe help with that or address that? They are very different populations and situations.
DR. IEZZONI: I just really want to think concretely at this point, because we have got to do that. If we say that what we want to do is first ask what do the various stakeholders want to know about Medicaid managed care, including states themselves, HCFA, CDC, SAMHSA, whoever else might be involved, is that a manageable thing to ask? Or do we need to be more specific and say what do the various stakeholders want to know about this aspect of Medicaid managed care?
I agree with Carolyn that you need to define your terms, but I think that you could differentiate financing and cost from other things. Do people feel that to be manageable, this project, that we need to focus in on specific topic areas, or do you think that we should just ask the question very broadly, which would result possibly in the same kind of thing that we did in July, where we came up with a list of 30 different questions?
DR. CARTER-POKRAS: With the president's initiative on race, we found that there were certain things we just could not get our hands on. I don't know if it would help, because it is such a broad spectrum to look at Medicaid managed care. But to pick maybe a couple of health problems that you want to get more information about, and just see what you can gather on the kinds of questions that you would like to have answered; whether those questions could be answered.
We found when we were going through this that we basically don't have any information in the department about diabetes management. We do on diabetes complications, but not on management. So that may be an example, like prenatal care or something else, that you may want to just pick a couple of key health indicators and flesh it out, what would you like to know about those health indicators, and see whether the data systems are in place to answer those questions.
DR. IEZZONI: That would be one way to narrow the focus.
MR. SCANLON: I kind of like the idea of starting with the fairly broad approach. The National Committee does this very well. You can get the right people to the table. You can ask what are their information needs, current and emerging.
DR. IEZZONI: Now what are the questions that they want to ask about Medicaid managed care, and what is the information that is needed?
MR. SCANLON: They will fall, as they normally do, into the categories of cost, access, capacity, quality, and outcomes, and you can sort them out that way. Then I think you can ask about -- there won't be a single system that solves all this, obviously. Encounter data will help, surveys will help, research will help, HEDIS-type measures will help. Just to sort of be able to lay that out and indicate where some improvements could help in how it all fits together I think would be immensely helpful. You would have to get the right people from all of these perspectives.
DR. IEZZONI: Do people think we should start with that as an open slate, that's fine. We just will need to make sure that we get the right people to the table, and that we have a diversity of people at the table; that we don't have all people who are interested in the cost side of the equation, but that we have people who are interested in disease management and access and advocacy groups.
MR. VAN AMBURG: I would suggest on the state side that you pick someone from the public health side, as well as the Medicaid side from the same state.
MS. WARD: Because I think what I heard as the theme yesterday was that potentially we are going to be building some sort of -- that HCFA is going to be starting to move in the direction of collecting more data. Without having heard from them, why are they collecting it?
Until they can tell states why they are going to mandate anything around data, I think it is foolish until they say what is it that they want to -- how are they going to use the data and how are they going to compare the states, if that is what it is. They have simply got to start with why are you collecting the data.
DR. AMARO: And in the processing of hearing this, there was a series of issues that we kind of have to keep in the back of our mind and figure out how -- for example, the issue of what happens to this information system when you have capitated rates, and people are maybe not motivated to fill out all the current forms that are in place?
So trying to think about not only where managed care is now in its many different forms and different states, but where it is moving to, and trying to think forward to a way of answering questions. Setting up systems that will still be relevant as that system changes over time.
MR. SCANLON: The other point, and the committee is always good at bringing this in is to start with a set of principles so that we don't continue to set up sort of separate, specific focus information systems to the extent that any of this can be built off the mainstream and what is going on generally in the industry.
MS. WARD: We are working in the background of data standardization. That's what we are saying, is there is now this national mandate. You federal agencies have got to work within that structure. That is, you can't all go off an do isolated, individual data collection systems when the world is telling you to standardize. To me, that's the sort of background of why we are saying, why are you doing what you are doing?
DR. IEZZONI: So basically I like this, because this goes to the top of our camera. The issue of what questions do you ask was the top of the camera. So I guess that is what we are going to do here.
I was just concerned, because as I have been talking to staff about this, they have been telling me, Lisa, you are not being specific enough. So that I am glad to hear Jim now saying that this is the kind of thing that this committee does really well.
So I guess we are being specific enough. So what we would do -- do we have a meeting in January scheduled? We have a special subcommittee meeting the 12th and 13th. That would be a good time to bring in people from the CDC, people from HCFA, people from states to the extent that we can, and that's going to be an issue, but we want to make sure that we get the states people there, and advocacy group people, people representing vulnerable populations. So that is what we could do on those two days, is hear from people about this topic.
MR. VAN AMBURG: Is there any possibility of getting anybody from the state legislature?
DR. IEZZONI: That's a good idea, and actually from the federal legislature too. It might be very interesting, because if it is the federal agencies that are asking all this conflicting or potentially burdensome requirements, where is the House and Senate on some of this?
MR. SCANLON: They are the ones who got the provision in the law that you read out earlier today.
DR. IEZZONI: Right, but it would be good to hear what the expectation is.
MR. SCANLON: What the rationale was.
DR. IEZZONI: What is the legislative history of that?
MR. SCANLON: I think CDC's interest is more in the nature of assuring that Medicaid managed care contracts in the states include some public health provisions. I don't think it is so much data systems as it is to assure that certain public health services are part of the contract, but I think we will find out.
DR. IEZZONI: In the presentation from Sara Rosenbaum yesterday that really indicated that the multiplicity of CDC requests for information has become enormous and confusing.
MS. GREENBERG: I didn't hear that. I was just reflecting on what you said about Sara. I think she said that there were a lot of different programs in CDC who were interested in how Medicaid managed care was playing out at the states, and how it would impact on these various preventive services. I don't know if it was so much conflicting.
DR. IEZZONI: It was more the HCFA thing. What was it that was talking? The Lewin guy, Danny, was talking about the MediCal people in California said that what HCFA is requiring them to report is really getting in the way that they would want to construct their information systems to be able to maximize what they need to do to manage their managed care. So we should hear about that.
MR. SCANLON: The methodology basically will be hearings and possibly some analysis.
DR. IEZZONI: I was just going to say, let's talk a little bit about the contract work, because I think that yesterday Sara -- is she one of the contractors?
MR. SCANLON: Yes. She's with G.W. Center for Health Policy Research.
DR. IEZZONI: You know I assume that she has already prepared a report for whoever has been funding her.
MR. SCANLON: She has reviewed literally the contracts in all the states.
MS. GREENBERG: I'm having a thought here. We talked to her or the folks at CDC over a period of time where each of the programs is working with her to see what type of contractual language needs to be included. The point she kept coming back to is if it ain't in the contract, don't even think you're going to see it. Even if it is in the contract, obviously it takes a long time.
I think they are interested more to see that certain services are provided; that they have been looking to somebody, possibly NCHS, to underwrite part of her work to really look more broadly at what is the information infrastructure that you want to build, and thus what kind of language do you want in the contract to assure that you have that?
This is a perfect question for this committee as Jim said. This is the type of camera and really sort of the broad issue that this committee I think was created to look at. It could be that in some what you are doing could lead to that. Could not necessarily tell NCHS do this, because I think NCHS to some degree hasn't felt like it was really in a position to define this unilaterally either. We could use the contract money to some degree to push that forward.
DR. IEZZONI: That sounds like a really good idea.
MS. WARD: I think of that as the next stage, if we can get people to say what questions they want answered.
MR. SCANLON: Just to describe what the various state contracts suggest about information requirements would be --
DR. IEZZONI: That's what I was thinking. Maybe this could be a part one and two project. Part one would be something that we could ask her to start on right now, which is kind of basically describing the contract language maybe with respect to information. Then part two coming after the meeting in January, where we ask her to move forward in thinking about --
MS. GREENBERG: With you; working with you as to what that language might be. I think this could be a really concrete accomplishment.
DR. IEZZONI: Yes, that would be good.
DR. AMARO: It would be particularly good to have her review with us if there are any sort of best practices or examples out there of contract language, sort of moving in the right direction.
I thought that there were several presenters yesterday who have access to data that if analyzed, from our perspective, could have help to be sort of part of the background work that could be done, including Mendelson and Jessica Banthin and Robin and I think Jeff also, where they could make their analysis more specific to the issues we are interested in, and give us more background information.
DR. IEZZONI: I know, I felt the same way, that it would be nice to have more background information specifically from NHIS and from MEPS around what is going on out there right now in Medicaid managed care according to NHIS and MEPS. So we wouldn't need to spend our contract money on that, because that is internal work.
If we could somehow try to get that on their agenda, that we would really like as much cross tabs and cross-cuttings, and descriptive statistics around the population that is the Medicaid managed care within their data sets, that would be great background information.
MS. WARD: I think what Daniel had started was that you can't answer the questions if all you have is just Medicaid data anyway. Part of what I was -- so, we're going to spend billions on just a new, enhanced single system, and still not be able to have states answer the questions, much like when they started the prenatal care expansions. Contracts that went from Medicaid actually required the Medicaid office to work with the public health office, because they actually at the national level said you can't do this by yourself.
I think that is sort of where I'm headed in the back of my head. I don't know if that's where we are going to go, but those kinds of contracts might say you're going to have to use these other data systems at the state level, and they have to be designed so it is flexible enough, so we have these multiple systems answering their questions.
MR. VAN AMBURG: I think that is why I prefer the term "data strategy," rather than information strategy and information systems.
DR. IEZZONI: Okay, so we will use the word "data strategy."
DR. CARTER-POKRAS: I just wanted to point out that there are other parts of the department that are interested in having their questions answered regarding Medicaid managed care. There are at least four separate offices -- HRSA has one; SAMHSA has one; CDC, HCFA have their own offices of managed care. In addition to that, even our office has been involved in review of the Medicaid 1115 waivers.
So perhaps we can use that as background information to check with the agencies as to what some of their questions are that they would like to have answered, and then we can pull that together in the background information, rather than having separate people come and report to the subcommittee.
DR. IEZZONI: Great. Well, we will rely on you guys to help identify the key federal level government stakeholders in this.
MR. SCANLON: Lisa, we would want to include the states, but I think we would want to include quality assurance and accreditation groups as well.
DR. IEZZONI: I would think so.
MS. WARD: Because those people are out there eventually being the reporters from this contract, are facing Joint Commission outcome performance requirements. They are facing NCQA requirements.
MR. SCANLON: I think we would actually like to get one or two contractors in.
MS. WARD: The state momentum to not respond to some of those Medicaid contracts is because the system is overwhelmed.
DR. IEZZONI: I guess the question is the Lewin database was interesting, the one that Dale and Danny talked about yesterday. They are among the contractors that we can work with.
It sounds like what we might ask Sara Rosenbaum to do would be fairly expensive. So we wouldn't have a huge amount of money left over, but is there anything from the Lewin repository of health information systems that we might want them to distill down and write us a summary?
MR. SCANLON: In the updates?
DR. IEZZONI: Yes.
MR. HITCHCOCK: They are starting the updating now. It takes about a year.
MR. SCANLON: Is there any analysis? Because we will literally hear probably from most states during that updating. It's an Internet kind of an updating process, so this would be the time.
MR. VAN AMBURG: Would it be possible to get an analysis of the barriers and limitations of linking and using multiple data sets. He indicated yesterday that he did have information about what some of these barriers were. That is going to be a real problem for looking at a strategy.
MR. SCANLON: We could ask Andy for a presentation.
MR. HITCHCOCK: It may not be fully comprehensive, but there will be --
MR. VAN AMBURG: What they have heard. These are the four major issues of using Medicaid data linked to public health data.
DR. IEZZONI: So why don't we see if we can ask Sara Rosenbaum and the Lewin folks to maybe ask us with this.
Do you have any questions for us, to help us be more specific?
MR. VAN AMBURG: Not yet.
DR. IEZZONI: Okay.
DR. AMARO: It seems that also he is another person who could sort of characterize a few of the best practices of states at the forefront, kind of like case studies.
DR. IEZZONI: Right, because we have to talk about our site visits. Should the site visits be best practices, or should they be -- now I was listening very carefully yesterday to all the presentations to basically validate the choices that we had made back in July when we had said, oh, let's go to these states, one of which was Massachusetts, and the other of which was Arizona during the snow season. Well, we wanted to do Southwest, because we did find that being far outside of the Beltway, not just within the north Atlantic New England region, is very helpful.
I did hear two separate people, and I wrote it down in my notes somewhere, one of whom did say that Massachusetts had an exemplar data system, especially for managing disease management issues. Also that Arizona had a great data system.
MS. GREENBERG: They have been at it the longest.
DR. AMARO: When are we scheduled for that?
DR. IEZZONI: What are the dates? Lynnette has all those dates.
MS. ARAKI: You had selected April 21 and 22.
DR. AMARO: There is one important event you might want to consider. In April in Tucson is the International Mariachi Conference.
MS. ARAKI: You also selected February 9-10.
DR. IEZZONI: Yes, February was going to be our zone out, because of the travel issues. You would probably feel okay about going to Arizona in February.
DR. AMARO: I'm going to the mariachi conference anyway.
DR. IEZZONI: I think though, to be honest, and Elizabeth would probably back me up on this, travel looks more glamorous when you are talking about it from the outside, than when you are actually doing it. So I do think that it is important for us to have site visits, but do people think that these are two states that we should visit? Are there alternatives, other states?
MR. VAN AMBURG: Tennessee is a state that has real data problems, and apparently has overcome those now.
MS. WARD: I think the contractors, the two we have talked about, can tell us where they think we would learn the most. I don't think it helps to go to a state that can't do anything.
DR. IEZZONI: Right. Well, let me see if I can find my notes about who was it who said that. Arizona was Susan Dodds. It was Sara Rosenbaum who actually mentioned Massachusetts. So these are researchers. So I guess the question is do we want to do Tennessee as a place that had a lot of problems and seems to have fixed them?
DR. AMARO: In place of Arizona?
DR. IEZZONI: No, in place of Massachusetts maybe.
DR. AMARO: Can I make a suggestion? It seems like making this decision, we should think about it, because we are going to devote all this time. I like Elizabeth's suggestion that we ask the contractors to say what would we get out of going to each of these, so then we can evaluate whether what they think we would get out of it is what we are looking for and what we need.
DR. IEZZONI: I agree theoretically that that is a great idea. I know in practical terms that from what Carolyn went through trying to organize the California meeting that we need to get a sense of where we are going to go pretty soon, especially if one of the trips is in February.
DR. AMARO: Couldn't we like ask the contractors in the next couple of weeks to do this?
MS. GREENBERG: Also I think a big thing is where there will be staff, Medicaid and otherwise, who really would devote --
MR. SCANLON: We need a host.
MS. GREENBERG: -- would be receptive to this, because we are going to be dependent on them really.
DR. IEZZONI: I know. This is going to be a lot of work for staff to organize these meetings. So could we maybe do the following? We have a large group meeting a full NCVHS meeting in November, the first week of November. Are we going to have breakout sessions for the subcommittee?
MS. GREENBERG: Oh, sure.
DR. IEZZONI: Could we at that point have -- so that would be a month from now -- a sense, as Hortensia just suggested, from some of these people what might be states where they know the contacts, and the contacts there might be willing to work with staff to pull together a meeting. They also are states that we would learn a lot from, and give us some choices, and maybe we can decide at our subcommittee breakout session at the November meeting which states.
MS. GREENBERG: I guess depending upon the type of tasks you put into the contracts -- you are talking about doing something with Sara and then also with Lewin -- it could facilitate setting up the site visits.
DR. IEZZONI: Oh, that's a great idea, because Lewin especially knows the contacts.
MS. GREENBERG: That could be a good use of their time.
DR. IEZZONI: They could also write a case study.
MR. SCANLON: Lewin actually was the consultant to help develop a lot of these managed care plans to begin with, so they have a big practice in this area. I think we can use Danny and others there to help us select the site and contacts, and we have some contacts actually.
MS. GREENBERG: I wouldn't just hand it over to them, because it would take all your money and more. I agree; I said facilitate.
DR. IEZZONI: Let's talk about what we want the site visits to accomplish for us. What do we want from the site visits?
MS. WARD: I'm concerned whether we learn anything by all going to Tennessee, or whether having two people from Tennessee come explain their strategies would be -- I want someone to tell me that we can't learn it unless we actually go look at it. I think if we have learned some things, and we want to have some hearings to help the world hear about what the results are, I like the fact that we get out of Washington, but a bunch of us all going to states to actually walk in and sit in their office and see them to tell me about their contract, I don't know what I get by traveling to Tennessee.
MR. VAN AMBURG: On the other hand, if you do go to a place like Arizona, you would get to see the public health side, the Medicaid side, the legislative side, the practitioners, if it could be set up that way.
MS. RIMES: That kind of came up a little bit yesterday that not everyone had ever been at the table together.
DR. IEZZONI: So that's a good point, having all the different stakeholders in the state at the same table.
MS. WARD: Something like that has to be put together at the local level.
DR. IEZZONI: Well, that should be our goal then. That's what we will try to do is make sure that we have public health, Medicaid, legislators --
MR. VAN AMBURG: The HMOs.
DR. IEZZONI: The HMOs and the population providers and patients, the consumer side. Actually we did that a little bit in California, and that was invaluable. It was more us sitting there watching them kind of interact, and it was really very informative.
DR. AMARO: We had mentioned accreditation and accrediting organizations. What I'm thinking about, substance abuse, that would be the state health departments usually. So there might be different people we need to think about, if you are talking about licensing mental health clinics such as abuse treatment programs and medical care providers.
MR. VAN AMBURG: I think you have to handle those a little separately, because a lot of them are still carve outs.
MR. SCANLON: We'll actually get a lot of background from our agency presentations I think, because SAMHSA is actually doing a lot on how this is being approached. But then you are right, I think we need the national accreditation.
DR. AMARO: I bring that up because in our own little state and specific situation, that sort of at the program level in terms of some programs that have gone from demonstration into the service delivery arena, that in now trying to work with reimbursement for say case management mental health services with the agency that has the contract to do that, that there are a number of requirements around for example the type of people you have providing the services that have a very important impact, that are imposed by carve out group, the partnership in Massachusetts.
They have a really important impact in community-based organizations who may not have always had the masters level people with all these requirements. Do you really need that for case management? Are there alternative requirements?
So they are being impacted in terms of what practice looks like, and what the profile of people who are doing this, and as a result, cost and knowledge of the client population and all that. So somewhere I want to make sure that we hear from them.
MS. GREENBERG: The carve outs is a big data issue too.
DR. IEZZONI: Yes, and that will be interesting to see in the contracts. We should make sure that Sara identifies for us the carve out issues.
MR. SCANLON: SAMHSA has actually paid Sara to do some of this, and Ron.
DR. IEZZONI: I feel that we are heading towards a kind of consensus. I was thinking should we take a break, but I think that we are close to having accomplished what we wanted to this morning. Do other feel that way? What I would like to do is give staff a chance to ask us questions. I know from having had conversations with you around this back in July that you might need some more specifics from us to be able to go out and set up some of these contracts.
Are there any questions that you have for us right now that would help you think about setting up the contracts?
MR. SCANLON: Well, first we'll probably meet with G.W. I think Sara has already got the contracts themselves, the database.
DR. IEZZONI: But you know kind of what we want?
MR. SCANLON: So maybe it would be worth spending a couple of minutes. Would we want her or the G.W. folks to basically review every contract in terms of the information requirement, sort of broadly stated, including performance measurement and reporting, any encounter or financial or quality or other reporting, client level or aggregate, and any other reporting? Or even broader than that, are we looking at public health reporting?
DR. IEZZONI: We want to know what their information reporting requirements are as stipulated by the contract.
MR. SCANLON: So we'll have to actually look at them and see.
MR. VAN AMBURG: It's almost a reporting participation type requirement. Whether they are required to report in the immunization registry, they are required to report communicable diseases, they are required to report encounter data.
MR. SCANLON: And what reports they have to make to the state in terms of performance or financing or utilization or whatever. So it is fairly open?
MR. VAN AMBURG: Yes.
DR. IEZZONI: And then I think we would like her to be at our January meeting when we hear from the field about what they want to know, because then the second part of what she would be doing is going back and thinking, okay, what contract language would be needed to set up the data strategies, to use George's appropriate word, to be able to address these questions.
DR. CARTER-POKRAS: You're talking about the contracts between the Health Care Financing Administration and the states?
MS. GREENBERG: Between the Medicaid state agencies.
DR. IEZZONI: It's what Sara Rosenbaum talked to us about yesterday.
DR. CARTER-POKRAS: There were two separate pieces. When we were investigating this earlier to prepare for the data users' conference there are two separate reporting requirements. There is what HCFA requires of the states, and what the states requires of the managed care plans. They don't necessarily match, which is part of the problem.
MR. SCANLON: We'll have the waiver folks come in to talk about that. This would be actually looking at the contracts that the state for example, has entered into with its five plans or whatever.
DR. IEZZONI: So that is for the G.W. contract. Is that pretty clear? Do you feel that you have enough to be able to move forward on that?
MR. SCANLON: I think so.
DR. IEZZONI: Now the Lewin --
MR. SCANLON: For Lewin I think we want to ask Danny first, and we may be able to just work an arrangement with him, could he summarize what we have learned from the registry so far, facilitators and barriers to linking different record sources. So that would be the actual analysis. I think we would like him to actually write something up for us.
DR. IEZZONI: I think it would be good also to see whether he could summarize what they do have on Medicaid managed care from his registry. He said that some states did have a focus on Medicaid managed care. So I would like to see that as well. It would be very interesting to match those states that have looked at this with what Sara Rosenbaum comes up with from her states.
So from the Lewin side, I think it's pretty straightforward. Do you feel that you have enough information from the subcommittee on that side too to move forward to a contract?
So we seem pretty well set. Then you guys -- Jason, I don't know if this will fall to you -- basically we want to know by the November breakout session what states might be good places to go so we could have all the people around the table that would make Elizabeth's criterion for it's valuable to take this trip, because we need to meet that criterion. It is worth getting on that airplane.
So hopefully we will have Massachusetts and Arizona among them, but we would like to know what the other options are so we can choose.
So is staff all set with us? Do you feel like you've got enough specificity?
Let's really aim for that November meeting, making sure that if you have to have contract language to G.W. and Lewin, that by that point we know that the contracts are going to meet what we want so we can review it, or at least have it done by then.
I seem to be moving towards again proposing that we adjourn. I have a tendency to do that. Are there any other issues that people feel a compelling need to spend time talking about right now? See how I phrased that in a leading question sort of way?
DR. AMARO: I would like to commend the chair for her excellent leadership in getting this through this business.
DR. IEZZONI: Well, it wasn't me, it was you guys that really came up with the ideas. So thank you for that commendation, but I refuse it.
DR. CARTER-POKRAS: Just an update item regarding the review of OMB Directive 15. It is not over. There is a guidelines development team. There are a few people from the department who are actually involved in the guidelines development team. Somebody from ASPE is involved in that; a couple of people from NCHS.
It's not quite clear how we are going to build in input from the entire department, because we have not been informed that there will be a formal or informal opportunity to make sure that all the departments have an opportunity to comment on what is being recommended. So we are still kind of going back and forth about that, and I know the National Committee has offered their assistance. Right now it doesn't look like there is an opportunity for that, but we are looking for the opportunity. That is number one.
Number two, I did inform the person who is taking in all the comments that the National Committee did send something forward.
DR. IEZZONI: On September 8th.
DR. CARTER-POKRAS: Once they get a final version of it, because I didn't have the final version, I will put that together with the package of the agency responses and send them a second copy, just in case they can't locate it.
DR. IEZZONI: We got a confirmation, didn't we Lynnette?
DR. CARTER-POKRAS: We sent three copies last time to the Public Health Service's comments, and they kept on getting misplaced, which is why I wanted to send a package with everything, a reminder that you should have received just in case, because this was an issue last time.
DR. IEZZONI: Well, let's make sure that we follow up and make sure.
MS. ARAKI: All the subcommittee staff should have also gotten a copy of the signed letter.
DR. CARTER-POKRAS: I didn't get a copy.
DR. AMARO: Could I also make a request that to David Williams. He provided us input. I promised him that when we had the final, we would send him a copy with a thank you for giving us some good input.
DR. IEZZONI: Thank you, Hortensia.
DR. AMARO: I did send him an e-mail thanking him, and telling him that we had worked to integrate his concerns and comments, but I think it would be nice to have a --
DR. IEZZONI: I actually was intending to mention that but forgot. I'm glad that you brought that up, because absolutely we need to do that, because David's was great.
MR. SCANLON: The OMB will actually announce in October --
DR. CARTER-POKRAS: We're hoping before they announce their decision there will be an opportunity at least for the department to make comment on the proposed decision one more time. Right now the feedback we are getting is there won't be that opportunity. So people who are not involved in the guidelines development team, we already know from the department -- do not know all the data systems in the department and certainly cannot speak for the entire department, so we are concerned about that. We are going to do what we can to make there is an opportunity for that input.
MS. GOLDEN: Do you have any idea how this might play out? I was asking you about that opportunity before, because when I was at the hearing, I sensed that whereas tentative approval had been given by the Congress to the recommendations, what was really a hold up was how this would play out in the tabulation.
What I'm not sure of is if the tabulations are just issued as fact. What do we expect to be a reaction from Congress if they are not liking what they see?
MR. SCANLON: How do you actually present the data when you've got more than one category? How do you do the tabulation policy? I think that is the work group. I think Census Bureau has to have a decision by the end of October, and I think they publish that in The Federal Register.
MS. GOLDEN: They publish that.
MR. SCANLON: About how they will collect the data.
MS. GOLDEN: Do you expect the Congress will have any commentary after we publish the tabulations?
DR. CARTER-POKRAS: There was a bill that was submitted by Rep. Petrie to add a stand alone multi-racial category to federal forms and applications. They have not pushed that any further, because they were waiting to see what OMB came up.
The initial reaction that we hear from the grapevine from Rep. Petrie's staff is that they thought that these were reasonable recommendations. So there is always the possibility they may decide if they are not happy with what finally comes, they may decide to pursue the legislative aspect.
MS. GOLDEN: It's more the tabulations than the actual collection.
DR. CARTER-POKRAS: Lisa, there are just a couple of other real quick things to tell you what is happening regard to racial-ethnic data issues within the department. One is that the Data Council has approved an inclusion policy for racial-ethnic data on HHS data systems which goes beyond OMB Directive 15, because right now there is no federal mandate that racial and ethnic data be collected.
MR. SCANLON: That's on its way to the secretary.
DR. CARTER-POKRAS: Right, to the secretary, so we're hoping that gets signed off, and when it does, we will be happy to report that.
The second thing is the President's Initiative on Races I had mentioned earlier, is heating up. They have requested someone for a 90 day detail to assist them with data. They have recognized that data and research is a major issue, and they have asked about how we can use additional funds, if they become available. So there has been a lot of running around, trying to get that information.
We hope that's good news that can be reported. Of course you never know until you actually get the money in hand, whether that is the case.
DR. IEZZONI: Good. So thank you for those updates, and we will follow-up in November, hopefully. Thank you everybody on the committee, and we will adjourn.
[Whereupon the committee was adjourned at 11:01 a.m.]