Wyndham Metrocenter Hotel
10220 North Metro Parkway
East
Phoenix, Arizona
Hortensia Amaro, Ph.D.
Lynette Araki
Kathryn Coltin
Don
Detmer
Joe Gaudio
Representative Susan Gerard
Jason
Goldwater
Dale C. Hitchcock
Lisa I. Iezzoni, M.D., M.S.
Brian
Lensch
Nelda McCall
Mary Moien
John Murphy
George H.
Van Amburg
M. Elizabeth Ward
Nelda McCall
John Murphy
Susan Gerard
Joe
Gaudio
Brian Lensch
DR. IEZZONI: Okay. So, I'd like to get started with the meeting of the Subcommittee on Population Specific Issues from the National Committee on Vital and Health Statistics. And thank you all for coming. We're looking forward to hearing from you.
What we tend to like to do at the beginning is go around and introduce ourselves. But I'll ask each of the speakers to maybe introduce themselves at a little bit greater length as you start your presentation for us. Okay?
I'm Lisa Iezzoni from Beth Israel Deaconess Medical Center and Harvard Medical School in Boston.
MR. DETMER: I'm Don Detmer. I chair the National Committee on Vital and Health Statistics. And, in my other life, I'm Senior Vice President at the University of Virginia in Charlottesville.
MR. VAN AMBURG: I'm George Van Amburg from Michigan Public Health Institute.
MR. HITCHCOCK: I'm Dale Hitchcock. I'm a staff member to the Committee. I'm from the Department of Human Services, in what is called the Data Policy Group there.
MR. LENSCH: Brian Lensch. I'm with the Division of Developmental Disabilities.
MR. GAUDIO: Joe Gaudio from Arizona Physicians IPA. I'm the Chief Financial Officer, which is -- Arizona Physicians IPA is one of the AHCCCS health plans here in the state of Arizona.
MS. McCALL: Nelda McCall from Laguna Research Associates.
MS. ARAKI: Lynette Araki from the National Center for Health Statistics.
MS. WARD: Elizabeth Ward from the Washington State Department of Health.
DR. IEZZONI: And, from the audience?
MS. EDWARD: Maria Edward from Lantex in Ironwood, Michigan.
DR. IEZZONI: We're far from Ironwood.
MS. EDWARD: Oh, no, I live in Tempe.
(Whereupon, Mary Moien enters the room.)
DR. IEZZONI: Okay. Mary Moien is just coming in. Mary is helping the Committee put together the report from our year-long effort on looking at Medicaid Managed Care. And then there's Jason in the back of the room, who maybe some of you spoke to in trying to organize this meeting. And I'd like to start by thanking Jason and Carolyn Rimes from HCFA for helping us put this together today.
As you know from the letter that we sent you, and from the questions, we're interested in Medicaid Managed Care. But our focus is really on data and information that are available or not available, to look at the impact of Medicaid Managed Care, and a variety of other questions about it. Did they give you like a time limit for speaking this morning, ten, fifteen minutes?
MR. MURPHY: Fifteen minutes.
MR. GAUDIO: Fifteen minutes.
DR. IEZZONI: Fifteen minutes, okay. Why don't we get started. We do have kind of a tight schedule, because we would like to have some room for some interaction at the end of your presentation. So if you could keep as close as possible to 15 minutes, that would be really great.
(Whereupon, Mr. Murphy enters the room.)
MS. IEZZONI: And, John Murphy has just joined us. And we'll ask each of you, as I said, to introduce yourselves a little bit greater length at the beginning of your presentations.
So, our first speaker isn't here, but, Nelda McCall, why don't you start us out.
MS. McCALL: Okay. Thanks very much, Lisa.
Thank you for the opportunity to testify on this important issue of data collection, data reporting, and data interaction in Medicaid Managed Care.
My name is Nelda McCall. I've been involved in evaluating the State Medicaid Managed Care Programs, including issues around management information, since the early '80s. From 1983 to 1995, I was project director of two health care financing administration evaluations of the Arizona Health Care Cost Containment System.
I'm on the National Advisory Committee of HCFA's five-state Medicaid Managed Care evaluation, which is studying implementation of Medicaid Managed Care in Tennessee, Rhode Island, Hawaii, Oklahoma, and Maryland. And I've also studied implementation of Medicaid Managed Care in California with funding from the Urban Institute. And I'm currently examining the two-plan model in California with money from Kaiser Family Foundation.
Although most of the evaluations I've been involved with are broader than just data issues, management information systems and their importance in a Medicaid Managed Care model has been an area of special interest.
I think I'm going to focus my remarks on two areas, sort of a description of the AHCCCS Program and its approach to management information from the standpoint of the evaluator. And I think we'll be hearing later from the standpoint of some of the providers under the program. And then recommendations about areas of importance for the Committee to consider regarding data reporting for Medicaid Managed Care.
I should preface my remarks by saying that our program evaluation ended in 1995. And I'm sure that many specifics of the actual workings of the AHCCCS Information System are probably different now. And so I'm going to focus my description more on the overall conceptual underpittings of the AHCCCS System as it was implemented at the time that our evaluation ended.
Just to give you a little bit of an overview, the AHCCCS Program provides services to Medicaid beneficiaries in Arizona, it's a HCFA demonstration project. It's composed of two separate programs, the Arizona Long-Term System which provides services to people who are a risk in institutionalization, and capitates a contractor for a full range of acute and long-term care services. And then the acute care part of the program, which capitates plans to provide a full range of acute care services and short-term, long-term care services to eligible beneficiaries.
AHCCCS' management information approach both for controlling their day-to-day transaction activity, and providing critical, operational, and management information systems is based on a prepaid management information system which they developed and implemented in 1991, after a five-year development effort.
The MIS needs for a prepaid plan like AHCCCS differ from those for our fee-for-service programs, both in terms of the functions performed and the data required. A prepaid management information system must support the procuring of contracted health plans, monitoring of plan service networks, and PCPs, enrollment of members, processing and issuing capitation payments, collection of data on service utilization, monitoring planned utilization patterns, inappropriateness of services, monitoring plan performance and financial condition, tracking of care managing providers, both PCPs and case managers, and processing of reinsurance and deferred liability claims.
Prepaid systems have to comport the information necessary to support these activities, and a lot of these activities are very, very different activities than one would see in a traditional fee-for-service transaction based Medicaid Program.
Their prepaid management information system is composed of 11 subsystems, provider recipient reference, and counterclaims, health plans, financial case management, information management, URQA. And for the long-term care beneficiaries, the long-term care eligibility determination system, and a long-term care client assessment and tracking system called CATS.
These latter two systems are specific to the long-term care program. The other systems are shared between the acute and the long-term care program. The PMMIS was designed as a relational database, with much of the information available on-line, rather than being spread across numerous files. It provides defined management reports, but I think more importantly, provides flexible access to information through quick response generation of ad hoc reports. And I know you're visiting them this afternoon, and I think it would be interesting to see, you know, the extent to which they do that.
By the end of our evaluation in 1995, the AHCCCS Program was functioning smoothly with respect to its collection of basic management information. Although the design, development, and implementation of the prepaid management information system had been more costly than was budgeted, it was about 50 percent higher than the original budget, and the operating costs were higher, at least in the early years when we were doing our evaluation, than Medicaid Programs, about 50 percent higher. The users were very enthusiastic about the system, and felt that it was absolutely indispensable to their jobs.
One of the greatest and tangible benefits of the PMMIS, is the ready access it provides AHCCCS staff to information about many different aspects of their program. With a program the size of AHCCCS, a supportive information system leads to improved decision-making with major financial impact. The relational database structure of the PMMIS was designed to make such queries easy to fulfill in a timely manner, with minimal needs for special programming efforts, and the structure has the potential for more effective support, and better management and decision-making.
The second area that we looked at in our evaluation, which is kind of, in a sense, an input to the whole system, is the collection of utilization data, and the recording of it. HCFA was very interested, very, very interested in assuring that as part of their demonstration activities, that AHCCCS successfully collected individual level and counterdata on the utilization of Medicaid services. And they put a lot of effort into that.
Although AHCCCS resisted this during the earlier part of their demonstration. By the late 1980s, AHCCCS of senior management had become convinced of its importance, and began a significant management commitment, which I think is critical, to take serious steps towards assuring its collection.
(Whereupon, Hortensia Amaro, Ph.D., enters the room.)
MS. McCALL: Even today, the states have only had limited success in the collection of utilization data in their managed care programs. A significant factor is the difficulty in providing contracted health plans with sufficient motivation to submit complete, accurate, and timely data. The second factor impacting the collection is the difficulty in dealing with a wide range of automated data processing systems installed by various plans.
And states, I think, have given only very limited attention to providing plans with standardized definitions of the data required, and their efforts to validate the accuracy and completeness of the utilization data have been lacking. Consequently, most states have not made significant use of the data that they do collect.
AHCCCS has shared many of these difficulties over the years, but by the end of our evaluation, had clearly surpassed other states in its effort to collect and use utilization data. During our evaluation, they devoted significant resources to collections and validation of individual level and counterdata.
Effort included adding the data, working with plans to overcome problems, implementing sanctions against plans that did not comply, working to resolve significant data reject problems, and implementing data validation approaches.
While we did believe, in 1995, at the end of our evaluation, that there had often been room for improvement in some of these efforts, they had done more than any other state was doing then, and much more than any other state is doing today.
(Whereupon, Kathryn Coltin enters the room.)
MS. McCALL: AHCCCS, by the end of our evaluation, actually was using their data internally to support a number of their functions. They used it in capitation rate setting, determining hospital reimbursement rates, supporting policy research and analysis, program budgeting, responding to external information requests, monitoring of health plan inpatient and emergency room utilization, monitoring under a utilization of quality issues, monitoring pharmacy utilization, and conducting data quality studies.
Well, we had suggestions for improvements that could be made. It was clear that by the end of our evaluation, that both the AHCCCS administration and the plans had demonstrated that credible utilization data could be captured and play an important role in managing the program.
Now I'm going to just take a couple of minutes and make a few recommendations, and if I start going over, you know, let me know, and I'll end quickly.
The success of a managed care program is intrinsically linked to an effective management information system, and the quality of the input data that is entered into the systems. The functions of managed care Medicaid Program are different than transaction based Medicaid Programs, and the hardware and software needs to be in place to develop the special systems that are important for the program, in terms of quality assurance.
Managed care has special needs with respect to quality assurance. Data can be used to analyze things like service under-utilization, treatment patterns, selective procedures, broaden abuse control, and physician and provider profiling.
The second area where a program needs to have great concern is with respect to utilization and AHCCCS monitoring. And that's, I think, especially important in Medicare Managed Care, both in terms of analyzing the specifics of what services are provided, and monitoring the adequacy of the ambulatory AHCCCS.
The third major area that requires support is financial analysis and rate setting. Monitoring the contracting entities in managed care for financial solvency is a critical issue, and can help identify problems before they become critical. And when serious problems occur, monitoring can provide early warning to help plan for orderly plan phase-out entering physician.
The ability to secure competitive rates also depends on the availability of data that can accurately track costs, and being able to do this in a way that makes it possible to identify individuals who are at the highest risks in paying capitated entities appropriately, is of substantial importance. So, we want to support the plan's viability, the rate development process, and risk assessment and adjustments.
And the fourth major area is future planning. Managing a capitated Medicaid Program requires being able to access data to satisfy external information requests from the legislature and the governor, estimating costs of the modifications to the program, estimating future costs, and identifying activities that promote long-run cost containments.
Probably even more globally, from your perspective, as people who have to look across one state to many states, are the societal uses for having this kind of data. The major societal uses for this kind of data, to help us to determine disease incidence, document treatment patterns, and develop knowledge of successful treatments, and provide a database for general research inquiry.
Now, I think I testified before to this Committee about standardization, and I guess I'd like to reiterate that standardization across states and across programs and across service providers, is substantially important. And as we move into more managed care for beneficiaries with car care needs, it's of special importance to ensure that their care utilization fits into the standard definitions.
I was going to -- I think although the current submission that we have where we're collecting, essentially, claims look-alikes is not, in any sense, ideal. It is a system which is currently in place and operating both in the fee-for-service world, and in a large number of IPAs and mixed model managed care organizations.
While this is not to suggest that it would not be worthwhile to improve this through the development of more clinically and more outcome-oriented systems, it does come, at least some of the way, towards helping to manage the programs in the areas that I mentioned before, important to the Medicaid Managed Care Program.
Giving up records of individual encounters and information that is collected now, seems to be a very dear price to pay for implementing capitated managed care. And AHCCCS, I think, has demonstrated that the price doesn't necessarily need to be paid.
I thank you for the opportunity to testify, and I'd be pleased to answer any questions.
DR. IEZZONI: I'm sure we'll have some questions for you.
Nelda, I saw that you're kind of running out of state quickly. Are you going to be able to stay through 11:30?
MS. McCALL: Oh, sure, sure, sure. No problem.
DR. IEZZONI: Okay, great, because you were on your way to the airport, or the hotel. Okay, great.
So, why don't we move on, and what I'd like to do is to hear from everybody, and so then the Committee can ask questions that might cut across all of your presentations.
Okay. John Murphy, you're next. Can you tell us just a little bit about yourself, first?
MR. MURPHY: Right. I'm John Murphy, and I'm the Executive Director of the Flinn Foundation, which is a private charitable trust or philanthropy here in Phoenix. We were established in 1965 by a local physician and his wife, provided a permanent endowment. Because he was a physician, most of our funds are distributed through grants in the health care field only in Arizona.
Prior to assuming this position, I was with the Robert Wood Johnson Foundation in Princeton, New Jersey. And that is relevant, I think, in terms of what I want to describe to you today, in that, if I can begin anecdotally, by indicating that one of the interesting things, when I was at the Johnson Foundation, having worked with many State Medicaid Programs, was that Arizona didn't have a Medicaid Program. And we used to kind of speculate, well, if Arizona ever gets one, what do you think it should look like?
So the fact that it was kind of an empty chalkboard, made it a fascinating interest to us, and it was a serendipitous matter that I happened to be approached to assume the responsibility for the Flinn Foundation, just at the time that the legislature here adopted the AHCCCS Program.
So the serendipitous issue was more momentous than I had realized at the time, because it occurred to me immediately that it would be very useful to apply some of the techniques that had been developed by Ron Anderson and Lou Anaday (phonetic) at the University of Chicago for the early 1970 studies by the Johnson Foundation, and to use those questionnaires regarding AHCCCS issues and apply them specifically to the Arizona low-income population prior to the introduction of AHCCCS, and then to follow that up with similar studies immediately after the introduction of AHCCCS, which is how we got involved in this. And I will describe the methodologies, and all, in a moment.
(Whereupon, Susan Gerard enters the room.)
MR. MURPHY: We have since followed that methodologies by doing a similar study in 1989, and another one in 1995, so it is an ongoing arrangement.
The methodology, essentially, if you're familiar with the work of Anderson and others, involves looking at AHCCCS measures from the standpoint of interviews with a designated population sampling method we use, and contracted with the Lewis Harris Organization for all of our studies.
We have essentially maintained the same basic instrument in place for all the studies in '82, '84, '89, and '95. Those studies have involved interviews with roughly 4200 randomly selected Arizona residents in each of those years, and both with interviews conducted in English and in Spanish. Those interviews with telephone were also supplemented by in-person interviews with low-income populations without telephones.
We excluded in those interviews, however, residents in college dorms, nursing homes, Indian Reservations, prisons, et cetera. And we deliberately oversampled, in all of the surveys we have done, low-income and rural residents because, as some of you are aware, those are the more difficult data to obtain. And then all of the parameters, age, race, income, et cetera, in terms of the sample, were then weighted with the U.S. Census parameters.
What was important to us, was to take a look first at how this program, the AHCCCS Program was being implemented in the state, to obtain a reading on the experience of low-income people prior the implementation of the AHCCCS Program, as a statewide effort. Essentially, each county had responsibility for its own system for the care of the medically indigent, as it has been referenced, and the income criteria and other criteria of eligibility varied by county.
And we, therefore, in the initial survey, were very interested in looking at what the positive and negative effect might be on each of those counties because of some people who would be stranded in the midstream arrangement. Also, we were interested in how the provider, source of provider altered, and also issues of the frequency utilization, ease of access to the provider, making the appointment, transportation, and then levels of satisfaction with the care received.
And the first results from the comparison of the 1982 and 1984 samples were very positive, in terms of the AHCCCS Program, to the delight of our elected officials, and those implementing the program, I might add. And there were several changes, which I will get into next.
But the second round of sampling we did in 1989, in many ways, was more descriptive because, by that point, some of the early experiences of the AHCCCS implementation had been resolved, and I won't go into all of those problems now, I'm sure you've heard of some of them. Nelda has previously reported about some of them, many of them. And, therefore, we thought that the 1989 study would, in fact, prove somewhat more helpful in terms of the longer term assessment from a policy perspective of what seemed to be happening to that eligible population.
Among the highlights of those findings in 1989, which have been validated in the 1995 study, which we have completed, is that AHCCCS, in fact, is serving its intended population; that most of those who are eligible, are enrolled. We can speak separately about the management systems and outreach efforts, in terms of getting more persons enrolled, but the point is, that most of them are.
Second, and probably the most important thing that the data validated, was that, in fact, most AHCCCS enrollees are obtaining their health care from a doctors office, or a free-standing clinic, as we called it in our survey; that fewer are using the hospital emergency room as their primary care source.
And, most importantly, what that means, in terms of a shift, is that many individuals who previously had used public health facilities, particularly hospitals and clinics were, in fact, now being seen what we refer to as mainstream physicians through the AHCCCS health provider plans, and that was very evident in the shift. It's been validated in other manners, the shift of number of enrollees in the Maricopa, particularly in Maricopa County health plan.
And, finally, another measure, which is the dissatisfaction of AHCCCS enrollees with their health plan and the health care they received, we found to be quite comparable to persons interviewed who had fee-for-service or HMO coverage. And we asked them several measures about that.
We asked them in terms of their most recent visits, whether the waiting time needed to get an appointment, the waiting time in the doctor's office for the visit before they were seen, the hours when the offices or clinics were open, the coverage for preventative care, such as checkups, well baby care, and overall, how they would rank their health plan.
We also asked about the ability to change plans, how frequently they changed plans, and what that experience had been. And, again, by almost all of those measures, the AHCCCS Plan, in terms of the response of the population enrolled, was very positive across the board.
Now, to contrast, we've also looked at those persons who were on Medicare and enrolled in HMOs, or similar managed care plans, to those who had fee-for-service, or other arrangements, but were in a managed care plan, and contrasted the same sets of questions to those respondents in the AHCCCS provider plans. And while the AHCCCS provider recipients -- excuse me -- the AHCCCS enrollees' responses were, across the board, uniformly favorable, they were slightly less favorable than those in private managed care, and most importantly, those in Medicare Managed Care Plans.
Maybe a word about the demographics in the state might be relevant at this point, in that a large number of Medicare beneficiaries have moved and relocated to this state, and continue to do so in large numbers. And one of the things that was striking from the 1995 study, is that in the three-year prior, those who had become Medicare beneficiaries three years prior, over 60 percent of them had left it to enroll in a Medicare HMO Plan in the state.
I haven't seen the latest numbers, but providers tell me it's probably approaching 70 percent, at this point, and that's why that becomes a relevant measure to us, in terms of what's happening with the low-income population on that side.
Our plan is to continue these types of studies periodically, and we think it is providing a valuable trend information. We find that it -- the fact that it's sponsored by a private charitable foundation provides a measure of objectivity, and we hope credibility, in terms of those we contract with to provide the work and the analysis, and it has proved, I think, to be a useful contributor to at least the dialogue and to those who do seek those types of broad-brushed measures of what the impact of a program such as this has been.
Thank you very much for the opportunity.
DR. IEZZONI: Thank you. That's fascinating. Stick around, we'll have some questions for you.
Susan Gerard, next maybe. Thanks. Can you talk a little bit about yourself.
MS. GERARD: Well, I was --
DR. IEZZONI: Just a little.
MS. GERARD: I was a small child when AHCCCS began, so I can't -- you have other people to depend on for that. But I've heard the stories about the program. I've been in the legislature ten years, and I've been on the Health Committee for nine of those ten years, and chaired it for the past five years, and so I've spent a lot of time dealing with AHCCCS.
And, actually, it's quite a dream right now, compared to what it was in the late '80s, when we still didn't have everything worked out, and the economy was bad and the population numbers were still going out. So a lot of the pressure's off now so we can start getting more picky.
You've got people like John Murphy, and I know you're going to AHCCCS, so, you know, what they have now, I don't think I'm going to spend a lot of time on. You know, I think they've done a good job, and through a lot of trial-and-error, have developed very good management information systems and methods for tracking billing and costs, and all that kind of thing. And so they're very, very good at managing costs, like they are also in the private sector, but we're still not doing a good job on data collection on management care. And, to me, I see that as the next evolution or revolution.
We don't really know anything about the quality or the value of the dollars that we are spending. We don't -- I even have trouble with the satisfaction survey, because people judge their satisfaction of how long it took to get an appointment, how long they have to wait, but nobody asked them did you get better, or were you able to return to work, or those kind of questions, and that's where I think we need to go next.
I also think that we haven't, maybe we have, but I haven't seen it, somebody will yell at me this afternoon about this statement, but I don't think we've really integrated what our public health goals with our Title 19 or health delivery systems, and I think that's something that we ought to be looking at because, you know, our Department of Health Services spends all of this time and effort, and you have, you know, goals 2000, and goals 205, and does anybody over at our Medicaid Office ever look at those?
And I think we need to integrate those, and then how you make it work on that, I think you need to integrate those goals into your contract requirements with your health plans, and then that, in turn, is the kind of information that you make them report, you know, the immunizations, the prenatal care, the low birth weight babies. I mean, you know, keeping diabetics out of the hospital. Everybody's laughing because you all have been talking about this, right?
DR. IEZZONI: No, we completely agree. We're right with you. You articulated it so beautifully.
MS. GERARD: So, that's what I think needs to be done.
Also, the integration, and this is both private sector and public sector with managed care. And then you need to integrate all your different departments, and that's where I think the fallacy of restricted formularies and access to care, because you've got your box over here, your manager of pharmaceuticals, and you've got your box over here who takes care of acute care. And the pharmaceutical guy's feeling real happy that he decreased his cost ten percent, but the hospitalization guy's going through the roof, and so you need to integrate that. I don't know they have. But you need to -- you know, it's the value that we have to do.
I've just got my little notes here. And I also think it might be valuable to compare, especially in a state like Arizona, where we're so high on the level of managed care in both private and public systems, is see if there's any comparison between the quality, and even the cost. You know, it's hard when you've got plans that cover different things, but just see -- because I have to listen to the doctors every day complain about how they can't get what they need, and they get dinged if they provide too much service.
But the small amount of data I've seen showed that there's no decrease in the health of the populations when they're in managed care. So, you know, show me some data that shows that the world's really following apart because of this, well, other than your world. And, of course, they can't do it, and they say it's because the insurance companies control all the data. But in a public system, we have an opportunity to collect that kind of data that we can't get from private companies.
As you look at specific programs, we're way behind the acute care on behavioral health data collection, and that's been extremely frustrating for me right now, because we've got a real crisis right here in Maricopa County. And I know it's tougher to come up with any kind of quantitative read on behavioral health outcomes, but I also believe that these providers have been even more difficult to make any attempt at trying to find a way to provide the kind of data we need, and we need to do a much better job of defining it.
And we fall down, and this is what I've -- we've got to -- our Department of Health oversees our Title 19 behavioral health, not our AHCCCS Program. And, as I've gone back and read, and because of all the mess, you know, you get out every report that's been done and there's, you know, three or four either independent accounting firms, or a HCFA report on what we've done. And, of course, they all show the same thing. I don't know why we wait until there's a crisis until we read these things.
But they have not -- even when there's evaluations and outcomes information required of the providers, or the regional behavioral health authorities, the Department of Health hasn't made them follow their own contract. And so, you know, it's just not the providers, but even we are not demanding of our contractors what they're supposed to be doing for us.
So, I think we have an -- you know, I'm trying to put the positive spin on it, because we have a crisis in Maricopa County, it's created an opportunity for us to move all the stakeholders and maybe get some of these changes made so that we can do -- and I think this is an area where the private sector is way ahead in managed care behavioral health in doing outcomes and evaluations of the products, you know, they're selling or providing for people, so that's a wide open area that needs a lot more data collection, I think.
DR. IEZZONI: Great. Are you able to stay through 11:30, because I'm sure we'll have questions for you?
MS. GERARD: I've got to be out of here by 11:00.
DR. IEZZONI: Why don't we, then, is it okay with the rest of you if we break and have questions for Susan now, for your other schedules?
Okay, Hortensia?
DR. AMARO: Yes.
DR. IEZZONI: Do you think you want to start?
DR. AMARO: Representative Gerard, if you could just clarify to the Committee that you're not a plant for me, since you said everything I've been saying?
MS. GERARD: I've never seen you before in my life.
MR. VAN AMBURG: It is a tape.
MS. IEZZONI: Yeah, it is. It's almost identical.
DR. AMARO: It's really important to get your perspective and the perspective of legislators, because we talked a lot yesterday about the need to do this, you know, in partnership with the legislature so that when resources need to be allocated, people are really informed and understand, you know, where those are going to go, and why.
MS. GERARD: Well, informing legislators, even when there is data, is another issue.
DR. AMARO: Yes. Right.
MS. GERARD: John, why don't you do a study on that, how to get through to us.
MR. MURPHY: I think we did one.
DR. AMARO: And I was delighted to hear your suggestion about integrating, instead of across these boxes. And that's particularly, I think, true also for the behavioral health care box.
A lot of times when we do outcome studies or cost analyses, we're doing them within specific boxes and don't look at the impact across boxes, and the behavioral health care box is one that usually gets left out. We know from when we provide the behavioral health care, we can lower rates, you know, and costs in the other boxes, like hospitalization, et cetera.
But one of the, I think, issues that we've heard a lot about has to do with the need to be aware that setting up all these information systems costs money, and that it has a real impact on everybody at all levels, the plans, the providers.
And I guess from your perspective, do you have any recommendations for us, with respect to how legislators can be brought into the process in understanding the need for allocating dollars for some of that, if we're going to, on a national level, try and develop a system of information that's integrated, that's systematic across states, and that gets us answers to some of the questions that you were posing?
MS. GERARD: Well, I think I just, you know, I've got a little bit of stuff here that I had a staff person put together for me, and you may have -- John may have talked about it before I got here. We wouldn't have the management information system at AHCCCS that we have today, if it wasn't because of the matching money we got from the feds to put it together.
DR. AMARO: Um-hum.
MS. GERARD: These systems are so massive and so expensive. And the real problem with legislators is, we have had so many major failures. I mean, Maricopa County spent something like $10 million, and then abandoned an entire system for their hospital with, you know, 4 or 5 million, supposedly to go, but that, of course, had started a 4 million, then it was 10, then it was 16. Our Department of Transportation, I think, has spent something like 20 million, and still doesn't have an operational system.
So, states are not doing a good job. I don't know if you need more -- not that the feds ever do a good job in any, you know -- it's like I love these local control people, and they say, well, let the State do it. I say, oh, yeah, they do a swell job with everything, you know, the school districts are so awful --
DR. AMARO: Um-hum.
MS. GERARD: -- but that's another story.
But it seems -- government seems to have such a terrible job of doing these systems. I don't know why. I don't know if it's the bidding process. I don't know if they don't have -- you know, let's face it, I guess you can't keep on the State payroll someone that can go to a computer company and make, you know, ten times as much money.
DR. AMARO: Um-hum.
MS. GERARD: But, I'm always amazed that you can spend all this money on a computer and have a contract, and then when -- and then you still don't have anything that's operational. If you were in the private sector, you had a contract you have to perform, damnit, you'd perform or you'd have your butt in court.
DR. AMARO: Um-hum.
MS. GERARD: I don't know why -- of course, they claim it always is because the State government people come in and keep asking for changes from the original contract. That's what their excuse always is. But it seems like it happens every time. You think somebody ought to learn after a while.
But, the government doesn't seem to do that good a job. You know, I think the private sector is way ahead of us, so it might want to look at what the private, like, for-profits are doing. That's what I'm looking at right now, especially in the area of managed care and behavioral health, because I think they've moved way beyond any State system.
DR. AMARO: Um-hum.
MS. GERARD: But, you know, it's tough -- actually, you know, the economy's good. Your chance of getting money for computerization is better than it was in the late '80s, but considering the track record, at least in Arizona, it's tough to sit and say, you know, we're going to give you five or ten million dollars to do something that you seem to never get right.
DR. AMARO: Um-hum.
DR. IEZZONI: Kathy, do you have -- George?
MR. VAN AMBURG: I think we'll wait for --
MS. GERARD: Oh, can I just say one other thing --
DR. IEZZONI: Sure.
MS. GERARD: -- in the behavioral health, which is my life these days? The new psychotropic drugs, I think we have to be very careful when we start looking at doing models and figuring out how we're going to run these systems, because I think the whole thing's going to change.
So, if anybody starts developing, you know, protocols and data collection based on, you know, where we are today, it's not going to be any good in another year or two, because the new psychotropics are going to revolutionalize and change the entire, I think, delivery system.
You're going to need more vocational training and, you know, the halfway kind of stuff to get people -- I mean, and you're going to get all those stakeholders of vested interests that have careers of providing therapy that I don't think you're going to be able to justify with these new medications. So I think that's going to be a real interesting thing to keep in the loop when you're looking at behavioral health.
DR. IEZZONI: Um-hum. Interesting. George.
MR. VAN AMBURG: We've heard a little bit of conflicting testimony between the two days on the AHCCCS data system, particularly on being able to utilize the system to extract information that is useful. As a representative, I'm sure you've queried that data system and have questions for it. How does that work for you?
MS. GERARD: Well, what we do is, like if you're looking for some information and you don't get it like in 48 hours and you put in a bill, like we incurred, a couple -- well, really what we did a couple of years ago, we had heard that health plans were sending people, who they were getting paid for to take care of, over to County to get their kids their immunizations. And we also heard that they weren't doing a very good job of prenatal care outreach.
So, you know, we kept saying to AHCCCS, what are you going to do about it, and we didn't really get a response that we wanted, so we put it in statute that they had to report to us every year on the immunization levels through the health plans and, you know, prenatal care outreach.
So that's, when we don't get the data we want, that's the way we respond. And they're still really -- I'm still trying to push them to actually set goals for immunization for the health plans, and I don't know why they're so resistent to that. I haven't taken that step to force that through legislation. I don't know why, just because I've got too much else going on, but I don't know why they're resistent to doing that on their own.
It seems like whenever you turn up the heat, we had a problem, we had all the dentists were complaining that kids weren't getting dental care as required for AHCCCS, and so then we just set up a study committee. And, of course, then AHCCCS, with these groups had been -- you know, people that work with kids, and whatnot, the Head Start Programs, they had all been complaining for years that kids couldn't get routine dental checkups.
So, all of a sudden we were hauling their butt in for a hearing, and they'd sit down and talk to all these groups, and guess what, everything's just wonderful, and we've got -- they've changed the system for reimbursing dentists, and they've now got more dentists doing AHCCCS patients than they've ever had before, and it's just a matter of us turning up the heat on them.
And then we just had really aggregate numbers. They were just telling us a number -- I mean, they could come in and they'd say to us we've got "X" number of kids in Title 19, and this is how many dentists we have. And we go, well, you know, so you've got ten dentists and, you know, two hundred thousand kids, give us a break, you know they're not getting any care. I mean, it basically came down to that.
Well, then all of a sudden they, you know, put the pressure on their health plans to do a better job on that. So it's -- you know, we just turn up the heat on them, haul them in.
DR. IEZZONI: I have a question, and then Kathy. You indicated that you feel as if you get adequate utilization data out of the system, but you don't get information on how patients are doing.
MS. GERARD: Um-hum.
DR. IEZZONI: Are your fellow legislators also interested enough in how patients are doing to spend the money that it would take to get more information on outcomes? It will require an additional layer of data gathering, but as Hortensia has implied, and you've confirmed would cost money. Is that something that you think the legislators would be willing to fund, and what, specifically, do they mean when they say that they want to know how patients are doing?
MS. GERARD: Oh, they don't want to know, I want to know.
DR. IEZZONI: You want to know. What do you mean, then?
MS. GERARD: Right. I guess the reason why I think I could get them, if I pursue this, to get them interested in it, would be is because everybody's into managed care bashing right now. So, the only way you can really bash well was if you got some information to bash with, because there's a real anti-managed care sentiment.
The other thing I could see is, when costs start going up, or populations start increasing during the next recession, then I think there'd be more legislators standing up and screaming, well, we need more information about what's going on.
Those are the only two ways, I think, that you can --
DR. IEZZONI: Well, what are the outcomes that you're specifically interested in? I mean, what --
MS. GERARD: Well, I'm --
DR. IEZZONI: -- if you could get two or three pieces of information from AHCCCS about how their clients, beneficiaries, whatever, are doing, what would those two or three things be?
MS. GERARD: What would the things be?
DR. IEZZONI: Um-hum. What pieces of information about how their clients are doing would be of interest to you?
MS. GERARD: Well, I think if you want to keep people -- if your goal is to keep people healthy, and then from that, wanting to not be dependent on the public system, I guess you'd want to be knowing if, you know, people get -- with kids, if you keep them healthy, you keep them in school, you keep them out of emergency rooms. With adults, if they're able to return to work after accidents or injuries, or if they, you know, stay on the system.
You know, I guess the specifics, you know, I think with diabetics it's, you know, once again it's the hospitalizations, the amputations, the -- you know, it's a crazy thing that we fight and we've got a bill in the private -- and I go back and forth between private and public sectors that, you know, we're having to mandate that managed care provide the testing strips, and whatnot, for diabetics. I mean, there's just -- it just seems nuts that you'd have to do something like that.
But, I also, I'm always interested in restrictive formularies, and how that affects outcomes. I think it plays a significant role in them. So I guess, you know, it's keeping, with the kids population, it's keep them healthy and in school, and with adults, it's getting them, really, back to work and off of welfare, I guess, or the things that you're -- you'd be looking for.
And I think that also getting your bang for your public buck, I think if we had better information, then we could do a better job of contracting, as well. If you actually -- I mean, it's not just the lowest bidder, but who's providing the best quality of care to people because, then, the next time your bid comes around, those guys that just had the lowest price, but, you know, had a lot of really -- people that never seemed to make it, they should be losing their contract.
DR. IEZZONI: One last question -- oh, Kathy. I know, I was going -- and then go ahead, Don, because I want to give the other speakers a chance.
MS. COLTIN: I actually have two questions.
DR. IEZZONI: Okay.
MS. COLTIN: The first is that, in the private sector, the fastest growing cost component in medical care right now is pharmacy costs. And you referred a couple of times to changes that will probably make it much more important to have good data on pharmacy utilization, whether it's looking at AHCCCS to new psychotropic medications, or whether it's looking at the relationship between getting medications and outcomes.
And, yet, we heard yesterday that that's one of the gap areas in AHCCCS. And, in fact, one of the speakers, in identifying her wish list for a minimal data set, provided a list of data elements, over half of which were pharmacy data elements.
And I wondered whether the legislature, or any of you have taken a role or made any plans to try to improve the availability, the collection and availability of pharmacy data which will play an important role, as you identified? That's my first question.
My second question is, that in order to monitor outcomes, it sometimes means collecting data that are sensitive, particularly from a confidentiality standpoint. And we heard from a health plan representative here in Arizona, that in trying to do a study of diabetes, and to look at control of glucose levels, that the plans, under law, are not entitled to have access to the laboratory result data.
So, on the one hand, it's reasonable and important to hold the health plans accountable for the quality of the physicians in their network and the decision-making that those physicians are providing. On the other hand, if they cannot have the information that they need to be able to do that, that creates a dilemma.
So, from that standpoint, there is potentially a legislative solution, as well. And I wondered, in terms of both of those two issues, whether they were being thought about at all?
MS. GERARD: Well, we just went through on the psychotropic drugs, really kind of an informal study at Department of Health Services because, of course, all the regional behavioral health's authority of complaining, hey, these numbers are killing us, and it's now become, really, the standard of care, and they all stated they're about 20, 30 percent saturation rate, so they see the potential what this can do to their budgets.
So, we just got done doing an information gathering, I guess, to see -- and this really could be simple to figure, because we know how many, you know, seriously mentally ill people, and by diagnosis that you've got in each one of these RBHAs, and then figuring out what the cost of the medications are, and they've come up with something like 12, $13 million.
And then you get into the thing, are you providing it to Title 19 and non-Title 19, and that's something we've never really resolved, is who we actually are serving in this state. But, I mean, I think that's real easy to figure out, the number of people that could benefit from these medications.
And, you know, you've got some, I guess, that won't, you know, a small percentage, but I also think there's enough clinical information from the pharmaceutical companies about -- go to a State mental hospital, they'll tell you who's not responding, you know, and what percentage of people aren't going to respond.
MS. COLTIN: But I understand that there aren't any data available to actually track who's getting them, or if they're getting them, that there isn't pharmacy claims data, automated pharmacy claims data available to the AHCCCS Program. Is that correct? I think that's what I heard.
MS. GERARD: Well --
DR. IEZZONI: We heard that from two speakers yesterday.
MS. McCALL: That was a compromise.
DR. IEZZONI: That was a compromise earlier.
MS. GERARD: So they're saying that it's the providers don't tell their regional behavioral health authorities, or their regional behavioral health authorities --
MS. COLTIN: I don't know what it is. I don't know --
DR. IEZZONI: No.
MS. GERARD: -- has it, but AHCCCS doesn't get it?
DR. IEZZONI: No. Nelda, do you want to just summarize quickly?
MS. McCALL: Yeah. AHCCCS doesn't collect pharmacy data --
MS. GERARD: Right.
MS. McCALL: -- for the acute care plans. And that was --
MS. GERARD: Well, does it --
MS. McCALL: -- and that was a -- and that happened in the early '80s --
DR. IEZZONI: Yeah.
MS. McCALL: -- when AHCCCS was having a lot of trouble collecting a lot of data.
DR. IEZZONI: And many other --
MS. McCALL: But that was also --
DR. IEZZONI: -- Medicaid Programs do.
MS. McCALL: But I also want it understood, because I remember asking that question a number of years ago, why -- you know, I used to say when you saw the map of the United States, and they had all these percentage things, or dollar amounts, and they always had "NA" in Arizona.
So I finally said to somebody, "Why don't we get this in Arizona?" And they told me that the reason for that was, is that you actually track Medicaid people, the number you've got in your program in fee-for-service states by prescriptions, because you don't have them in your system any other way.
But when you're paying a capitated rate, you know how many people you've got in your system, and you know what your rate is, so you don't collect data in that way. That's what I was always told.
DR. IEZZONI: Okay. And how about Kathy's second question?
MS. McCALL: So that's your question. I mean, the data is available; AHCCCS doesn't track it. But I know that DHS that does our Title 19 behavioral health, I know they could tell me, if I got on the phone right now, if I could get ahold of anybody, how many there are, because they just got done calling all the RHBAs and getting the information from them.
DR. IEZZONI: I guess it goes beyond that. Looking at people who are on insulin, that would be a great way to identify diabetics, and things like that.
How about Kathy's second question?
MS. GERARD: I know, and I knew --
MS. COLTIN: About the access --
MS. GERARD: -- I was going to be in trouble with more than one question.
MS. COLTIN: -- well, access to laboratory data --
DR. IEZZONI: The laboratory data.
MS. COLTIN: -- sort of holding them --
MS. GERARD: That, I didn't understand.
MS. COLTIN: -- accountable for something, but --
MS. GERARD: That, I didn't understand.
MS. COLTIN: -- didn't have access to data.
MS. GERARD: Who doesn't have access to lab data?
MS. COLTIN: My understanding from one of the speakers who is from one of the health plans in Arizona, he said that the health plans were not allowed to have access to the laboratory results data.
In other words, they have claims data, they know that the person has the test, that they had a hemoglobin A1C, but they don't know whether it was normal or abnormal. And so if you're using that as an outcome indicator because it's predictive of --
MS. GERARD: Um-hum.
MS. COLTIN: -- whether this person will need to be in the hospital, or will need an amputation, that they can't measure that because, under law, they are not allowed to have access to the results data. The physician has it, but the health plan does not, and, yet, it's the health plan that's being held accountable --
MS. GERARD: Well, I find that hard to believe that happens in the private sector managed care, because I understand your employer can even find out your test results. I mean, that's a whole other issue of confidentiality of medical records. If there's something we actually have in the law, as opposed to what's into their contracts, that's easy. That's easy to change.
And, I mean, it's just like what we've got -- I mean, we've got a whole -- I remember doing the bill four or five years ago, we realized we didn't have any laws talking about confidentiality of medical records, and so we went in and did a big two-year, you know, put something together, but -- and, you know, it's just like when you go to your doctor and you sign all those forms that you don't read, you're authorizing them to send it to your insurance company, to this, to that, you know, to God, and everybody else.
So, you know, other than HIV tests, where you really have to, you know, do the specific signing of a form, you know, if there's something in our public system that prohibits that, that's easy to change. That might even be an AHCCCS rule, and I don't know why they would have that, but --
DR. IEZZONI: Kathy, maybe we can ask that this afternoon.
MS. COLTIN: Okay.
MS. GERARD: That's easy to change.
DR. IEZZONI: Don, do you have a quick question?
MR. DETMER: Well, first I'm delighted to hear your testimony, particularly the idea of moving toward a valued based health care system, which I think really is the target, because it's a set of systems, and I don't need data, but that's the goal I think that we are interested in.
One of the things that this Committee, as a full committee, is charged by Congress to do in the HIPPA legislation, is to advise the government, federal government, on issues of confidentiality and privacy legislation. And one of the hottest issues in that set of questions is state preemption, or federal preemption of state law on that.
Out here in Phoenix, how lathered up would you get if the federal law were to, in fact, preempt state law?
MS. GERARD: Well, you guys know how to do that so well. It's the old, you know, you don't get your federal highway funds if you don't do this. And then they make it sound like it's optional. You've got that down pat in Washington.
MR. DETMER: I think I got your answer.
MS. GERARD: That's how you do it.
MR. DETMER: Yeah.
MS. GERARD: I mean, so you allow the state a little bit of wiggle room if they want to -- I mean, it's like the S chip. I mean, that's just going so well because we think we've got choices, which, when you actually put it together, there ain't a whole lot of choices in there, but we think we've got choices. So it's just a matter of how you present it, to do that.
But, you know, the thing is, is I'd like to see us move to this value thing in both private and public sector, but we have -- we are better able to control the public sector one and make it happen, and then it can almost force it, I think, on the private sector.
DR. IEZZONI: Okay, great. Susan, thank you. This has been extremely informative.
MS. GERARD: Thank you.
DR. IEZZONI: And, we want to hear from the two remaining speakers, and then if you all can stay for even just a few minutes after our 11:30 stop time so we would have a chance to ask you some more questions.
Joe, I think that you're next on the list.
MR. GAUDIO: I'd like to thank the Committee for this opportunity to testify, and I think I can get a lot of insights from a health plan perspective to the issues that were raised here.
I'm the chief financial officer of one of the AHCCCS Health Plans here in Arizona, Arizona Physicians IPA, and I've been with Arizona Physicians IPA for the past seven years. And prior to that, I was in public accounting.
My remarks today, I will try to cut my presentation, in the interest of time, but my remarks today will focus on the data that is utilized from a financial perspective in the Medicaid Managed Care environment, and provide a little more of the details, sort of embellish what Nelda was presenting earlier, getting into a little more of the detail behind the system, and what we look at from a financial perspective. And I will also be able to touch a little bit on quality of care and risk management data that we collect at Arizona Physicians IPA.
Real quickly, I think it's very important that you understand Arizona Physicians IPA and who we are. We are a Medicaid Health Plan serving the AHCCCS members here in the state of Arizona. We are the largest health plan in Arizona. We have over a hundred and thirty-five thousand lives representing roughly 25 percent of the market share in Arizona. And we employ more than 350 individuals in six regional offices, and we also have received full antiquated accreditation, and we are one of the first health plans in Arizona to receive full antiquated accreditation.
Real briefly on background, a hundred and thirty-five lives we cover, a hundred and fourteen thousand of those are in the acute population, five thousand in the developmentally disabled population, six hundred in the long-term care system, nine thousand in the small employer group, which is not an AHCCCS Program, it's actually providing commercial insurance coverage to employer groups that have numbers of employees between two and fifty, and which Flinn Foundation is very involved in, and family planning services.
One thing to keep in mind as I make my remarks, and I'm sure this is not a surprise to anybody, but 70 percent of our population is under the age of 21. We are primarily a population of young mothers and their kids. And with a little perspective on that, Arizona Physicians IPA will deliver, or we will coordinate the delivery of over 9,000 babies this coming year. That is our core business at Arizona Physicians, is young mothers and their kids, and we are very concerned with prenatal outcomes, prenatal visits, small birth weights, and so on.
And the majority of our quality procedures and our risk management procedures are all focused around young women, pregnant young mothers. Just some perspective, that 9,000 babies equates to roughly just under a hundred deliveries per thousand members, which is quite extensive.
From a financial reporting perspective, or from a financial perspective, there are four main areas that we cover: budgeting, financial reporting, included in the financial reporting would also be the significant encounter reporting that we report back to the State, as well as bid preparation and claims liability reporting.
My comments here will focus on claims liability reporting and the bid preparation, because those are the two main areas that we are concerned with in a financial reporting system. Anecdotally, if you are familiar with the history of the AHCCCS Program in Arizona, several plans filed for bankruptcy and failed early on in the program in the early '80s. And the reason for the failure was their inability to identify and estimate their total claims liability reserve. And part of that inability was due to an inadequate information system which would embellish what Nelda had said.
Our whole financial reporting system, and our whole system, period, from processing claims and managing the care of the members is all dependent on our information system. And to give you a little detail on our information system, at Arizona Physicians IPA, 14 and a half percent of our total administrative dollars go to cover IS related costs, that's personnel and system, primarily the licensing -- the fee to pay for the license for the software, 14 and a half percent, which is just under $3 per member per month. It's an extensive amount that we play in IS systems, but our building a managed care to our population that we serve is dependent on accurate and timely data out of that information system.
In finance, we are concerned with a variety of data that we also distribute and is used by senior management in the operations of the company. In finance, we are very concerned with our daily inpatient census. We like to know how many people were in the hospital the night before, and we have systems in place to capture that. Thirty percent of our medical costs are inpatient-related.
Just to embellish a point that was made earlier, our pharmacy costs are rising significantly, and I thought I'd just add that. We have seen that, and we have seen that across the board in all lines of business, the long-term care, developmentally disabled, and so forth.
We also track weekly emergency room visits, and our daily deliveries, just as an example of some of the information that's used in finance, but is also used by senior management in managing the operations of the company.
As I said, claims and liability reporting is one of our main focuses at Arizona Physicians. Eighty-four percent of our medical costs are reimbursed on a fee-for-service basis, and we only capitate sixteen percent of our medical costs. With such a high volume that we are at risk for, our claims liability system is paramount to our survivability. We have to be able to know what truly we will be looking at to pay in the future.
A claims liability system is a system that we put in place to estimate our claims that are incurred but not reported, which is, ideally, you've heard those as IB&Rs, which is our biggest risk. And there's a lag between the time service is performed and the time you actually received the claim.
Well, under GAP, I have to accrue for that expense in the month it is incurred. And what we use is a lag methodology, which I won't get into here because it'll probably bore you to tears. But, in a lag methodology, it's the tool that we use to estimate this liability.
But some of the components, the data components that we use, and that are critical in this methodology are paid claims by category service, by month of service. Again, the information system requirements here are tremendous. Member months, utilization data, inpatient days, emergency room visits, deliveries, and that data comes off our prior authorization system.
So I'm estimating my cost the month that they are incurred. Well, I don't have a paid claim, so the only way I know how many days that I've had is through my prior authorization system, and it's very critical that we prior authorize all inpatient days.
Our deliveries, as I've mentioned before, that's our core business, and we have developed an entire database around that which we call the Perinatal Tracking System, and in that system, we will track every pregnant mother that comes onto our system, when did they receive their first prenatal care, which is very, very important to us.
We are, unfortunately, seeing a high incidence lately of mothers coming onto our plan in their late second and third trimesters. We even have mothers that deliver within three weeks of coming onto our plan, more than likely have not received any prenatal care.
The system tracks the mothers, it tracks the outcome of the delivery, cesarian section, B-back, low birth weight, very low birth rate, premature, et cetera. But these are all types of data that, you know, people are very concerned with on a clinical side, but we also use them extensively on the financial side to estimate our liability and our total cost.
Bid preparation is also a very extensive piece of what we do, it's our lifeblood. In Arizona, we competitively bid this program every five years. And, again, we actually come up with a bid rate, a PMPM rate. Well, to come up with a PMPM rate, you need -- it's a function of utilization per 1,000 times an average unit cost. But we need to capture all that data by county, by rate code, by service category, rate code being CANIF, SSI with Medicare, SSI without Medicare, and so forth.
Again, the system requirements here are tremendous, and you must have your arms around the system in order to be able to put together a competitive bid, and a bid that will ensure your survivability over the years.
From a quality of care perspective, first I'd like to mention that we are a hundred percent compliant with HEDIS 3.0 reporting requirements. And some of the areas that we track with our quality of care and risk management, grievances, both provider and member grievances. And those are reported back to the state on a quarterly basis. Physician profiling, a very extensive physician profiling system. We like to compare our physicians to our peers. Unfortunately, we can't quite compare them to norms, because we haven't seen any norms across the country for AHCCCS, or for Medicaid, which there are some risks and issues associated with that.
We have a whole system for tracking quality risk management referrals, where if somebody wants to make a referral on a quality management issue, we take that referral from anywhere in the company, or outside of the company. And those usually come in through phone calls via our Customer Service Department, and they're loaded into what we call a Complaint Tracking System.
And from this Complaint Tracking System, we then compile them on a weekly basis and take them to the Service Improvement Committee, which ultimately we could take them to a Quality Management Committee, based on the seriousness of the quality management issue.
But that provides us with all kinds of data, complaints per 1,000 for the various PCPs, which we use in our profiling, and so forth. It gives us a handle of what type of quality issues that we see out in our network, and gives us a basis for coming up with an action plan.
We also have an extensive credentialing program, where we actually go out and do physician office reviews with the chart reviews, waiting times, handicap accessibility, and so forth.
And just real quickly, some of the examples of the indicators that we measure and the sources that they come from, from a physician profiling standpoint. Emergency room visits, and our source there is paid claims. Specialist referrals, again paid claims. Complaints per physicians comes from our Customer Tracking -- our Complaint Tracking System. Cesarian section by physicians from our Perinatal Tracking System.
With regard to risk management, we measure fall with an injury, avoidable complications after surgery, intubation injury, repeat cesarian section, admit post-outpatient procedure, and these all come off that referral system of ours.
Preventive health indicators. Childhood immunizations which we both look at paid claims data and chart reviews. Mammographies, Pap smears. Again, we are a plan of young women and their children. Low birth weights, very low birth weights, initial prenatal care. The diabetic retinal exams.
And, again, all of these come from our paid claims data or, preferably, our Perinatal Tracking System, where we incorporate a high risk assessment tools as a means of collecting that data initially, and whether or not we should case manage the young women. By definition, all of our pregnant women under the age of 18 are case managed, and as well as all other high risk drug abuse, and that type of thing. That's it.
DR. IEZZONI: Thank you. I know we'll have some questions for you.
Brian, can we hear from you? Thanks.
MR. LENSCH: My name's Brian Lensch. I've worked in the field of developmental disabilities for about 25 years, and the last approximately 10 years here in Arizona in the Medicaid Program that we operate. I work in our central office. We provide services both to the Medicaid population, and to those who don't qualify for the Medicaid. On a statewide basis, we serve about 18,000 members. About 8,000 of those members are in the Medicaid Program.
We are called a program contractor. We contract with the sister state agency, AHCCCS. As a part of our responsibility, we also subcontract with health plans, so we subcontract with APIPA to provide acute care services. And, in addition to that, we provide the long-term care services predominantly on a fee-for-service basis.
The state agency is at risk. We are capitated. And from there, we then provide for the services on both acute and long-term care. We're also responsible for the behavioral health services, which we subcontract back out to the state behavioral health agency.
I did want to correct a statement from yesterday. I believe Ms. Temm indicated that there is no mental health or behavioral health program for the 21 to 64 year olds. There is a Medicaid Program for the 21 to 64-year-old persons. The State implemented the behavioral health program in stages, and they started out with a zero to eighteen thinking they were covering EPSDT, until the federal government took a second look and said, wait a minute, EPSDT goes to 21. So then they implemented a second program for the 18 to 21-year-old program. Then they implemented the 65 and older, and then they implemented the 21 to 64.
So there is a program for all ages, it's just that it came in stages. Ms. Temm probably was not aware that the 21 to 64-year-old program had started. That's just to correct something I heard yesterday.
DR. IEZZONI: Thank you.
MR. LENSCH: I, too, was not sure, as was Betsy Trombino, why I was being contacted to participate in this testimony. I appreciate the opportunity to give you whatever information I may be able to, to help you. Most of my experience is not in the information system, it's in the program side.
And since you've heard from a number of consultant positions and other folks who are program contractors, or health plans, I want to kind of reinforce what Betsy Trombino said yesterday, and that is, let's make sure that we know why we're gathering the data, and what we're going to use it for.
I liked the description yesterday of DRIP, I had not heard that before. But I think the biggest issue is that we have to balance why we're gathering the data with what our mission is. And our mission is to serve people in our particular division, people with developmental disabilities. And a lot of times what was intended as good, causes barriers for us to do a good job. And that may be through the systems that are set up for gathering the data.
We've run into problems because of the way the provider information system is set up for AHCCCS. It has a tendency to limit our network that we can use. Developmental disabilities, I think, is a lot different than the majority of medical service delivery systems. And I know from my experience that state-to-state it differs greatly, even within the developmental disability system.
And part of what happens is, and maybe if I gave you an example, we're expected to ask every one of our members about their intent to have babies on an annual basis. Parents don't appreciate that, okay? And so they -- while it has good intent, potentially for the Medicaid population, it doesn't always have good intent for the specific populations that are also being served. That's just one example.
They talked yesterday about multiple requests for the same information. We're trying to implement a program called Targeted Case Management. I don't know if you're familiar with that service. It's something that we pushed in order to get additional federal revenues. We have a tendency in our field to look at ways of getting more money to do more things.
And we've run into problems, because AHCCCS gets its demographic data from multiple sources. They don't always have their own data entry folks entering that. So they'll get the information from SSI, they'll get the information from a sister agency in our agency, we call it DBME, which is our Medicaid -- or, I'm sorry -- our welfare program that also does eligibility for Medicaid.
And so if someone forgets to enter the "Junior," when someone is a junior, or they forget to enter the initial, you'd have data entry problems. We have our data entry folks, and when we try to match up with what's in the AHCCCS system, it doesn't match.
And what Betsy was trying to say yesterday, is SSI is asking her for all that same information. If she's involved with any of the welfare programs, welfare's asking for the same information. ADD turns around and comes in and asks for the same information. AHCCCS does do eligibility for ALTCS. It does not do the eligibility for the financial side on the Medicaid, but they do for the ALTCS Program. They go out and ask the same information.
In fact, they will send a case worker or a nurse out to the family's home to do an assessment and ask for all the demographic information. And families are constantly telling us, why can't you, as state government, or as an enterprise trying to provide these services, just ask for the information once, and keep -- instead of keep asking for the same thing over and over again.
The other problem that we run into, is that a lot of the data that we're required to gather, particularly on demographics, but including TPL issues, we'll ask the family when we go out and do the survey, we'll try to ask the family on an annual basis when we do our assessments with them.
But the reality is, for most folks, it doesn't click with them sometimes when they have, for example, maybe a change in their health status, maybe the father changed business, so now they have a different insurance company providing the coverage, they don't connect to what the father's doing, with the services their child's getting, so they don't tell us that. And so our data system is not always accurate after the initial.
I guess what I'm trying to say is, it's easy to get the data up front when you're doing the initial intake. It's hard to keep it current on an ongoing basis for folks who have been in the system for a long period of time.
And I think the last thought that I wanted to make was, again, something that was said yesterday, and kind of reiterated this morning with Nelda's comments. One of the problems that we have is that there's not a link between the public health systems, and the systems that we have, and the systems that APIPA has.
Probably immunization is a good example for our particular population. We have 50 percent of our population is children under age 21. A lot of those folks have families who are working, who also have secondary insurance other than the Medicaid Program. And the families, for the most part, when they have routine care, they'll go to their physician for the routine care.
It's when it has significant and cost duplications, they go to the Medicaid Program, maybe APIPA, so they may be getting their immunizations from a physician that's associated with the father or the mother's work insurance, and those immunization datas are not transferred then to the PCP or the primary care physician who's doing the work for them through the Medicaid Program. Or they'll go to a free clinic, a free health clinic and get those services, and that data's not available.
And so when you start looking at the outcomes, as we were talking about earlier, and look at immunizations and how well you're doing, the numbers look maybe worse than they really are, because there are other places that those services are being made available to those folks that are not coming back together. So the best intent in trying to gather all this information and provide for all of the analysis that we want is not always going to get us exactly where we want to be at, at least that's been my experience in the last seven to eight years.
DR. IEZZONI: Brian, your comments have been very helpful to us, so we're glad that you came, even though you might not have known why we asked you.
Thank you for the speakers. Let's see whether the subcommittee members have questions. I know that we must. Yes, George?
MR. VAN AMBURG: We have two questions for Joe. You must submit counterdata to AHCCCS. Okay?
MR. GAUDIO: Correct.
MR. VAN AMBURG: In the background material we had, you have up to 240 days to do that. What is your average submission time?
MR. GAUDIO: We submit our counters to AHCCCS within 30 days of us paying the claim. It's very important for us to get the data over to AHCCCS as soon as possible so it can run through their primary edits, and they will report the exceptions, so to speak, back to us so we can get them corrected, because it is the counterdata that is used for, ultimately, in the bid setting and rate increases in the future, at least from a financial perspective.
MR. VAN AMBURG: Okay. My second question relates to your bid process. The background material indicated that both price and quality are considered in awarding the bids. What are the quality measures you submit on your bids?
MR. GAUDIO: When we submitted our bid, we spent a lot of effort in documenting the programs that we have. And one program that I'd like to touch on, which we felt works very well for us is our Young Women's Case Management Program, which we pioneered several years ago. As a young woman is enrolled with APIPA, she is immediately contacted, our internal goal is within 48 hours.
Again, the risk there is that she's coming on, perhaps, in the third trimester, or the second trimester. Our case manager then works through a work assessment form, and determines if the member's high risk, meaning young or under 18, or a drug dependency, or something of that nature. And then all this information is then located into our Perinatal Tracking System and the mother is tracked. And if she is a high risk group, she is actively case managed, where she encouraged to go to her prenatal visits, and so forth. That's probably our number one quality program that we placed in our bid.
And in addition, we have our whole quality management committee -- or, our whole quality management process where we have created the Complaint Tracking System, where anybody is free to make a referral into that system regarding a quality issue. It could be a provider, it could be a member. It could be somebody in finance. We are constantly beating up our data and cutting it every which way you could possibly think.
And perhaps we might notice a trend, and a trend that looks suspicious, we'll investigate it, and then perhaps that could lead to a quality referral that will go into that Complaint Tracking System. It will then be, on a weekly basis, the complaints into this system are summarized for the Service Improvement Committee, and the Service Improvement Committee will refer the referrals into the system and determine whether they warrant further processing into the Quality Management Committee, which is made up of our -- a broad-based selection of our providers. It's external.
And then from there, we can either -- then we categorize the level of the referral, Level 1, 2, 3, 4, 4 being the ultimate adverse outcome, member was hurt in some particular way. There is policy in place that we report to the appropriate authorities, BOMEX, if need be, and take correction action to the point of terminating contracts with our providers, probably the second largest area in quality that we emphasize in our bid, and a variety of areas, the grievance tracking, the EPSDT monitoring that we do, significant EPSDT monitoring.
We have nurses that go out there and track. Our efforts to obtain immunization rates. We have a dental outreach program at APIPA which, again, is unique for APIPA, again, another one of the quality areas that we like to emphasize. What we do, is we have a person that goes out into the public schools. Sorry. I was getting the --
DR. IEZZONI: I'm sorry, I --
MR. GAUDIO: We're very proud of quality program.
DR. IEZZONI: It sounds like it. We're wanting to write you an agreement, and I'll sign up with you.
Can I just ask Nelda and John, maybe, it does sound like the company that Joe works for is doing a marvelous job. Yesterday, one of the things, though, that we heard, was that there are a number of plans in Arizona that only have four or five hundred enrollees, but, in fact, they are crucially important to serving the local communities, primarily, rural communities, and are very integrated with the local folks.
What are the kinds of quality monitoring, Nelda, or John, or anybody else, that those kind of plans do, if you have any notion of how that happens?
MS. McCALL: Well, you know, I haven't been here since 1995 --
DR. IEZZONI: Um-hum.
MS. McCALL: -- and so we probably haven't been out in the field, so it'd probably be unfair to talk about, you know, what happened in the past.
DR. IEZZONI: Um-hum.
MS. McCALL: I think, you know, APIPA is in, I guess, just about every county except two now.
MR. GAUDIO: Correct. Well, we are in all counties between all our lines of business, on the acute side, or in 13, 15.
MS. McCALL: Right. You're in 13 or 15 counties. So, the same methodology that he's talking about is statewide, I assume.
MR. GAUDIO: Yes.
DR. IEZZONI: No. But, I know. It's just that there are these companies that only have four or five hundred enrollees that we've heard about, and --
MS. McCALL: Maybe some of the providers, because I -- are you talking about the acute care plan, or the long-term care plan?
MR. GAUDIO: There is, if I may, Doctors Health Plan and Southeastern Arizona --
MS. McCALL: Arizona, which has --
MR. GAUDIO: -- which serves, you know, not Cochise, Graham County.
MS. McCALL: Yeah.
MR. GAUDIO: And I think they only have about 500 employees.
DR. IEZZONI: Um-hum. Yeah.
MR. GAUDIO: Graham County is very small.
MS. McCALL: Right.
DR. IEZZONI: Okay.
MR. GAUDIO: And they do an exceptional job servicing down there. They're locally owned, and they have the rapport with the physician group.
DR. IEZZONI: Can I just ask John a question?
One of the other things we heard yesterday was that each of the health plans in the state is required to do a satisfaction survey, but they're not required to do the same satisfaction survey. And so, the satisfaction numbers that are reported by the different plans are based on a different methodology.
Now, you are doing a wonderful public service, I think, with your Flinn Foundation, and doing your own satisfaction survey. How does what you do relate to what some of the plans do, and is there any sense within Arizona that maybe there ought to be consistent reporting of satisfaction? We didn't have a chance to ask Susan that, but it does seem a bit --
MR. MURPHY: And I think she would probably, if she were here, agree with that objective.
DR. IEZZONI: Um-hum.
MR. MURPHY: I think a lot of the plans, patient satisfaction is really more based on the marketing satisfaction, if you will. And a lot of the -- in our final survey in 1995, we went a little further, we used some of the material that Karen Davis and others have developed through the Commonwealth Fund.
And we were asking very specific kinds of questions which I wish were incorporated in the type of things you're talking about, in terms of was care appropriate and correct from the patient's perspective; was the most up-to-date tests used; did the doctor take the time to make sure you understood what you've been told about your medical problem or medication and its use; did they treat you with dignity and respect. Not many of the plans are asking those kind of questions, at least the last time I saw them.
DR. IEZZONI: Joe, how would you feel as a plan about having to think about some consistent way of collecting that?
MR. GAUDIO: I think that the best thing that you can do, and what I would like to emphasize to the Committee, is consistent reporting. Most plans, from across the whole gamut, from utilization, down to member satisfaction surveys, and then plans, legislators, regulators, members, would then be able to compare the plans on an equal basis, but you do have to make sure you address the areas of comparability and consistency, especially when you go across state where different states have different carve-outs, different benefit packages and, to an extent, different eligibility requirements.
But, from a plan's perspective, we would endorse it.
DR. IEZZONI: Yeah, okay.
Nelda, you seem to want to say something.
MS. McCALL: No, I just want to say that during our evaluation, which went on, as I said, from 1983 to 1995, we criticized AHCCCS relatively heavily about non-standardized reporting with respect to grievances and appeals, and those kinds of things. And I think, you know, that clearly is an area where there should be standardization, and I don't know if they've moved as much in that direction, you know, as we would have liked to have seen them. But I think that's a critical issue.
You know, AHCCCS has done their own satisfaction studies of the program, and I'm sure they'll talk to you about it this afternoon, though -- and I think they have representative samples of the plans within that, but maybe you got some comments that people didn't like that study. I don't know. I've not looked at it, because it all happened after we were gone and done.
MS. WARD: This is a follow-up to you, Joe. That whole issue of reporting grievances and complaint tracking --
MR. GAUDIO: Um-hum.
MS. WARD: -- I'm always concerned that we can prove the purpose of asking anybody to pay money to report something. And what you described internally is monitoring, yourself, in terms of what you're doing with grievances, it sounds very reasonable.
If I were the State and you reported your grievances and complaints to me, what's the value of my knowing? Is it the fact of the number, the rate, what to do about it? What's the standard for knowing what I'm supposed to do with that data when you send it to me?
MR. GAUDIO: I think it's not necessarily the number, because we do get -- we seem to get provider grievances because of being a Medicaid Plan, and then a lot of reimbursement issues, obviously. But it's more the focus on the type of complaint --
MS. WARD: Okay.
MR. GAUDIO: -- and is the population getting mainstreamed. You can make that assessment, to an extent.
And then as part of our grievance tracking, we also -- we just don't, you know, report the number and the type, we also report the action plan and status, and what are we doing --
MS. WARD: On every grievance?
MR. GAUDIO: Every grievance has a status. Was there a required -- corrective action plan; did we have to go out to that provider; was our member referred to case management, that type of thing, and not necessarily the volume, but as opposed to the types and what types of issues are those relating to, and as a health plan, address them accordingly.
MS. WARD: And do you think the value of that, from the person who's getting that data, is worth your trouble and cost of reporting that?
MR. GAUDIO: Absolutely.
DR. IEZZONI: Hortensia?
DR. AMARO: Yes. For both Brian and Joe, because it seems that the services you provide are so very family focused services. And we know, for example, with your population that you describe as primarily pregnant or young women in the prime child bearing years, that a major contributor to low birth rate, and birth complications, and developmental problems in kids is alcohol and drug use during pregnancy.
And I was wondering if you had a way of tracking the availability receipts and quality of those services to mothers as a way of looking at outcomes for kids, or factors that might contribute to outcomes for kids, or for infants or babies, in this case?
MR. GAUDIO: What we do with our Young Women's Case Management Program, our case managers are primarily social workers, and they are well-aware of, or at least we hope they're well-aware of the other services available for the regional -- I hope I'm answering your question, I don't know if I am, but we do track, if we've referred our members to some other, you know, behavioral health organization, or a support group. Or, you'd be surprised of the incidences of sexual abuse.
DR. AMARO: Right.
MR. GAUDIO: And we have protocols to make sure that a referral gets to the appropriate counseling center, and so forth, and that's what our case managers are trained in doing, and they're responsible to do, but we do track that data now.
Outcome related to that, I, unfortunately, can't answer that. I don't know, and I don't know if we've been able to really determine -- actually, what I can tell you, is when we first implemented the Young Women's Case Management Program, our primary measure that -- or, primary factor that we measured was low birth rate. And our incidences of low birth rate, for lack of a better term, and I'm sorry, I don't have the statistics, but they dropped like a rock.
DR. AMARO: Um-hum.
MR. GAUDIO: And we saw a continuous drop for a while, and now it has plateaued, and we think we've achieved -- you know, we try to reduce it as best we can, but I think we've made our most significant gains, and we've pretty much leveled off.
But that statistic we did measure; and, yes, there was a significant positive outcome as a result, and we directly attributed that to our Young Women's Case Management Program.
DR. AMARO: So that's your data you collect, yourself, not through linkages, but through data from other services provided --
MR. GAUDIO: No, that's data we collect ourselves through the Perinatal Tracking System, where we cover everything.
DR. IEZZONI: George.
MR. VAN AMBURG: This is for Joe. Yesterday we heard some concern about the multiple layer of reporting, the physicians report to the plan, the plan reports to AHCCCS, sometimes it's at three levels, and some thoughts that maybe providers should report directly to AHCCCS by them going through this layer, and I wondered how you felt about it, and how your system actually works.
MR. GAUDIO: I would still recommend that reporting come through the plans. We have the systems in place that can capture the data and wrap it and present it to make it useful for this state. We can submit it electronically, we can submit it on tape, on any medium. When you're talking providers, and physician offices, you know, they have a hard time billing on a regular basis, so I can't imagine relying on them to submitting counterdata.
MR. VAN AMBURG: Without billing it to you -- for you.
MR. GAUDIO: True. But, as I said, we have the large systems in place. And, to put that cost onto the State, I'd rather have that cost be funded into the plan, rather than the State, and let the State focus on another area.
MR. VAN AMBURG: What about the very small plans we mentioned earlier?
MR. GAUDIO: Excuse me?
MR. VAN AMBURG: How about the 500 member plans, how do you think they should work, a plan that couldn't support a big data system like you have?
MR. GAUDIO: I still think they should be responsible for reporting their data, and reporting it through the -- from the physicians to the health plan.
DR. IEZZONI: Nelda, can I go back to something that you said earlier that has stuck in my head, that there were 50 percent cost overruns on developing the information systems.
Are there any things that Arizona learned during that difficult time of those overruns, that you think could inform other states as they are developing their information systems around Medicaid Managed Care?
MS. McCALL: Well, I think that when you develop these kinds of programs, that, you know, in a lot of cases there are cost overruns, and that you should probably almost budget for some level of cost overruns.
I mean, I think they made the decision, without getting too technical, to sort of go to a state-of-the-art-type system with a language that has limited programmer availability, at that point in time, because of where technology was, at that point in time. I think if it were to be considering it now, that technology has improved greatly, and they probably would have made different kinds of decisions.
I don't -- I mean, I think one area had to do with the contracting process, and whether the contractor was actually going to be able to be involved with the actual running of the system. And it may be that they didn't attract as many contractors as they could have if they had more of a stake in making the system operate smoothly, and it wasn't going to be a system that was basically going to be taken over by the State.
We've got a long piece on that, that we'd be happy to share with you. But, I think strategic decisions about, you know, what kind of software to use, how to put out your RSP, and what kind of decisions to make around that, in terms of attracting the right kind of people to be involved with the State and the development.
But, in general, I think just understanding that often these things cost more than you think they're going to when you get into them, is probably a good lesson that needs to be learned.
DR. IEZZONI: And, one final question, I guess, this might go to Joe, as well, do you know about the standards under the Health Insurance Affordability and Accountability Act for data transmission, and is your company planning for how to implement them?
MR. GAUDIO: I'm personally not aware of the standards, but we will follow the lead of AHCCCS and, you know, from our perspective, you know, we will do whatever it takes, because we understand the importance of data reporting, the importance of it being consistent and comparable among plans in the state.
But, I know AHCCCS, at least in their last bid, made reference to the fact that they may be requiring -- or, they will be developing standard reporting, electronic, and we have every intention of complying with that a hundred percent, if not, you know, helping lead the way.
DR. IEZZONI: Any final questions for our panel? No.
Oh, John, yes, your turn.
MR. MURPHY: Excuse me. It's not a question, but just an observation. The issue of immunizations arose several times today, it may have yesterday, as well. And just to make you aware of a new system in the state, it's statewide, and it's called, I hope I have it right, the Arizona Infant Immunization System. It's a statewide registry.
And due to legislation -- excuse me -- the last year introduced by Representative Gerard, it now mandates that all infant immunizations, regardless of the provider, will be entered into that centralized registry. And we're hoping, in that way, both to track and follow up, and it's implemented both by electronically, as well as through an 800 number through every school district, as well as every private physician office in the state.
DR. IEZZONI: Do you have a problem with illegal immigrants in this state?
MR. MURPHY: Do we have a difficulty with --
DR. IEZZONI: Yeah, do --
MR. MURPHY: -- do we have them, yeah.
DR. IEZZONI: It does. Because I always think that random immunization, especially, that that might be an issue, you know, parents being willing to report this if they're not -- if their status isn't labeled. Is that something -- yeah.
MR. MURPHY: It is. Of course, for school entry, that's another issue.
MR. GAUDIO: Under the AHCCCS Program, we cover the illegal alien population for emergent services only, unless, of course, the child is born in the United States, and then they are covered for a year.
MR. LENSCH: A lot of families won't access the care, because they're concerned that once they do that --
MR. MURPHY: Right.
MR. LENSCH: -- it exposes them to the fact that they're not legally in this country.
MR. MURPHY: Um-hum.
DR. IEZZONI: Yeah. I would think that that would be a public health issue, especially maybe in certain parts of the state.
MR. GAUDIO: That's right.
MR. MURPHY: It is getting worse.
DR. IEZZONI: It's getting worse?
Yeah, Joe.
MR. GAUDIO: To reemphasize the points on immunization, our immunization rates, when we initially measure them, you know, that's just based on the data that we have, the paid claims data that we have, you know, have not been what we wanted them to be, obviously, but we firmly believe that it is not a utilization issue, it's a reporting issue.
We believe that the children are getting immunized. But as Mr. Lensch reported, they go to the clinic, they go to the mall, they go anywhere, and that data just is not getting back into the chart review.
MR. MURPHY: That's the purpose of the --
DR. IEZZONI: So, if this wonderful --
MR. MURPHY: If the registry works, then we'll address it.
DR. IEZZONI: -- program that Representative Gerard set up has a hole in the middle of it because of fears of people to reporting this kind of information, would you --
MR. MURPHY: Well, it's reported by the provider.
DR. IEZZONI: By the provider.
MR. MURPHY: Not by the individual.
DR. IEZZONI: But the main --
MS. GERARD: That would identify us --
DR. IEZZONI: -- but a registry says that there's a name.
MR. MURPHY: Yes. In fact, the registry actually begins at birth --
MR. LENSCH: You're right, though.
MR. MURPHY: -- in state, so we don't --
MR. LENSCH: I think that it will not resolve the issues of those families who are here illegally, and don't want to either access it or --
MR. MURPHY: Or who were not born here.
DR. IEZZONI: Yeah, okay. Thank you. Very, very helpful. We really appreciate your sticking around a little bit longer than originally intended. Thank you.
MR. MURPHY: Appreciate it. Good luck to you.
DR. IEZZONI: Okay.
(Whereupon, a lunch recess was taken at 11:40 a.m.)
CERTIFICATE OF REPORTER
STATE OF ARIZONA )
) ss.
COUNTY OF MARICOPA )
BE IT KNOWN that I took the foregoing tape recorded proceedings; that I was then and there a Notary Public in and for the County of Maricopa, State of Arizona; that this is a true and accurate recording and transcription of the proceedings consisting of 80 pages, done to the best of my skill and ability.
WITNESS my hand and seal of office this
day of February, 1998.
Angela T. Thornton Notary Public
My Commission Expires: