Health Care Financing Administration
7500 Security
Blvd.
Baltimore, Maryland
Lisa Iezzoni
Barbara Starfield
Don Detmer
Simon Cohn
Robert Gellman
Elizabeth Ward
Kathleen Fyffe
George
Van Amburg
Jeffrey Blair
William Braithwaite
Judy Ball
Vincent Mor
Robert Moore
Carolyn Rimes
James Scanlon
Olivia Carter-Pokras
Steven Clauser
Helen Fredeking
Tom
Hoyer
Gail Janes
Welcome and Opening Remarks -
Liza
Iezzoni, MD, Chair, PSI Subcommittee
Barbara Starfield, MD, Chair,
HDNSS Subcommittee
Overview and Issues for Post Acute Care: Health
Care Financing Administration Panel -
Tom Hoyer
Steven
Clauser, PhD
Helene Fredeking, Health Care Financing Administration
National Perspective on Post Acute Care Panel
Marilyn
Field, PhD, Institute of Medicine
Karen Seitz, Veterans Affairs
Marc
Freiman, Agency for Health Care Policy and Research
Panel on Research and Demonstrations
Korbin
Liu, ScD, Urban Institute
Chris Murtaugh, Center for Home Care Policy
and Research
David Rabin,MD, Georgetown University Medical Center
Nancy Miller, PhD, Health Care Financing Administration
Rehabilitation, Assisted Living and
Performance Measurement for Long-Term Care Panel
Bill
Buczko, PhD, HCFA
Catherine Hawes, PhD., Meyers Research Institute
Panel on Current Collection and Data
Standards Issues
John Morris, PhD, Hebrew Rehab. Center for
Aged
Ye-Fan Glavin, PhD, New Health Management
Nell Wood,
Maryland Hospital Association
Peter Shaughnessy, PhD
Kathryn
Crisler, RN, MS, Center for Health Services and Policy Research
Terry
Moore, RN, MPH, Abt Associates, Inc.
DR. IEZZONI: Why don't we get started? Can everybody take their seats so we can get started? I would like to thank HCFA for hosting us. This is the first time I have been in this building, and it is gorgeous surroundings, and so, thank you very much for having us out here.
This is a joint meeting of the Subcommittee on Population Specific Issues of the National Committee on Vital and Health Statistics and the Subcommittee on Health Data Needs, Standards and Security, and we are very happy to be here to learn from you today about an issue that is growing in importance.
I would like to first thank Carolyn Rimes for all of her hard work in putting together this meeting. I know that Carolyn and some other folks have worked very, very hard at getting this together.
This is a meeting for us on the National Committee to basically learn from you about issues having to do with data systems around sites of care that often actually seem to be forgotten by many people even though these are sites of care where the health care costs and expenditures are growing at a faster rate than health expenditures are growing in many other aspects and sectors of the health care economy.
That is long-term care, home health care, rehabilitation care, etc., and so as I said we are here to learn from you. This is our first effort to get kind of a systematic overview of what is going on in this area, and so, I would like to stop speaking and see if Barbara Starfield, my Cochair has any brief comments, and then we will introduce ourselves and begin the meeting.
DR. STARFIELD: Thanks very much, Lisa.
I chair the Subcommittee on Health Data Needs, Standards and Security, and today is our day to hear from you. You have a list of questions, those of you who are going to come around the table, and we would like answers for those questions.
I would like to add another question, and that is a question on what it is we are here today to talk about which is supposedly post-acute care. I guess I am confused. I may be the only one, but I am very confused about what post-acute care means because as I understand it a lot of what we are talking about is not post-acute, and in fact some of it may be very acute.
So, I would like first for all of you to sort of address the issue about what it is we are talking about. Lisa said that it was long-term care, home care, etc. So, I wonder what the etc., what is it we are talking about because it will be very difficult for us to deal with data needs unless we really know what we are talking about. So, that is basically all I have to say, and let us move on.
DR. IEZZONI: Okay, Barbara, why don't you introduce yourself, and I will introduce myself, and we can go around the table.
DR. STARFIELD: I am Barbara Starfield, and I am from Johns Hopkins University.
DR. IEZZONI: I am Lisa Iezzoni. I am from Beth Israel Deaconess Medical Center in Boston. I would like to go around the table, have everybody at the table introduce themselves and then, also, have folks in the room introduce themselves.
MS. GREENBERG: I am Marjorie Greenberg from the National Center for Health Statistics. I am the Executive Secretary to the Committee
DR. FYFFE: Kathleen Fyffe. I am a new member of the Committee. I am with the Health Insurance Association of America. We represent approximately 250 commercial health insurance companies.
MS. WARD: I am Elizabeth Ward, a member of the Committee, and I am here from the Washington State Department of Health.
DR. MOR: I am Vince Mor. I am a member of the Committee, and I am at Brown University.
MR. MOORE: I am Bob Moore. I am the HCFA liaison to the Committee.
MS. RIMES: I am Carolyn Rimes, and I work at HCFA.
MR. SCANLON: Jim Scanlon, Director of Data Policy in ESBE(?). I am the Executive Director of the Committee.
MR. CLAUSER: Steve Clauser. I am with the Office of Clinical Standards and Quality at the Health Care Financing Administration.
MS. FREDEKING: I am Helene Fredeking. I am at HCFA in the Center for Medicaid in State Operations.
MR. HOYER: I am Tom Hoyer, also, with HCFA.
MS. JANES: I am Gail Janes from CDC in Atlanta and staff to the Subcommittee on Health Data Needs, Standards and Security.
MS. BALL: I am Judy Ball from HHS. I am staff to the Subcommittee on Health Data Needs, Standards and Security, also.
MR. BRAITHWAITE: Bill Braithwaite from HHS, staff to the Committee.
MR. BLAIR: Jeff Blair with the Medical Records Institute.
DR. COHN: I am Simon Cohn. I am a member of the Committee, a practicing physician and the senior consultant for clinical data for the Kaiser Permanente Medical Care Program.
DR. IEZZONI: Could we start with you there and go around the auditorium.
MR. RABIN: David Rabin, Georgetown University.
MR. GREEN: Mark Green, Agency for Health Care Policy and Research.
MR. LEVY: Glenn Levy, Health Care Institute.
DR. LIU: Korbin Liu, Urban Institute.
MS. CRISLER: Kathryn Crisler, the Center for Health Services and Policy Research, University of Colorado.
DR. FIELD: Marilyn Field, Institute of Medicine, National Academy of Sciences.
MS. CORNELIUS: Betty Cornelius, consumer.
MS. ROBINSON: Crystal Robinson, EDS.
MR. MORRIS: John Morris, Hebrew Rehabilitation Center.
DR. IEZZONI: Very good, thank you.
We have an ambitious agenda today and with respect for the speakers I would like to try to keep on time as much as we can. It is nine-fifteen, and we have the first panel comprised of the three of you, and I leave it up to you. If you like the order that you are listed in, you can go in that order or whatever order you would like.
MR. HOYER: As bureaucrats of course, we would never question the order. So, let me start out? Like most of the people who work for the Federal Government I was previously unemployed, but this is an engaging activity, and one of the things about it that reminds me of my remote English major past is dozens of quotations that try to attempt to say that an artist is somebody who can simultaneously proceed on things that are somewhat inconsistent, and as the years have gone by I figured out that one of the things that never works in health planning is consistency.
I have never yet run into the perfect plan that ever got adopted or enacted. There was a perfect health care reform plan proposed not long ago which met the same fate.
So, with that let me start out on post-acute care because it is HCFA's attempt to try to keep thinking conceptually about something while it continues to act practically in specific instances, and it is endeavoring not to feel bad about whatever inconsistencies may occur while it is doing these two things simultaneously.
I hope to suggest that it is probably the better pathway to pursue. One of the things that Bruce Vladick forced us to acknowledge after years of careful ideology is that despite the fact that Medicare didn't have a long-term care benefit we certainly bought a lot of care for people who were chronically ill for a long time, a lot of home care and increasingly a large amount of SNIF(?) care, rehab hospital care, long-term care hospital care and keeping our honor bright was sort of of secondary importance to acknowledging what we were doing and how efficient it might be altogether if considered in terms of long-term care.
Before he left we had adopted what we sort of think of as our post-acute long-range approach and our post-acute short-range approach, and I will try to deal with both of them.
The long-range approach is really sort of the 21 year old's dream of retirement. It is a happy perfect set of thoughts with no clear pathway to it. The shorter range is a good deal clearer. In the short range we have a bunch of prospective payment systems put in place, one for home health, one for skilled nursing facility care, one for rehabilitation hospitals, one for long-term care hospitals.
Virtually all of them will rely as nursing home care has up until now on assessment instruments, at this point different assessment instruments, but what we hope to do while we are putting these systems in place is to look carefully at the nature of our assessment instruments and assessment in general with the hope of coming up with something more universally applicable, a sort of more catholic instrument that might be more susceptible to being widely used for patients who might end up in a variety of settings.
We, also, hope to do a fair amount of studying of the costs of different types of patients in these different settings, and we hope to get the information to do that in part from data we will get out of these assessment systems.
Obviously that is pretty much all to happen in the future. The MDS data is, I gather beginning to arrive here from the hinterlands, and I am sure it will be very useful in a year or two, but I suspect there will be a fair amount of work required before then.
DR. IEZZONI: May I just interrupt for a second? We are here to learn from you today. I know what MDS means, but some of the other folks around the table don't, and so, when people speak in acronyms, could you please just define what you mean?
MR. HOYER: Sure, absolutely, to the extent that I know what they mean.
DR. IEZZONI: MDS, minimum data set.
(Laughter.)
MR. HOYER: I did know that one. The minimum data set which at this point is longer than it was at the beginning was mandated by the Nursing Home Reform Statute.
It is a data set that must be completed by every nursing home under Medicare and Medicaid at least once and often more than once for each patient it admits, and it is supposed to be the absolute expression of the needs of the patient, and theoretically if you look at that patient's plan of care you will see services ordered that reflect the assessment and if you look at the actual patient you are going to be able to see the services have been rendered that reflect the assessment and the plan of care, seemingly a simple progression but apparently not so simple in the nursing home world.
In home health for which we are developing the next prospective payment system we will be putting in place we will be using OASIS, and I am afraid I don't now what OASIS means, but go on and tell them.
DR. CLAUSER: I don't know. Kathryn?
DR. IEZZONI: Outcome and Assessment Information Set.
MR. HOYER: This is a different instrument than MDS in that it approaches the assessment of the patient more by outcome than by input about which there has been some debate around here.
However, it is an information set which we began to develop as a result of some amendments in 1987, intended to reform the home health survey process. It is an instrument that after a long effort we negotiated with the home health industry to accept, and it is the instrument I believe that we will be using for this for home health prospective payment.
It, too, will produce data that are collected centrally and analyzed for quality issues, as well as with the SNIF(?) data used to classify patients for payment.
On the skilled nursing facility side for prospective payment we hope to use the resource utilization group's technology version RUGS-3(?) which is a technology that pays for care prospectively on a per day basis, fundamentally gauging the amount of payment on the functional status of the patient and the amount of nursing and therapy services the patient consumes.
On the home health side we hope to mount a prospective payment system which is based on facts as yet to be learned in groups as yet to be defined, in amounts as yet to be dreamed of at some point in the future. However, we have a plan for doing that, and we expect to be finished by October 1, 1999.
I will let the interim payment system go by. For rehabilitation hospitals which is our next target after that there is a requirement that we develop a prospective payment system and our preliminary decision has been to expand resource utilization groups to apply to this category of providers and to that end we are currently expanding the minimum data set to embrace the elements that we think we will need and we have recently gone through a budget process somewhat like the Second World War and now have enough money to do the staff time studies that we will need to determine what RUGS, what the weight of the RUGS should be in these groups.
We, also, have a requirement to produce a study or a set of recommendations on how to pay long-term care hospitals at a point farther out in the future, but basically we have a requirement by the year of about 2000 to have figured out prospective payment systems for skilled nursing facilities, home health agencies, rehabilitation hospitals and long-term care hospitals.
In each case we hope to do it by using grouping technologies which are to the extent they can be compatible with one another and assessment instruments which we hope down the road can be made compatible with one another.
We are doing this because we think we will learn enough to continue to increase the size of the bundles we are pricing. At the same time we are hoping we will learn enough about the outcomes from the care to apply some quality outcome measures to these same bundles.
Obviously this is all on spec. It hasn't happened yet which is why I started out by saying that you have to be able in order to pursue this with anything like enthusiasm to see that you have got two things to really do.
One is to have this vision of the future. The other one is to be charging along in the present. I think it is my view that as we go along attempting to do these things that we will be creating the systems and the data and the outcomes that will ultimately be necessary for the Congress to enact a sort of next generation system which I think will be much more widely bundled and which I would not be surprised may involved both Medicare and Medicaid as the current PAICE program of all-inclusive care for the elderly, lest you think I know none of them, PAICE program which was enacted in 1997 will do for Medicare.
So, that is what we are doing, and we recognize in doing it that there are significant challenges in making the assessment systems compatible. There are significant issues with respect to the grouping technology, and there are significant issues with respect to pricing, but leaving all that aside, it seems to me it is the only way to go knowing what we know now and looking at the kind of budget horizons we have. So, that is what we are doing.
DR. CLAUSER: I don't know, I had a couple of slides just to help kind of structure my remarks a little bit, and I don't know if those, my understanding was those might have been reproduced for distribution. Do they have them? Okay, great.
So, there is this kind of a thing up there so you can follow along in your piece of paper. What I wanted to do was just kind of follow up a little bit on Tom's remarks and talk a little bit about first of all kind of understanding our post-acute care instrument development activities, and what I am going to be talking about a little bit is more of our clinical data set initiatives that we are undergoing in the Office of Clinical Standards and Quality and to talk about those priorities in the context of the thing that Tom called vision but, also, to talk a little bit and just amplify a bit on what Tom talked about with the BBA requirements, the Balanced Budget Act requirements and how that is impacting our clinical data set activities and then to talk about a few long-term care data concerns which I am hopeful that through activities such as the Committee is doing and other efforts we can kind of establish a dialogue from all the stakeholders in this process how to kind of move through this very, very difficult area of post-acute care in trying to address some issues as we move ahead.
If we could move to the next slide, it is much easier to see, I think on your handout.
What I want to talk a little bit about first of all post-acute care instrument development in the context of what we call our HCFA Quality Improvement Program, and you cannot really see this well on the chart, but if you have it on your handout there are really kind of three things that are really important to that.
First of all, in the context of our reorganization and I did remember my unit's component, I practiced it all morning to make sure I got it right, Office of Clinical Standards and Quality was really kind of developed in the new HCFA reorganization to be a focal point for kind of integrating all our quality care and quality improvement strategies as it relates to trying to infuse quality issues into many of our traditional administrative and regulatory functions, and the diagram itself kind of summarizes our strategy for kind of implementing that vision.
We have an executive function, kind of what we call our measurement function and intervention function which really tries to do a much more systematic job of identifying priorities, developing clinical data sets, performance measures that support those priorities and that present tools for action through the variety of what we call our quality intervention initiatives that really impact quality in our programs, running everything from our more traditional enforcement activities of setting standards, conditions or participation through beneficiary information, and as well as even moving into the payment area as Tom has alluded to, we are trying to use some of this clinical data set to inform and improve the equitable payments, but for the purposes of discussion here I think the one that is most important is the boxes really in the middle related to collecting data, adopting measures and identifying improvement opportunities because one thing that is very clear in our evolution in HCFA is that we are not only developing these clinical data sets to try to promote clinical decision making and care planning.
Clearly that is a cornerstone for any use of clinical data in our programs, but as we move on to meet the challenges of both the Balanced Budget Act and kind of our evolution as a program, we are trying to use these clinical data sets for multiple purposes, a framework for developing quality indicators which hopefully can be transformed in performance measures which can be useful for both surveillance and evaluation activities, hopefully to kind of support our executive decision-making functions, but, also, program accountability tools through quality intervention programs for improving quality of care of our Medicare beneficiaries, and that really speaks to the bottom role of interventions.
If we move to the next slide, it shows a little bit more specifically how we see kind of our PAC instruments evolving.
As part of our new agency mission we are moving this thing called value-based purchasing and while we are still kind of sorting that out in all aspects of our programmatic responsibilities if nothing else we are clearly seeing a greater emphasis in demand for the use of clinical data in any of our core business functions, whether it be enforcing standards, whether it be expanding our quality improvement efforts through the peer review program or beneficiary information or payment, and I think one of the best examples of this is in the area of how we are trying to enhance some of our traditional quality assurance functions whether they be in provider contracting such as managed care or survey and certification which is more involved in fee for service to focus more on quality improvement, and what we mean by this is really kind of supplementing our reviews of structures and processes with reliable and valid process and outcome measures to try to more effectively promote accountability in improving care for our beneficiaries, and I think while this is the vision, it is clear from what Tom said that we have got a long way to go, and as you heard this morning, one thing that is really kind of has moved into that process is the Balanced Budget Act which as Tom mentioned has some very short deadlines and very high expectations for making improvements in the program, and this is really occupying a lot of our energies in the agency, and it has an impact on what we are doing with clinical data sets today.
Just again to briefly emphasize the scope of some of the BBA activities that Tom mentioned that impact the development of our clinical data sets and post-acute care, PPS does require case mix and quality tools, if we are going to be successful ultimately in implementing our skilled nursing facility PPS program.
Tom mentioned the resource utilization group system which is built on data collected from the minimum data set in the area of home health, in our home health prospective payment system.
Our Office of Strategic Planning is undergoing a lot of research activities now to see if we can build some of our payment system initiatives out of the outcome assessment system information set or home health.
Again, that is next October, and they just roll off the tip of your tongue, rehabilitation hospitals, prospective payment system in the year 2000, and I will talk a little bit about our activities in expanding and extending the minimum data set through the minimum data set post-acute care project that we are doing and, also, a proposal that has to be developed for long-term care hospitals and again, we will talk about how we are trying to use our clinical data set again by extending the MDS post-acute care project to support that effort as well.
If I could move to the next slide and just talk a little bit about some of our instruments that are in development, Tom talked about the OASIS system and the minimum data set which clearly are at least now some of the cornerstones of our initiatives in post-acute care, but we are, also, very involved in trying to extend the minimum data set to make it more applicable not only for the changing nursing home environment but, also, for other post-acute care institutional providers as well.
I think one thing that is clear about all this area in addition that these tools have to have multiple purposes to serve our mission as an agency, they, also, have to evolve as the health care system evolves, and I think in the area of nursing home care when the MDS was created, nursing homes were not serving Medicare beneficiaries that had the extent of the complex clinical needs that are now seen in nursing homes today, and thus, to try to maintain its utility in nursing homes as a tool to facilitate patient assessment and care planning HCFA decided to revise the form to better serve a more clinically complex clientele of Medicare beneficiaries we now see in skilled nursing facilities, and, also, I think because of the belief that many of these clinically complex short-stay patients in nursing homes are very similar to those in rehabilitational long-term care facilities, we, also, wanted to research the utility of this instrument as a patient assessment and care planning tool in these two hospital settings as well.
Now, given the Balanced Budget Act we have kind of altered our schedule again to try to make these research findings relevant to the work that is necessary to research and implement some of the rehabilitation PPS proposals and long-term care hospital payment proposals that Tom alluded to earlier, and we are now in the process of seeking approval to begin data collection with a phased testing of our new assessment form for MDS PAC that will include I think at this stage, and Sue correct me if I am wrong, I think four waves of testing and revision that we hope will improve ultimately continuity and quality of post-acute care in institutional settings.
The next one I want to talk a little bit about again is the uniform needs assessment instrument or the UNAI. As many of you know, OBRA '86 mandated the development of the uniform needs assessment instrument in order to try to improve discharge planning, not only in hospitals but really throughout the post-acute care system, whether it be through hospital discharge planners, nursing homes, home health agencies or even other providers of post-acute and long-term care.
Currently, the UNAI contains eight domains ranging from questions on health and functional status to nursing and other kinds of care requirements, family and community support, patient and family goals and preferences and need for continuing care. So, it covers a broad number of dimensions.
We have completed the first field test of the UNAI and the results I think are very promising and suggesting that the use of this instrument is feasible. Clinical staff in both acute and post-acute settings were very positive about its use and value in transmitting essential information from one setting to another, and we hope to make refinements to the UNAI to sort of enhance its compatibility with other HCFA assessment instruments, whether it be the MDS, the MDS-PAC that we talked about or even OASIS and, also, trying to develop a set of screening instruments that will identify hospital patients that really have need for extensive discharge planning.
This is something that did come out of the field test as a real need and, also, to determine in another field test the effects of the UNAI on quality and continuity of --
DR. IEZZONI: Can you tell us what the acronym means?
DR. CLAUSER: As I said earlier, it was the Uniform Needs Assessment Instrument.
DR. IEZZONI: Thank you.
DR. CLAUSER: If we can move to the next slide just briefly talking about turning to the future, you know, in addition to the extensive work that is ahead of us that Tom outlined with the Balanced Budget Act we are, also, mindful of other requirements that we have in planning for the near future that are going to impact on post-acute care data sets, and one of those is clearly looking to the future in developing what we kind of call clinical data architecture that will be useful in terms of trying to make this data more flexible and more useful to meet the multiple purposes not only within our traditional HCFA administrative programs but, also, to make it more useful to our partners and such as providers that will need to rely on this information as well for their own internal quality activities.
DR. STARFIELD: One second, please, the uniform needs assessment instrument, that was not something that Tom mentioned. Is this something that brings all these different instruments together or is this some unifying theme?
DR. CLAUSER: Right now it is an instrument that is used, again, these instruments are sometimes developed for different purposes. This one is developed largely for post-discharge, but there is the potential that we could possibly use work that is being done for this to try to perform a framework to bring these together, and I will touch briefly on that in a moment.
What we hope to do with this is we are very mindful, for example, of the Health Insurance Portability and Accountability Act requirements that have to do with creating common data standards for all, both in the public and private sector and to the extent that any of the data is going to be attached to claims or other administrative data some of these post-acute care clinical data sets could actually be subject to some of these initiatives that are under way here.
We are very mindful of that and knowing that that will require some attention to looking both at the content standardization in terms of you know, data definitions and other things, but we, also, think that it is going to have impacts or transmission standardized requirements in terms of how this data will be exchanged between various parties that have to use that, and we are trying to develop some tools to try to facilitate that exchange.
One is our Med Quest which is a data exchange that we have used extensively for clinical data for medical records as a way of trying to really in kind of a much more flexible user format to actually allow people to use this tool, abstract the data and use the data for a variety of both clinical studies and other kinds of programmatic activities.
We are in the process now of trying to import a minimum data set and in the future we want to look at data systems such as OASIS and MDS-PAC, again, with the purpose of trying to support better systems integration so that as we have needs to use the data, link this data and exchange this data both internally within HCFA and between HCFA and other partners on the external side that we will have flexible tools in order to do that.
And finally, of course, thinking about the use of core data sets across post-acute care settings the UNAI is one example of where we are trying to look across these various assessment instruments and begin to think about creating as much commonality and uniformity as possible.
That is a very ambitious project, a very long-term view which will probably have to be tested in a variety of demonstration contexts before we actually are in a position to implement it as a program, and I believe that there will be some discussions about research and demonstration activities later in this program, and I think that is where some of those issues will be talked about.
Just one final thing I want to mention, and these are some of the complex challenges that I think are ahead. I think these strategies are still kind of in place, and there is a lot of discussion going on, both internally and externally.
We are currently refining where we are trying to move with clinical data sets, but whether or not you kind of agree with that strategy or all of it or part of it, clearly you have to agree that the issues are very complex, and we have some real challenges particularly given the way as Tom mentioned post-acute care is structured and organized in Medicare, and what I have tried to do on that page is just list some of the major challenges we are facing, and we are hoping that through forums like this we can provide the kind of dialogue on these issues so that we can improve our chances of being successful, improving our PAC system both within the requirements of the Balanced Budget Act and beyond as we try to work more collaboratively to address these challenges in this difficult environment of post-acute care.
Helene?
DR. IEZZONI: Helen, I would like to just introduce a new Committee member who has just joined us, George Van Amburg. Where are you from, George, these days?
MR. VAN AMBURG: Michigan Public Health Institute.
DR. IEZZONI: Okay, and we need to make sure that we kind of move on. We are very interested in hearing what you have to say.
MR. FREDEKING: Okay, Tom and Steve have given you a conceptual basis for all the things that HCFA is attempting to do. I am going to focus more on the nuts and bolts where we are in some of the implementation activities. I will give you a brief overview of our national information system of clinical data sets and where it is, talk a little bit more about the uses and then talk about some of the key issues at least as I see them.
For starters you have already seen these dates before, but I wanted to point out a couple of things. The implementation, the nursing home MDS, actually nursing homes started using the MDS in 1990, and it was revised in 1995, and right before Christmas of this past year in December we issued a final regulation saying that nursing homes now had to submit that information to states encoded and transmitted at least monthly, and that rule goes into effect June 22, just a week before PPS starts, of this year.
The OASIS instrument has not yet been implemented nationally. There is a rule in progress that will require implementation of it.
You see a date up there targeted for winter of 1999. That is about 6 months before the information, the PPS system will go into effect, but we are aiming to get the collection of the OASIS information started and having information in here so that a lot of the PPS calculations can be finalized.
So, that is a very short time frame, and then as we talked before the MDS for the rehab is 2000 which is so far away we don't think about that right now.
Okay, the next, I will just give you a brief overview of how the data system is set up. Basically it goes from the provider to the state and the state to HCFA and then there is a feedback loop, and what will go from the provider to the state is either OASIS or MDS data, MDS for starters, and then all that information will be submitted from the state into HCFA into a national repository.
The flow back will be the state will be sending back to the provider edit reports showing things that failed to pass edits and so on, and there will, also, be a whole analytical system that will be put in place for both provider types which will use quality indicators developed by Dr. Shaughnessy and Dr. Zimmerman initially in terms of information being fed back to the facilities for their use in quality improvement.
The MDS data specs were developed about 3 to 4 years ago and have been issued, and those are specifications that vendors and facilities can use in developing their own software. The providers will use this software in coding and transmitting the information to HCFA. Also, we have just put up on our Web site a set of free software that providers can use for the MDS system, and it is called the Raven software, and it, also, can be used by vendors, and they can incorporate it in their own systems, and our goal was to try to deal with some of the implementation issues for those providers who have not worked out a method for submitting the information to HCFA.
Eventually we will, also, have a similar system for the OASIS program. We will be communicating to the state from the provider through Netscape.
The state system from August 1997 to February 1998, we installed in every state a data server and data communication equipment, hardware. It was sized according to the states. So, there are bigger ones in big states and smaller ones in small states.
We now have an 800 number for states to use in getting information that they need or resolving questions that are coming up about software that is in place. The software that we put in with the hardware was basically data management software. It was software that would help edit and sort of check out the information that is coming in.
Later on in the fall we expect to for MDS put in a system for an analytical system that we will feed back to the states from HCFA and from HCFA to the providers.
Let us move on. The national repository is being built now. It will be at HCFA. It is being built by a company called DCCA. It will be effective when the system goes in place in July. We don't expect data to flow in probably until a month later because of the time frames, but it will then be linked to all the other kinds of information that HCFA needs to link it to including survey data and particularly claims, and it will be used for monitoring PPS.
Next one?
Just in case you are interested, it is on your thing. It is our Web site. There is all kinds of information, everything from specifications to regulations, to training materials to the Raven software to test cases. So, it is a major link that we are using to communicate with providers, and it is accessible to anyone.
The data benefits, a lot of these have been talked about before. So, I am not going to spend much time on them, but a couple that the provider improvement activity that we think will be very important is the providers are able to use this information for their own improvement activities.
We will use it for the survey process, survey and certification process, provide better data for survey agencies in making decisions about where they go. Eventually we hope to have this information available for consumers and to help them make better health care choices. Case mix we talked about, improving payment accuracy. We have talked about the pro system. We use this data in developing quality initiatives, moving along there on the overheads, and we, also, expect it will be used for a lot of decision making in terms of coverage and payment issues.
I wanted to spend one moment talking about some key issues or some of the things that I think are most difficult as we try to put this rather major system in place, and one of them is the whole implementation challenge.
We are talking about over 10,000 home health agencies and there were 15 or 16 thousand nursing homes, and to put in place a fairly complex set of requirements. We have tried to develop a series of training programs. We developed some communication links. We are encouraging facilities to test things out before it goes live in June or whenever for OASIS.
We are developing a whole series of Q's and A's. However, it is something that we are very concerned about, the ability to reach all the various providers and all the various users of this information in order to assure that we have better information and that they are all at least as up to date as they possibly can be on what is expected of them.
We would appreciate any suggestions you might have along those lines. A second issue that is very important to us is the whole issue of the confidentiality and the privacy of the data. At the provider level basically this data really is protected in the same way of any medical records information would be protected, and we have fairly explicit regulations on that.
The biggest issue at the facility level is the requirement that we will need to inform beneficiaries that this information is going to be submitted to the state, and we are still trying to work through how to best do that. There is a system of records that will be published this spring, and that system of records will be applicable to the data at both the state and the national level, and it is fairly comprehensive, basically never allows for any kind of release of individual information.
The final point I wanted to bring up that is something that we continually concerned about regarding the system is how we assure the accuracy of the input data, and there are several things that are going on. We are in the process of contracting or have contracted with the University of Michigan to develop a plausibility index to look for trends in data. We will, also, probably be letting a contract to develop on-site analytical approaches for auditing the information, determining what it is that we will need to do in order to assure that the information that is being submitted is, indeed, accurate.
So, I have just sort of briefly gone over some of the major issues and status of our whole implementation effort, but it certainly does have a lot more that we need to do and a lot of challenges that we face.
Thank you.
DR. IEZZONI: Thank you. Excellent presentations and introduction to a totally daunting task.
May I ask the Committee members first, Barbara, do you have any questions?
DR. STARFIELD: I do have a question. If you could have a word or two words or maybe even a phrase to characterize the essential difference in the data sets that you are dealing with, settings that you are dealing with from those that this Committee has dealt with in the past, in particular with regard to the core data elements, how would you characterize the difference? What is the difference in the challenge of the settings in which you deal?
MS. FREDEKING: Between the home health agencies and the nursing homes, for instance?
DR. STARFIELD: All of those together compared to everything else that say the core data elements was developed to deal with?
MS. FREDEKING: The core data elements was something actually I think that had grown out of years of experience in the National Committee on Vital and Health Statistics to characterize a lot of data that comes from health care settings, and it is basically divided into enrollment data and encounter data, basically.
Now, it would have all the kinds of things that you would expect in enrollment data, a lot of information about people, about the clients and about the providers, and encounter data would have information about a particular encounter including clinical information, as well as information about the provider and the patient.
Let me just tell you what I think the difference is, and you tell me if I am right or wrong. What we do in the conventional settings, that is hospital settings, office settings, clinical settings is episodes, very defined episodes, relatively short term, and what you are dealing with is time. It seems to me the settings that you are involved with are in the area where you are characterizing things over time. Is that a fair description?
DR. STARFIELD: That is one.
MS. FREDEKING: There are others?
DR. STARFIELD: That would be one. There is a difference. We are having a longitudinal database versus a point in time.
MS. FREDEKING: Some of the others, to me I think that it may have to do with the experience of those that are collecting the information and their ability to have expertise in being able to code and assess and to provide accurate information. I think that that may be a difference. I am not sure what would come out of the core data set, but I think in some instances, for instance home health agencies may be fairly small and just getting started. We are expecting them to put in place a fairly complex system fairly fast. That is the second one that I believe may well be a difference.
DR. STARFIELD: Isn't the unit of analysis time?
MS. FREDEKING: Time?
DR. STARFIELD: Time. I mean I realize it is about a person, but is it a person over time?
MS. FREDEKING: It is a person over time, and it has looked at a person for a period, say, of the condition over a few days or something like that, and then it is done on a periodic basis during the time that they are receiving care from that organization.
DR. STARFIELD: What if the time is short? We need to come back to that.
DR. IEZZONI: Yes, we can come back. We have a lot of questions around the table. I want to make sure since we only have 5 minutes left -- yes?
DR. COHN: I just have a very basic question or two. No. 1, is it possible to get copies of these data sets? Is there a document that identifies the similarities and differences between these data sets as opposed to more standard UB92?
MS. FREDEKING: You certainly can get copies of the data sets. There has been some draft work done, but I don't know if there is anything very formal in terms of the similarities or differences.
MS. CLAUSER: Yes, there has been a variety of attempts by a number of groups to try to do mappings across many of these data sets. I have got to believe some of them are available. We can go back and see what we can scrape up quickly and try to get that to you.
DR. IEZZONI: Try to get something that you all have done.
MR. CLAUSER: Yes, we have done some of that work internally for developmental purposes. I don't believe, have we done it for public dissemination?
MS. FREDEKING: The Committee has it.
MR. CLAUSER: Oh, okay, the Committee has their own report.
MS. FREDEKING: But you have revised minimum data sets and so it may not be as up to date.
MR. CLAUSER: Many of these systems we talked about are in development. The way the field testing and all that works, it is kind of like test, feedback, change, test, feedback change. So, we are still early on to say that some of these sets are really firm, and the same thing with the UNI. If we go into field testing there we anticipate there are going to be some changes throughout.
DR. COHN: I just have one follow-up, and then I will stop since we only have 5 minutes, and that is your comment, Steve, about the issue of a core data set across settings. Now, you have to realize I come from an integrated health care environment, and I don't think of my patients as being, well, you are in this box, and you are in this box, and then you are in this box, and I am sort of curious about how that works with the overall work going on in HCFA which seems to be a series of separate initiative. How well do those integrate into that vision that you described? Actually it isn't a vision; it is a current data strategy.
MR. CLAUSER: I think particularly in the institutional side I think that vision is playing out very directly with our MDS-PAC work because clearly that is building on looking at trying to build a more comprehensive assessment instrument that has been designed obviously to the 2.0 in the nursing home to try to extend that same sort of architecture to look at assessing more clinically complex patients, not only in the nursing home but, also, in the rehab setting and long-term care hospital setting.
So, I think there there is a real active effort to try to create that kind of standardization in institutional settings.
The issue is in the ambulatory settings. When you look at home health in OASIS and other types of data sets, they are using other types of long-term care settings, whether they be assisted living or otherwise where the challenges, I think, are much greater. You know, instruments have been developed for different purposes to serve different things, and we are trying to use systems that have been well established and well integrated to see if we can back into core data requirements which will increase some standardization across these areas.
There is already some similarity between OASIS and some of the MDS items themselves. There are many areas where there are some real challenges. We hope to start a process of beginning to look at that so as the long-term care systems evolve, I mean Tom alluded to such things as bundling and trying to create more integration across the post-acute care settings that we have clinical data systems that can facilitate that as well. That is a long way off, I believe, and we are in the process now of doing some work to look at commonality across that, and I think we will talk later about kind of a research and demonstration strategy to try to test some of those things in like a live demonstration environment, but it is much more of an experimental issue than it is a program issue right now.
DR. IEZZONI: Okay, we have three more questions, Kathleen, Vincent and Elizabeth.
DR. MOR: I have two very quick questions. First, Medquest, is it a software system that is structured? I am not familiar with it. I am sure the people around the table are not either.
MR. CLAUSER: I think, Bob, you probably can talk about it more specifically than I can, but basically it is a data analytic tool that serves two purposes, one, to try to create a mechanism to bring clinical data sets into kind of a software environment where literally you can manipulate them easier and try to have them interact with one another.
Most of our work with Medquest has been through medical record abstraction data done through the PRO program and that system now has received considerable interest and use both within the program and outside the program. I think we have like 300 different groups that are now using that literally worldwide, and it has really shortened cycle times like for clinical studies and for a number of things.
What we are trying to do is see if we can use that same analytic platform for the MDS and some of these other systems as well.
Again, the point is to try to create more flexible tools so that we can serve these multiple agendas that we have with these clinical data sets. Bob, do you want to say more on that?
DR. IEZZONI: We should probably move on. I am sorry.
DR. MOR: Helene, a quick question. You said that states would be getting the home health data as well. Why would states get the home health data if it is only Medicare patients who are or is it all patients?
MS. FREDEKING: All patients.
DR. MOR: Medicare and everyone in that home health agency? Okay, I wasn't aware of that. So, everybody is going to get this instrument and all of that data. So, the denominator will be every patient in that agency.
MS. FYFFE: Is there a report or a 5-year plan on the overall strategy of what you all want to do? I mean I understand that the data sets and so forth are supposed to be supporting a grand plan, at least I hope? Is there something that I can read? I am brand new to the Committee. Perhaps something has already been issued.
MR. HOYER: I think having listened to the three of us you pretty much know all there is to know about or organized 5-year plan, but this gives me a chance to say one sort of last thing at the end here which is we find ourselves both due to budget reasons and due to the history of the program and for whatever other reasons just sort of here now in history, and having at least thought that after 30 years of disorganized pursuit we can at least begin to think in a general conceptual way about where we would want to be in post-acute care, this is pretty much what we are doing, and at this point it is probably not much more credible than the idea of the European Common Market was in 1950, or even last year.
So, I mean you cannot look for a pattern in the carpet here. What you can look for as Steven has been alluding to is our increasing attentions to try to use data across settings as much as we can to try to make sense of this thing, to try to keep every provider from being able to allege forever that they separate, unchallengeable and impossible to integrate with anybody else.
Beyond that I think I think it is just an operating principle, and if we trumped up a 50-page 5-year plan to make it look like we had thought about it in more detail it would be just that. I am sure we could do it. We have the skills for that, but you are better off with the remarks I have just made I think.
DR. IEZZONI: Okay, great response.
Elizabeth?
MS. WARD: I don't actually have a question but a statement. I think that we have identical concerns about eventually getting to compatible data sets, and I would just like to say that I empathize with your having to do this when the world of health care is chaotic and you have to keep trying to figure out what that path is, but if we could together look at that long-term goal and work with you futuristically that would be what I would like to do and particularly with that future being altered by HIPPA(?) and what that means in terms of all of these data standards and what that means in terms of getting at it. I would like to just start from here, trying to move forward in that same very difficult path which is all of those providers, you are right, thinking they are independent and different, but we have to track patients through all of those things regardless of those providers and their sort of proprietary focus. If we could do that in some way, that would be really helpful.
DR. IEZZONI: Okay, let me really thank you. We thank you for bearing with my autocratic style in trying to move things forward.
Will the panelists for our next set move forward?
Welcome. This is a panel that has been entitled National Perspective on Post-Acute Care, and Dr. Field is the first person to speak to us from the Institute of Medicine, and if each of our speakers could give a very brief background or just who they are, that would be very helpful.
DR. FIELD: The Institute of Medicine is a non-profit, private organization chartered by Congress, part of the National Academy of Sciences which was chartered by Congress in 1863, to provide advice on matters of science policy to the government. We do work not only for government agencies but at the request of private organizations, and in fact, the work that I am going to talk about today was begun at the request of the Robert Wood Johnson Foundation.
The Robert Wood Johnson Foundation asked the Institute to take a look at the world 10 years after its 1986 report on improving quality in long-term care. That report was a government funded report that had a good deal to do with the direction of the subsequent year's legislation on nursing home reform.
In trying to think what would be worth doing 10 years later, we decided that an important focus now was to look at the changes in the world since 1986, to look at in particular the move of patients and care out of the nursing home setting into many different settings. Home care is certainly more important, assisted living arrangements are more important and not very well studied. So, what we have begun to do is to undertake a study looking at the strengths and limitations of existing methods and tools to measure, oversee and improve quality of care and outcomes in nursing homes and other long-term care settings and how these methods and tools could be improved to promote better quality of care and other outcomes regardless of setting.
So, that last phrase certainly links us to you. Unfortunately we are at the stage in the Institute of Medicine study where we can tell you what we see as our objective, but we don't have any findings, conclusions or recommendations at this point.
We have had one meeting of the committee. Vince is on the committee. The committee is chaired by Dr. Peter Coler who is President of Oregon Health Sciences University.
Next week we are holding a public meeting in Washington to hear from interested organizations. It is sort of a hearing to use the term loosely.
Those who are interested can find information on the National Academy of Sciences Web page which is www.nas.edu and on the front page of the Web page is an events listing which has the agenda for the meeting.
One thing for those who might be interested in attending who aren't on the agenda already is that it is not at one of the Academy's buildings. It is not on Constitution Avenue. It is at St. Columbus Church in Northwest Washington near Tenley Circle, and there is information that you can get from the Web site that will help you there.
The one point I guess I would add here is that we are probably going to be focusing a good bit on some of the conceptual issues. We use the term long-term care, not post-acute care, and essentially aren't going to focus on the short-term patient, and in a sense the notion of post-acute may not mean much today in the way that it did or it may not mean very much in the context of long-term care for many people.
So, a good bit of our work will be conceptual, I expect, and we are trying to work from the patient focus, the person in need of long-term care rather than the facility or program or organization focus, but it is really so intertwined once you get into practical issues that the HCFA group was talking about that it is going to be as much a challenge to look at the institutional organization needs.
So, if Vince wants to add anything as a Committee member?
DR. MOR: You might want to just enumerate the specific aims. I think we have the aims. They are on the Web, I know that, just the specific purposes of the committee, the goals.
DR. FIELD: In addition to looking at the specific instruments and tools intended to both measure quality and outcomes of care, we are looking at the demographic health and other characteristics of individuals requiring long-term care in different settings and how they have been changing over the last decade or so and how they are expected to change in the future. We are looking at the role of the various long-term care settings in community health care systems and trying to understand how they relate to and other components of health care systems today in an environment that as everyone says is changing and much more complicated. So, those are the three broad aims.
We are, also, hoping to expand our scope a bit with some additional support, but we haven't got that yet. So, I don't think I will talk about that.
DR. IEZZONI: Okay, thank you.
Ms. Seitz?
MS. SEITZ: I am Karen Seitz. Dr. Mor, I realize now that you are probably on every committee around. Dr. Mor serves on our newly founded Federal Advisory Committee for the Future of VA Long-Term Care.
DR. MOR: It just completed its work.
MS. SEITZ: And you just missed our meeting. I am Karen Seitz. I am with Veterans Affairs in geriatrics and extended care, and I am going to, if there are those of you who are familiar with the VA system, I think you have to look again because like I think every health care system we are changing drastically. To couch what we are doing in post-acute or subacute care, I am going to share with you that our system, we have 173 hospitals, and about 500 plus community-based outpatient clinics, and this is our fastest-growing segment. We have 131 VA hospital-based nursing home care units and 40 domiciliaries. As an adjunct to the VA assets for providing care we, also, have a very significant contract and fee-basis program where we contract or have a fee basis for in excess of $1 billion worth of care that is purchased and the majority of that care is either home care or nursing home care. In addition, we have 94 state and veterans homes. Those are matching funds, federal funds and state funds and the state nursing homes care for veterans and in some cases the spouses of veterans.
It is easier to talk about that than about our information system. We are not Medicaid, Medicare reimbursed, and to date in our own nursing home care units we have not implemented the minimum data set.
Considering the amount of care that we purchase in nursing home care there is a tremendous incentive for us to have comparable data, and so, the goal at this point is full implementation of the resident assessment instrument in our own nursing home care programs and looking to a future that we can probably obtain MDS data on veterans whom we purchase care for in post-acute care or for nursing homes.
The challenge for us, we have a very rich information system which is MUMPS(?) based, and it is like 122 various data sets.
Our challenge is that we want to bring the minimum data set in and do some interfacing with our own Vista programs including our financial or accounting packages and so the automation is moving forward, and we look that toward the end of the year we will have the REI-MDS up and running.
It is very attractive to us in the sense that we are looking for a system that as a patient moves from one care environment to another that we feel that the MDS, the fact that we can be compared with our counterparts in the community and as our patients move from one care setting to the other the minimum data set can afford having a baseline data.
I think I will pass it on to the next speaker.
DR. IEZZONI: Marc Freiman from the Agency for Health Care Policy Research.
MR. FREIMAN: Thank you, Lisa. I have some overheads.
In the previous panel we heard a lot about administrative databases. This will be a little bit of a shift in that here we are looking at survey data although we utilize and are very grateful for the administrative data sets, particularly in some of the sections of the survey that have been put in place.
What I am going to be talking about primarily is the nursing home component of the 1996 MEPS which stands for Medical Expenditure Panel Survey, and the Medical Expenditure Panel Survey is a family of surveys. The part of it that I am going to be emphasizing today is the nursing home component although probably in a lot of the world that is the tail of the dog rather than most of the dog.
The other parts of the survey are the household component which is a survey of people in the community, non- institutionalized and then as adjuncts to the household survey there is a medical provider survey that obtains information on and from providers of services to people who are sampled in the households and lastly an insurance component that provides information on the insurance that people who are sampled in the household survey have or in some cases have available to them whether they choose to use the insurance or not.
The main purpose of the nursing home survey or nursing home component is to gather data on nursing home use and expenditures, other health care use, the health and behavior of nursing home residents and the characteristics of the facilities themselves.
So, to that end the survey was designed to try to deal with the unique characteristics of this health care setting, the main characteristic of which is you actually take up residence in the place where the care is being provided.
The sample frame stems from, the base of it is the 1991, national health provider inventory, and it is augmented or it was augmented with data on nursing homes open for business up to mid-1994. It is augmented with hospital-based nursing homes and, also, with VA facilities.
So, what do we end up with in the sample frame and therefore in the sample for the nursing home component? These are facilities that are either certified by Medicare as a skilled nursing facility or certified by Medicaid as a nursing facility. Obviously these are and/ors not simply ors or they are licensed as a nursing home with three or more beds and with an RN or LPN on site 24 hours a day, 7 days a week.
The overwhelming majority, about 95 percent of the sample does turn out to be certified by Medicare and/or Medicaid. That last category is only a very small percentage. So, what we have is a two-stage nationally representative sample of 800 nursing facilities and then there is a second stage where we sample people who use the facilities. Part of that is a sample of residents on January 1, 1996. We tend to call those current residents, and that is about 3200 people, and then a sample of about 2600 of people who are admitted to the sampled nursing homes during calendar 1996.
A key characteristic of the nursing home component is that we try to follow the sampled persons throughout 1996, whether that is after their stay in the nursing home or before their stay in the nursing home so that we get data that allows us to look at some of the issues that have been raised here about transitions among types of care and locations of care.
Data collection in the nursing home consists of three rounds of data collection. It involves CAPI interviewing which is computer assisted personal interview, and the typical respondents are the facility administrator, the nursing staff, bookkeeper and, also, abstracting is done by the interviewer.
There is a fair amount of that in this survey, and the MDS is used a lot. I mean when the MDS is there, the abstracting is quite easy and straightforward and goes quickly, and we feel we are getting good responses, certainly compared to interviewing the nursing staff and the MDS isn't always there, but when it is there that helps a lot and in this survey as opposed to our previous survey in 1987, a lot of the interviewing on certain topics was done by having the interviewer abstract from the medical records.
There is, also, one round of data collection in the community, and that was done through a telephone interview. Typical respondent is the next of kin. In some cases it could be the actual sampled people themselves.
Okay, so, let us look at some of the data that we do collect for each sampled person. There is a set of basic background data, demographics, prior long-term care use, information about spouse, siblings, children, marital status, health coverage. Then we, also, try to develop a very rich set of data on activities and health characteristics during 1996. Amounts billed for nursing home care and sources of payments, the primary focus of the nursing home survey is to determine the use of nursing facilities and the costs of that care.
We develop a residential time line that allows us to know where each person was during calendar 1996 throughout the year, data on functional limitations and behaviors of the sampled people, health conditions in the nursing home, and prescription drug use in the nursing home.
We, also, do, well, I guess I will get to that, other health care use in the nursing home and then from the community respondent we get information on living arrangements prior to nursing home entry, functioning and health status, use of assisted services, potential and actual caregivers and income and assets.
Now, to provide just a little more detail on prescription drugs, that is an area that I am certainly looking forward to getting data on and I think provides a substantial added richness to these data compared to other data sets that are available, prescription drug data were collected month by month throughout 1996, when the person was resident in a nursing home and they include the drug name, the form and strength, the dosage and the number of times taken in each month.
So, a strength of the nursing home component is that it does provide us the ability to look at changes over time within calendar year 1996, and to some degree going back before that.
For example, health status is asked at two different points. For start of year or current residents it is asked on January 1, and on December 31, and for new admissions it is asked at the date of admission and 3 months later.
As I mentioned, we construct a residential time line that tracks where people are throughout calendar 1996. We obtain information on nursing home bills and sources of payment to allow us to look at changes in those, and as I have alluded to we collect prescription drug use for each month that they are in the facility.
So, these are a pretty rich set of data, and I just want to talk briefly about getting these data out to the public.
Our first round of data were released in March 1997. They only applied to the first of the three rounds of the survey, and a file was released on sampled facilities with data on characteristics, facility structure, Medicare and Medicaid involvement, special care units and details on personnel and wage rates.
We, also, issued in March 1997, a public use file on the current residents, as of January 1, a variety of data on demographics, their admission dates, health insurance, ADLs, mental functioning, behaviors, disease checklist, diagnoses and physical characteristics.
Now, data sets that will be coming out in August 1998, we will be releasing a data set for both current residents and new admissions. That will be our first glimpse at all of the people for all of the year. That would involve demographics and family background, aggregate data that we take from the residence history and critical dates such as when someone died or how many days they did spend in nursing homes and data on health insurance although these data at this point won't involve the extra information we get from the actual billings and sources of payment for their stays.
Then in November 1998, we will have a much richer data set put out in public use. It will include health status and conditions, coded to ICD-9 codes, nursing home expenditure aggregates, better data on health insurance, use of health care services, some caregiver data and data on income and assets, and then there will be other data sets that will come at a later date, a facility level file that will, also, include data on facilities that persons may have gone to if they left one nursing home, went to the community and went to another nursing home, detailed data on somebody's residence history, sort of place by place, billing period level data on nursing home use on sources of payment and bills and then lastly a prescribed medicine file that would get into the details of what these medicines were and over how many months they were received.
That is the end of the overheads. I just want to mention briefly that the household component, the household survey, also, contains data that are relevant to the topics of this section of the Committee.
In 1997, the household survey consisted of about 33,000 persons and 13,500 households, and in 1997, there are oversamples of both children and adults with limitations in functioning and of the elderly and of high-expenditure cases all of which has some relevance to subacute care or long-term care and as part of gathering data on all that health care use and expenditure of these people there are questionnaires for these people who are sampled in the community regarding many similar issues on their health status and a lot of detail on their use of home health and of medical devices and equipment and, also, on potential caregivers and real caregivers.
DR. IEZZONI: Thank you.
Comments, questions?
DR. STARFIELD: Thanks very much. That was helpful.
Karen?
MS. FYFFE: Does the VA has a 5-year plan on what they intend to do in terms of post-acute or long-term care?
I am particularly interested in this because I, in fact, am a veteran.
(Laughter.)
MS. SEITZ: I think in some ways, the VA, I can talk historically, we have a level of care called intermediate medicine or intermediate psychiatry, and that came into being in the early eighties, and it was a recognition of care level that was less than acute but more than was typically in the skilled nursing home or hospital-based nursing home program.
I think now post-acute or subacute, if you will we have that care being given in a number of environments. It is not environment specific. As far as a 5-year plan per se, I am not familiar.
DR. MOR: The closest thing to a 5-year plan with regard to long-term care is the report that was just written and came out of this Committee on the Future of Long-Term Care in the VA. I don't know that it has characteristics of a 5-year plan, but it certainly has the recommendations that presumably will be implemented through the revised Veterans Administration management structures of VIZONS(?) whatever those happen to be. I don't know what those mean anymore. I just know they are called VIZONS as the management structure in the VA.
MS. FYFFE: Is it on the Web or published?
DR. MOR: I don't think it is public yet.
MS. SEITZ: The report is not completed. It will be a report to Congress that will be available I think early spring.
MS. FYFFE: Okay, thank you.
DR. COHN: Karen, I was actually going to ask you a question, also. As I look at the agenda for today, you are the closest thing to another peer that I think we have on the panel that I can identify in any way, and I notice you were commenting on, maybe the 5-year plan will give us the answer or this publication will give us a better idea of what your future plans are around MDS and all that, but you had commented that you haven't implemented anything currently to capture that sort of information, and you are considering or mean to put MDS in; can you clarify that?
MS. SEITZ: We have very rich databases, but I think in the area of long-term care we do come up to the next century. We are running a patient assessment final that uses RUG-2 data, and the minimum data set will be put into place for all of our nursing home care units and ambient medicine.
DR. COHN: Okay, and you think that that will help you be able to manage cost and quality?
MS. SEITZ: Right. It will help us with our performance measurement, and all of the VA facilities are either CARF(?) or JCHO surveyed and accredited. It will help us in some of those measurement systems. The CARF are currently using the FEM(?) instrument as well in all of our rehabs, I think.
DR. IEZZONI: Jeff, you had a question?
MR. BLAIR: Yes, I heard you describe a number of different data elements that you were collecting, including functional assessment and that you, also, interviewed next of kin. I didn't hear a mention of interviewing the patient for indicators of patient satisfaction or patient's assessment, patient's view of his functional assessment. Is that in there?
MR. FREIMAN: That is a very good comment and the area that one would want to study. Unfortunately, the medical expenditure panel survey is strictly a voluntary survey, and we are going into an institution, and we have very strong confidentiality safeguards built into the survey and the process. We did find that in early pre-test situations that we encountered a lot of resistance from the staff in allowing us to interact directly with nursing home residents.
So, we have just eliminated any attempt to do that. You are certainly correct that those issues are important and certainly many of the residents are quite able to speak for themselves about a lot of issues, if one could talk to them directly, but we just found that to be too difficult in order to keep up the cooperation of the facilities.
MR. BLAIR: Given the reality of that situation, do you feel like with the set of questions that you are asking and the way you are interviewing multiple people that even though you are not able to directly get that answer from the patient that you are getting a -- how confident do you feel that the information you are getting, at least indirectly is giving you a good feeling of the health care performance and quality?
MR. FREIMAN: I think in the areas we are collecting I feel pretty confident since we aren't asking questions about patient satisfaction although that is important. I guess it is a little beyond my specific areas of expertise as to how to evaluate some of the questions about needing assistance in that I gather sometimes then can become tautological, that if they supervise or watch someone who may be recorded as needing assistance if they decide that it is appropriate for that person to be considered as needing assistance and some of those issues, we might not be able to get out as well as we would like, but I think overall I do feel comfortable with the measures that we do collect.
DR. IEZZONI: Vince had a question and then Barbara.
DR. MOR: Two questions. Karen, you mentioned that one of the reasons you are looking forward to having a clinical information system in place in the nursing home setting is that you can make comparisons to the non-nursing home, I mean to the non-VA nursing homes, but you, also, intimated that you were, also, looking at tracking patients from one care setting to the other. What is the VA thinking about in doing that?
MS. SEITZ: In long-term care using the minimum data set for both the long-term care and the post-acute as that patient moves you know, in various environments we have not made decisions regarding home care, and clearly this patient population moves through the whole continuum of long-term care services, and we are still looking at and making decisions regarding the home care instrument, but it would be -- go ahead, Vince.
DR. MOR: Okay, but you do anticipate using a similar instrument in the hospital-based skilled units and the domiciliary units to the extent that patients transit from one place to another?
MS. SEITZ: Right.
DR. MOR: Okay. Marc, let me ask you a question. I know that you guys have just gotten the data in and are just grappling with the longitudinal files now, but as you could tell from the conversation earlier this morning a key issue for this Committee and for HCFA policy altogether is understanding something about the rates at which people transit from one kind of setting to the other, whether you are starting from the community in your large MEP(?) sample of 33,000 or starting in a nursing home in your 3200 or plus 2600.
When will you guys have information that you will have begun the analysis of the longitudinal person, I guess the person time line, history file?
MR. FREIMAN: In terms of us analyzing it, it won't be that much different than the public use files. This round of the survey we are very slowly committed to issuing data at about the same time we get it. We will get it a little earlier, in that we have to see a preliminary version of all the data to make sure the public use file will look correct, but --
DR. MOR: But that longitudinal file will be then or the person history will be sometime in the late fall of this year; is that right?
MR. FREIMAN: Yes, and let me, no, data from that longitudinal file will appear this fall, but the actual piece-by-piece file will appear later, and by the way we have none of the data in the house at AHCPR yet. It is still at the contractor. We are working with them to edit and clean the data to produce the public use files, but we don't have those accessible for our own use yet.
DR. MOR: And how about for the larger MEP sample, the community sample? Are you planning a person file, a person history file for that as well?
MR. FREIMAN: I don't work in that area. I am not as expert on it, but I think the answer is since it is not a care setting to be in the community there is no plan I believe to have any file where you track somebody other than that to the degree that you are in a hospital; well, actually even then you would have to construct it. I mean there is no attempt to construct a time line per se as part of the data that would be publicly sent out.
DR. IEZZONI: Could I just ask a follow-up question to that, Barbara, before you ask your question? I am just curious as to whether there was any plan for the survey market that you have been talking about to inform policy by the big federal organizations that fund this kind of care. You know, so often we pay for these wonderful surveys that researchers; Vince, I am sure you are waiting for the CD-ROM of this, you know, but we hear that HCFA is struggling to think about what they should be doing, and I just wondered how the information that you are going to be generating will inform policy decisions elsewhere within Health and Human Services or whether there is a formal plan for having that happen?
MR. FREIMAN: I think the process that we have gone through in the past may not be as structured as we would like, but there is a tremendous amount of feedback among the agencies. The actual structure of the MEPS, the Medical Expenditure Panel Survey itself is a result of substantial interaction and negotiation on, I forget the exact name of it, an interagency data collection process to try to streamline and make the data collection more efficient and a great many government bodies were involved in that.
DR. IEZZONI: We appreciate that, and we have heard about that and are excited about that, but now we have got the results or we will, and I am just wondering, you know, I guess it is a rhetorical question at this point.
MR. FREIMAN: I think that it is a good rhetorical question. We have made some presentations to other government agencies about the data, and it probably makes sense for us to have more involvement.
DR. STARFIELD: This may be the same kind of rhetorical question for Marilyn, but at least you are just getting started. So, you have a chance to think about these ahead of time. You did mention it when you talked about one of your interests is in the linkage across the different kinds of settings.
The first question is what are the different kinds of settings you are dealing with. I think that is the easy one. The second question is to what extent is your work, your inquiry going to be informed by HIPPA requirements of HIPPA in data standardization, and will you take into consideration the example of the core data elements that this Committee has been thinking about?
DR. FIELD: In answer to your first question, we are still in the process of trying to sort out our focus, and I can tell you that at this point our focus certainly runs from the institutional settings through formal home care through assisted living arrangements, and at this point it is that latter element that is the greatest mystery in terms of how it fits, both conceptually and from a practical perspective. We are trying not to let the theoretical overwhelm the practical or vice versa, but, also, to some extent the question has arisen what about informal home care because a great amount of long-term care is not provided by formal providers. So, if you want to add to the complications of what we are looking at, at least conceptually or theoretically that certainly does it.
As far as the second question, Vince, can you --
DR. MOR: Let me respond from the perspective of somebody on the IOM Committee. The Committee specifically is not at least at first blush going to be doing an evaluation of the Nursing Home Reform Act and the implementation of the initial 1986 recommendations of the IOM Committee on Nursing Home Quality.
There is a broader agenda, and the broader agenda looks at quality in other broader, long-term care settings. While there is a lot of interest of people moving from one setting to the other as a conceptual framework, that is largely as a conceptual framework to grapple with the issue of how you understand quality across as a meta idea, not just within a particular setting, but it doesn't have the same explicit focus on post-hospital care which is largely what I understand the discussion of post-acute to be or post-hospital care.
It is much more with the long-term care focus on that, and in terms of the core data sets it is not clear from my understanding of what direction the Committee will take as to how much detail there will be about specific data elements. There will be a lot of discussion, at least at the conceptual level about the measurement of quality indicators, quality monitoring kinds of strategies, but it won't likely get down to the bits and bytes or what core data elements need to be there.
DR. STARFIELD: So, it really isn't dealing much with standardization of information in terms of policy implications?
DR. MOR: That is not at least how I think of it.
DR. STARFIELD: It doesn't appear that that will be the main focus.
DR. IEZZONI: I have a question for any of the three panelists. Kathy Colton from Harvard Pilgrim Health Care who is one of the Committee members regrets that she couldn't be here today because here company is now paying increasingly for what we are calling post-acute care or whatever this range of kind of morass of care that is being given in these shifting sands settings.
Do any of you have a sense of what amount of this care is paid for by HCFA versus private payers increasingly and the states, the distribution of the quote, payment burden, if you will for this kind of care across the Federal Government and other places?
DR. FIELD: We have got a paper that we are commissioning to try to help us sort that out, but at this point we don't have an answer in terms of just basic data, and, also, the role of the individual and family contribution which certainly on the assisted living side will be important.
DR. IEZZONI: Marc, you don't have a sense of that yet, since you don't have your data yet?
MR. FREIMAN: I mean whatever I would say would not be based on the data. Clearly there is an increase. I have colleagues who may be able to speak better on this than I do. I guess the one area that I would speak on is just within the Federal Government between Medicare and Medicaid, given that Medicare pays for a lot of hospitalization and Medicaid pays for a lot of nursing home care there are interesting issues of transfers of people back and forth between those two settings that in some sense you might think would be just one pot of government money that should be used to maximize efficient care, but in the real world to the degree that they are separate programs and separate providers getting money from the separate programs it creates a lot of fascinating incentives and dynamics as to where people get treated and for how long.
DR. IEZZONI: The reason that I asked this question is to kind of get to the point that Elizabeth was making at the end of the prior panel, that we as a Committee would like to help think about this issue perhaps and there needs to be a variety of people at the table when we do start thinking about this. Obviously HCFA is the biggest single organization. It is easy to point to, and they have this huge building that everybody can say that that is where a lot of this is happening, but increasingly private payers are beginning to think about the data that they want to collect as well to manage the care that they are paying for, and the extent to which they begin to engage in the debate around what the data systems should be, I think is an important issue that we are going to have to help think about.
You know, back in 1972, I guess when the National Committee first proposed the Uniform Hospital Discharge Data Set everybody, you know, even the private payers were willing to pick it up, but I think nowadays things are maybe a little bit different, and so, that is something that I think we are going to have to keep in the back of our minds. I mean, Simon, this is kind of what you were alluding to earlier when you were talking about it from your perspective.
DR. COHN: Yes, and asking Karen as another large payer of long-term care. I think many of you by the questions I have been asking are probably aware that I don't think myself to be the world's expert in post-acute care or in fact, using PACs in many environments in something different until I got here today, but I find myself a little, and once again what I am saying may be very obvious to Vince and others, but it is really just sort of a question that I find myself sort of listening to the discussions both the first panel and then here thinking from sort of a patient-centric view, and so, I am perhaps a little confused.
I mean we discussed about moving from care setting to care setting. We have discussed, you know, we haven't really discussed acute hospitalization because that is not post-acute care, of course, even though the patient goes through that at interim bases and all of that, and I keep thinking of geez, this sounds like chronic disease in many ways is really what we are talking about, and we are really talking about the patient.
DR. IEZZONI: But not necessarily.
DR. COHN: Maybe not. Okay, once again this is my own naivete, perhaps on this, but I keep listening to the conversations, and it feels to me that if we were talking about in the more medical model, we would be talking about a pediatric data set and a urology data set and a neonatal data set, and that would be sort of looking at little tiny pieces of the patient.
Now, am I mistaken on this?
DR. IEZZONI: That is what I think exactly. Barbara, I will speak for you right now before you chime in and speak for yourself.
DR. COHN: Okay, and maybe Vince will have a comment.
DR. IEZZONI: Especially for home health. Often the need for home health is very acute, very specific, very focused on taking care of something that the patient is going to get completely better from, you know, and so it is not a chronic disease model based kind of thing, and so, that is what -- Barbara, is that kind of in a paraphrase what is kind of confusing? And so I think that talking about all of this in one breath is a shorthand, but I think, also, what is very interesting that we heard from the first panel is that Congress itself has compartmentalized this, and so even though we all are struggling to think conceptually, there are some very explicit congressional mandates around payment that HCFA has to take care of that Congress has in its wisdom decided to compartmentalize in a way.
DR. STARFIELD: Yes, I really think that is right. I think part of the problem that we are having today with defining the field is because we are so constrained with the model that we have been using for other forms of care, you know, instead of thinking about care in the context of the person over time. We think about hospitalization, physician office visit which you know I think the whole framework is limiting our ability to deal with this particular issue, and maybe we just have to rethink the whole thing to help you.
DR. IEZZONI: We need to talk to Capitol Hill and see what they are thinking.
DR. COHN: Vince, do you have a comment on that?
DR. MOR: Barbara has a very good characterization. There have been many papers written about the whole issue of long-term care as a person-centered issue not just being a provider-centered issue, but, Simon, your characterization of the urology database versus the surgical database or the cancer database or what have you, that is how the acute care sector breaks people apart. The long-term care sector breaks people apart as to who has got them that day. You know, they will take care of the whole person for that day or at least that designated part of them, and the chronic disease model probably does make more sense to think of it as the whole person over time, but it is amorphous because someone coming home from a surgical procedure will have 2 days of skilled nursing, and then that is it. They are a home health patient, however. They get post-acute care.
The more complicated patient, however, will be somebody who will go from acute hospital to a hospital-based skilled nursing unit, to an extended therapy, maybe another 8 days of therapy in a skilled nursing facility and then home care after that, and one of the questions that I think is very, very important from the AHCPR data or from HCFA's own data is to find out what is the distribution of people as they move through these various settings, all of which take some sort of piece of the pie, payment and person, and all of whom then contribute something presumably to the outcome of care, the outcomes that that individual experiences.
So, it is not a provider-specific vision.
DR. STARFIELD: The prospective payment doesn't help very much. You know you think of prospective payment as a payment for a period of time, a year or something like that which is a lot of the way we do prospective payment. It is very different than if we think of prospective payment for a hospital stay or a nursing home stay. So, in a sense HCFA is motivated by this need to deal with prospective payment. I am not really sure they have come to grips with what they mean by prospective payment.
DR. IEZZONI: Yes, and I restrained myself and didn't ask a question to the first panel because we were running out of time, but I do not see how they will have the data in house to be able to produce a respectable prospective payment system in the time frame in which they have to, and so, I think that that is a lingering question that maybe we can deal with later.
Anyway, what I would like -- oh, Jeff, a quick question.
MR. BLAIR: As a non-clinician I am always nervous when I ask questions like this because I feel like it reveals my ignorance, but, Vince, could I piggyback on the picture you painted to ask a question because I am wondering if in terms of the overall cost and overall effectiveness of health care I am visualizing situations where one part of the system either isn't funded or resourced properly or performing its function well enough like, for example, I am thinking of a scenario where home health care may not be available either with the right skills or time or resource requirements, and as a result a person who might have just gone through an acute care setting into rehabilitation and now is in home health starts to cycle back through the system to the more expensive parts of the health care system because of the lack of those resources or skills or ability to track, and I am wondering if the data sets that you all have been describing to us are capturing the data so that at least in the future during the next few years we could begin to identify these things and begin to make the overall system work better; are we capturing the data we need to identify failures which cause patients to cycle back to more expensive health care settings?
DR. IEZZONI: Jeff, we might leave that as a rhetorical question as well. Do any of the panelists care, because I think trying to identify failures to do the right thing is one of the hardest things to do in medicine as a whole. It is intractably hard, but it is an excellent question.
MR. MOORE: This is Bob Moore. I think that is what Steve Clauser was trying to say when he was talking about our approach toward quality of care and looking at the providers and having quality improvement projects so that we would be able to get with the PROs, get back to the provider about things that are going awry.
DR. IEZZONI: But if there aren't providers in the community, that is I think what Jeff was kind of getting at.
MR. BLAIR: Either providers or funding or resources, and I just was wondering if we are at least capturing the data to be able to identify and measure those things. That is all, but I accept your guidance that maybe that is too theoretical and shouldn't be addressed right now.
DR. IEZZONI: No, it is not. It is just that it is really hard.
DR. MOR: It is a view we should have as we talk to the remainder of the panelists.
DR. IEZZONI: Yes, and I would like to break early so we can start our last morning panel early.
Jim?
MR. SCANLON: Lisa, a related point, Marc described the MEP survey. At NCHS, you will recall that there are a number of provider-based surveys, as well and traditionally they have gone along the route of setting by setting, a hospital discharge survey and ambulatory care survey, a home health survey, emergency room survey, and I think virtually everyone agrees that this is certainly one way to look at things, but there are other ways as well, and there is, in fact, the group in NHHS looking at how you reconfigure and rethink, take a step back and look at this differently. So, any advice the Committee would want to give in that direction I think would be welcome, but it is quite difficult, and even MEPS is not large enough, I would think that you could even get much experience in some of the home health in those settings.
DR. IEZZONI: That is a good thing that, Barbara maybe your working group might want to look at.
Okay, I notice that the last morning panel has four speakers, and so, I thought it might be good to start that a little bit early.
So, we are breaking now at eleven. We reconvene at eleven-fifteen.
(Brief recess.)
DR. IEZZONI: We are going to try to start again with the fourth panel of the day. People, why don't we start again?
I would like to introduce Bob Gellman who is a new Committee member who has joined us. Bob, can you say who you are?
MR. GELLMAN: I am a privacy information policy consultant in Washington.
DR. IEZZONI: Okay, great. We have the third panel that we are going to be hearing from that is going to discuss with us research and demonstrations around these issues, and we are going to be starting out with Dr. Korbin Liu from the Urban Institute.
Dr. Liu?
DR. LIU: Thank you.
I am personally pleased that Congress was able to pass some of the provisions, the BBA, notably the mandate for SNIF prospective payment system. I am pleased because I worked on the first HCFA report to Congress on a prospective payment system for SNIFs, and this was 1984. So, there is a gestation period that is longer than we would generally like and then there is a delivery period that is probably shorter than HCFA would prefer at this point, but anyway today I would like to talk to you about a couple of studies that we are engaged in in connection with post-hospital SNIF and home health care, as well as we have hospitals and long-term care hospitals.
The first is a study that we are conducting with the Medicare Current Beneficiary Survey, and this is under the auspices of a cooperative agreement with HCFA. We just finished a report on the determinants and cost of post-acute care for SNFs and home health, and it has actually been accepted by inquiry, and Carolyn Rimes is my co-author and Doug Wisicker is another co-author. He is a colleague at the Urban Institute, but in this study we asked three questions. Who uses post-acute care? This is right now referring to SNIF and home health.
The second question is what characteristics differentiate people who use SNIFs from home health, and a third is the question how much do episode costs cost, and this is as Vince and others noted earlier there was a tendency to study one service at a time. Here we wanted to look at all post-acute care costs during a particular episode. This is after the hospital stay. Some of the patients would go only to skilled nursing facilities. Others may go only to home health care. Others may do both, and they could do it sequentially a number of times.
So, what we tried to capture was the total post-hospital, post-acute care costs of SNIFs and home health.
So, this required essentially linking Medicare claims to get both SNIF and home health. We came out with a particular definition of post-hospital care. We came up with a particular definition of episode, and I know various researchers have their own definitions, but ours essentially was with the SNIFs any SNIF because of a requirement that there be a qualifying hospital stay, all SNIF stays are post-acute by definition.
With home health it is a little bit different because a lot of Medicare home health takes place without a hospital stay preceding it. We defined post-hospital home health as home health that started within 30 days of a hospital discharge. In order to get the episode we stuck with the 30-day number where any post-acute care that was linked, that occurred within 30 days of each other became part of that particular episode.
So, using that rule we were able to come up with what we consider one estimate of post-acute care costs. We created a multi-source data file to do this analysis. The principal data sources are the Medicare current beneficiary survey, MCBS and the associated claims, Medicare claims that are provided by HCFA for analysis of the MCBS data.
We used the claims data to create essentially the events and the costs, the use and costs of post-acute care. The MCBS provides a rich collection of explanatory variables, demographic characteristics, health conditions, living arrangements, marital status and so forth.
What we, also, appended to this data analysis file were data on supply because one of the subquestions that we addressed was whether supply drove post-acute care use or did essentially demand or need drive post-acute care use. So, we used another data source that HCFA maintains which is the Medicare-Medicaid automated certification system, essentially the survey data now known as OSCAR and from that data source we created three supply variables, the number of RNs in home health agencies per 1000 enrollees, the number of SNIF beds, Medicare-certified SNIF beds per 1000 enrollees, and number of rehab hospital beds per 1000 enrollees, and these were constructed for market area based on three-digit zip codes.
The last data source or last set of variables were Medicaid related policy variables, and here we were able to, these were created at a state level, and the ones we included were Medicaid home care expenditures by state per 1000 and Medicaid nursing home payment rates by state.
So, with these four sources we developed an analytical file to address the three questions. Let me just highlight some of the findings. On the first question, who uses post-acute care we found that use was related to age. The older you are the more likely you were going to use post-acute care. This was in a multivariate context, and we are talking about Medicare enrollees. So, everybody is over 65.
Females were more likely to use post-acute care. People who were on Medicaid were more likely to use post-acute care, and people who were disabled were, also, more likely to use post-acute care. We did some interactions and between supply and the same demand variables and our general inference was that supply did not seem to be driving post-acute care use. We found very few significant variables. Again, it seems like it is need that is driving post-acute care use and supply of SNIF and home health providers seems to be reasonable and well distributed nationally.
The second question actually still on this, the second sort of big finding is some of the Medicaid variables were significant, like home health expenditures per stay were negatively associated with post-acute care use of Medicare. So, there does seem to be some substitution between Medicare and Medicaid. This is a finding that is consistent with some other research that addressed policy variables.
Mark Cohen and my colleague at the Institute, Jenny Kinney have found similar kinds of relationships. So, the system, the Medicare-Medicaid nursing home, home care system is quite interactive and meshed. It seems like what happens to one piece or one element will only affect the rest of the system, and just from a policy perspective I think we need to sort of keep that whole system in line as opposed to looking at one, not only just one service but Medicare versus Medicaid.
The second question, we did find that there were some characteristics that differentiated SNIF from home health use. Perhaps not surprisingly the more disabled you are, the more likely you are going to be using SNIF relative to home health. We, also, found that Alzheimer's disease patients or people with Alzheimer's disease tended to use SNIFs rather than home health.
So, you have got a lot of the long-term care variables that are predicting nursing home versus home health care, and despite the fact that post-acute care is supposed to be a different animal in a sense than long-term care the same characteristics of people predict nursing home versus home health use, whether it is post-acute care or long-term care.
On the third question we found that very few variables were significant in predicting episode costs for post-acute care, not too surprising. The other thing that we found was that the variance that we could explain in our models was relatively low. It was about 4 percent, and again, this is not surprising either because any research that addresses Medicare costs comes up with the same variance explanation.
I guess the lesson here is that as we begin to think about policies that may integrate post-acute care, SNIF home health, etc., that it is going to be a challenge and we are not going to have a lot of guidance from a lot of research. I think there is a lot of unexplained heterogeneity that we just cannot pick out from these surveys.
I have got some specific -- our study using the MCBS provides one baseline for looking at the impact of the BBA provisions in the future. Fortunately, the MCBS is an ongoing survey, and presumably it will be ongoing throughout the implementation of the BBA. So, similar kinds of analysis can be conducted.
In a case of who uses SNIF, the characteristics that we identified, being old, being poor, these are people who are using post-acute care now. These are people who are particularly vulnerable because of their frailty, plus their sort of frail enabling resources. So, I think as BBA goes on it is important to keep in mind this group of people.
On the data side we were able to do this analysis because we could merge files. The claims data are incredibly powerful, I mean particularly in connection with analysis of BBA provisions because the target of the BBA provisions is Medicare services.
I think it was important for us to have the supply variables in other Medicaid policy variables. Again, a lot of these files are maintained by HCFA, and it is important to have sort of ready access to this type of information for these policy-related purposes.
We were very fortunate because of the cooperative agreement nature of the support for the study and had ready access to information. Another aspect of it is the claims data in our study we only looked at the Medicare Part A services, but some of the post-acute care is actually financed by Medicare Part B. We did not merge Part B to Part A, but in this particular study my colleague, Barbara Gauge who is PROPAGAS(?) now at Urban is through another auspice studying the 5 percent claims file, and she will be analyzing A and B use again. What we are trying to do is to conduct parallel analyses based on episodes.
There are certain questions we couldn't answer. One is this question of hospital ownership of post-acute care providers. One of the things that we found difficult was to determine whether a SNIF or home health belonged to a hospital, and if somebody can tell me how to do that with Medicare data, I would be very pleased, but that is one of the sort of data gaps, I think, and in the sort of environment of vertical integration it is probably a good thing to try to figure out.
In this analysis, again, we focused on Medicare. So, we did not look at the interface very carefully between post-acute care and long-term care. The MCBS does collect information on nursing home use and home care not financed by Medicare. So, it will be possible over time to study better the interface between at the individual, the person level, acute care and post-acute care and long-term care.
The second study that I want to just mention or talk a little bit about is --
DR. IEZZONI: We should be quick so we can hear from the other panelists.
DR. LIU: Okay. It is a synthesis and analysis of information on post-acute care. We want to try to pull together information on costs, use and outcomes. This will be through literature review, review of unpublished literature and so forth. The focus is on the effects of Medicare coverage and payment policies, on post-acute care use. Through the study we, also, want to develop some insight on managed care organizations, how they handle post-acute care and, also, more information on how state Medicaid policies interact with Medicare.
Thank you.
DR. IEZZONI: Thank you. Sorry, we want to make sure we have time for questions.
Are there any quick questions just of clarification of any things that were confusing to the panelists or to the members of the Committee?
MS. RIMES: You may want to mention, Korbin, the second studies in the ASBI(?) project that you are looking at a very broad spectrum of post-acute care issues.
DR. IEZZONI: You just mentioned it. Great. Okay, thank you.
Chris Murtaugh, please?
MR. MURTAUGH: I have been at the Center for Home Care Policy and Research in New York for a little bit over a year, and our parent agency is the Visiting Nurse Service of New York which is the largest Medicare certified home health care agency, non-profit in the country.
I was going to talk to you a little bit about a couple of studies that are either finished or that we are starting or planning and some of the data issues around those studies.
First, in general I think that we have found we are, I should mention an OASIS demonstration site, and we are actually expanding as we speak the number of teams in the agency that actually use the OASIS instrument.
We started with just a select number of teams, but it is now fairly widely used, and even with the OASIS instrument and internal data that are available in the automated data systems that the Visiting Nurse Service maintains we found that it is always necessary to collect additional data, that those data sources alone haven't been sufficient. In general for post-acute care it is an issue of not knowing exactly what package of interventions has been delivered.
For example, we had a congestive heart failure study. We do studies both of the internal population as well as studies using national or other data sources, and in a study of congestive heart failure on internal folks getting care, post-acute care, we needed to know more about exactly what kind of services were received and who provides the care. The issue of the physician and his or her role is not easy to determine at all from data sets that are maintained by home health agencies, and outcomes from care are, also, often not specific to the type of problem that is being studied, and it is an issue of collecting data on specific outcomes.
With the OASIS instrument we have some concerns which will probably be discussed more this afternoon with the reliability of the data. It is collected by different types of individuals, providers, nurses in some cases, physical therapists in others. I think we don't know a lot about how these people might differ in the way they record information.
We, also, have some concerns about the validity of the outcome data if we were to try to use that instrument alone, and this is something that actually Shaughnessy and the crew that developed OASIS are well aware of.
There is a difference at the point when you measure outcomes if you measure it at discharge which is the way it is currently structured, and there are some systematic differences in the follow-up period.
For example, managed care patients systematically spend less time in general receiving home care than people who aren't in managed care. So, when we try to compare outcomes if you simply look at the discharge information on OASIS you are looking at different periods in time, and maybe their trajectories in their disease process are different. So, we have some questions about that.
Another issue that was brought up earlier is the type of information available on the home environment and informal care, and that is really a critical issue in home care settings and how outcomes are assessed.
We are planning a study of managed care, and we are interested in the financial incentives and their effect on the choice of post-acute care settings and eventually would like to look at the outcomes associated with those choices. We are aware that at least in a large setting that we are negotiating with that physicians are at financial risk for home health care use but not at financial risk for SNIF use, so that there are certainly some different incentives there which could affect where people end up.
When working with managed care data there are always issues of the access to the data, No. 1, concerns about the quality of the data. It is often hard to determine that, and then there is the issue, of course, of their representativeness and the generalizability when working with one plan or even several plans.
We have, also, been thinking about some studies of payment system changes. One concern with the interim payment system in the Balanced Budget Act is an issue of whether it does, in fact, favor hospital-based providers and actually I didn't realize it was going to be so hard to determine whether they were hospital based or not, but the feeling is that in fact with the caps that have been put in place that makes patients who are relatively healthy, have short-term care needs especially attractive, and thus tend to currently be patients served by hospital-based providers.
With the episode of care which would be a part of the prospective payment system there is an issue of identifying the index hospital stay. We have certainly had that problem in work that we have done, for example, with congestive heart failure patients who may cycle through the hospital all too frequently. Which of these do you say is the initial point of their home care episode? You know, 30 days, I have certainly used these arbitrary definitions myself. So, I cannot criticize that, but conceptually it is tough to figure out where did the process really begin, and a final comment, in general we are struggling with the issue of case mix adjustment in our work, and both the methodology to be used and having enough data to actually do it. With the OASIS instrument as much information as is available we still find that after controlling for a whole host of factors when you include whether or not somebody is eligible for Medicaid as well as Medicare; so whether or not they are dual eligibles sill has a very large impact on outcome and use of services.
So, despite the fact that we are controlling for a great many factors, we still are left with wondering what is being captured by dual eligibility; is it some of the supply and family arrangement issues or home environment or exactly what is going on?
DR. IEZZONI: Thank you. That was very interesting.
Any really quick questions, clarifications?
Okay, Dr. David Rabin, from Georgetown.
DR. RABIN: I am going to talk about home health care. It is a service that most of us and our families hope we never have to use. It is a service that taxpayers are not very happy about paying for and a service that researchers and providers hope is effective.
In all of these areas we have been unsuccessful including the certainty that home health care is effective. I am going to address that issue in what I am presenting today. It is a group from Georgetown ably assisted by Carolyn Rimes at HCFA, our Project Officer. Is there a human being that is going to move that?
Next one, please?
Thank you. Our question is does the use of post-hospital home health care; it is about 65, 70 percent of home health care affect Medicare spending in the post-hospital period or does it improve health?
We used the MCBS --
The next overhead?
-- as our source of information, initially did it for the first year and expanded it now to look at data from 3 years, and the eligibility criteria within our study was a person who had a hospital discharge within 6 months of the baseline in the MCBS in-person interview that provides functional information and within Medicare the 65 and older population have to be community dwelling for the use of home health care, and we looked at whether they completed their post-interview the year later or what proportion of time they were alive during that period of time.
On our next overhead we looked at a home health care user as a person who had a claim for home health care within 60 days of the time they left hospital.
Next overhead?
Our outcome measures, we looked at Medicare spending for all services for the 6 months following discharge and then looked at a change in health status, reported health status between the baseline pre-hospitalization and 1 year later on average which is when the next survey getting this information was given, and we asked about a number of variables but for purposes of today the self-assessed general health status, number of ADLs and IADLs were ones that we looked at for functional outcomes.
A problem in this particular area using data on users is that we are confounded by virtue of the fact that the underlying issue is the person's health status at the time they enter into an episode. That factor we are unable to effectively or to precisely measure and it clearly affects the use of home health care, and it affects people's subsequent health status and their spending.
People are clearly in worse health if they are going to be assigned, prescribed home health care and they are likely to have worse health outcomes than spending outcomes if they are in worse health, so that there is a major problem basically in the observational data we look at to get some sense as to the cost of outcomes from home health care.
It is more desirable but socially impossible and inappropriate to do a random-designed study which sends people into one or the other to see what happened.
Next?
So, in lieu of that there is a technique called the instrumental variable method which can be used effectively with home health care because there is great variation that has been shown by state, by area within state, urban and rural and within communities in the use of home health care. Basically people are in some places getting it and other places not.
So, the issue is to identify those factors that influence home health care use but are not related to a person's health status and then to try to use those factors to categorize people into predicted home health care user groups, predicted user or non-user and then to compare the outcomes for those who are predicted users having a similar baseline health status for a post-hospital care episode which effectively creates a pseudo or imprecise attempt at randomization design.
Next overhead, please?
As our instrumental variables we used after looking at a large number of things including a variety of ways of characterizing people within a geographic area by their Medicaid programs and resources, ended up using a person's state of residence and the year, and we did 3 years and in each of the years there was a substantial increase in the proportion of Medicare individuals who had services and even greater increase in the proportion of time they stayed in those services, and then we looked at differences by whether people lived in metropolitan or rural areas and then a strong factor associated with home health care use in terms of getting into it and staying into it is the proprietary area where a large proportion of services are provided by for-profit agencies.
As our independent variables in our final model we looked at age, race, education and living alone as well as from the point of view of morbidity 10 DRGs which are highly predictive of home health care use, number of ADLs and IADLs, social activity limitations and the proportion of time that a person is alive following the hospital episode.
Finally, just a little bit of data on the next one. We were able to show by this that using the observational method, this is people who do use home health care really have large Medicare expenditures. However, if you compare users and non-users by whether they are predicted uses or not, the difference between those who are non-users and users is much diminished over what you find just by observational data, and then in turn if you looked at the question of visits and divide people by whether they are above or below the median in terms of numbers of visits that persons relative to spending observed have tremendous increases in their total Medicare spending as they get divided into a low and a high use group, but by comparison the difference particularly is for high users is substantially less when you use the instrumental variable method, and in regard to functional outcomes on the next overhead, now, looking at mean changes in ADLs and general health they were scaled so that a negative sign indicates that there is a worsening of the condition.
Next overhead, please?
Looking at it in that way, when you observe people who are sick getting prescribed a service they, as one might expect, have a worsening of their ADLs, whether they perceive themselves to be about in the same general health status some months later. However, using the instrumental variable method is actually an improvement in persons as compared to non-users in ADLs and a substantial improvement in terms of their perception of their general health status, and when you divide the home health visits as to whether they were a high or low number of home health visits in the observational data, again, there is a worsening of ADLs either in the low or the high users, general health status wherever it is perceived by those who are high users to be improved and using the instrumental method there is an improvement in ADLs for both groups even more striking for those that are high users and then in regard to general health status an improvement in their health status.
Next, please?
We conclude from this that the use of Medicare post-hospital home health care clearly increases program costs, but appears to increase those costs substantially less than would be seen just looking at the observed data.
Use of home health care appears to improve patient's functional status and their general sense of well-being and it is particularly true if there is particularly high use of home health care.
Since we are going into an era the intent of which is to reduce access to and the intensity of home health care, the legislative intent and wish is met. I would suggest that this may be associated with an increase in other Medicare program costs and therefore, compromising the whole desire which is to contain Medicare program costs and of course the greatest concern was whether that, also, may be associated with a decrease in patient's functional status, and there are a couple of remarks that go not direct perhaps to what we found but from the particular area of home health care and its needs. It is terribly important to continue things such as MCBS and the issues that were mentioned earlier that are the intention of HCFA so that one is able to assess the personal characteristics of individuals, particularly ideally at the beginning of an episode for care and not more crudely removed from the beginning of the episode of care as we have done so that one can look at functional status at the time of intentional need and at the time of discharge, and I would suggest some period of time after discharge.
There seems to be a good suggestion that people may continue on an improved thrust and may, also, be improved by alternate ways of providing for care under different health care systems. So, the linkage of personal characteristics is terribly important. It, also, has to be, we feel linked to Medicare program costs. I think the big issue is the program not the specific form in which a person has been treated.
I think that within the Medicare program there is a rapid increase as you know in the proportion of people that are in managed care. It does affect people who are home health care users although at this point is the people who are sickest are not as likely to be in managed care, less for that group but I think that is a matter of demographic time, and when you are in the services. We feel it is extremely important that service use should be home health care service use, and indeed the pattern of service use and the total area of cost should be looked at in managed care as well.
We are, on the other hand, looking for as a society to use managed care as a way of controlling costs and improving outcomes, and this is going to be particularly important for the Medicare population, and I think we are going to get some insight as to whether this is feasible and what the costs of it and if we are successful only by looking at our current experience which is a managed care experience.
Then I think we are moving into an era of prospective payment, changes in the pattern presumably of the way post-acute services are provided which suggests that the changes in use are likely to reverberate in other forms of Medicare use. It is terribly important to study the impact of our prospective payment changes on both the patient well-being and Medicare program costs.
Thank you.
I would like to make one comment additionally. The Co-Chairman mentioned about the issue of what is this animal in terms of post-acute services; who is using it? I think we have a sense historically that this is an acute care benefit given to acute care people, and I think it is increasingly clear that home health care, at least is a benefit given to people who are acutely ill, the pneumonia patient getting an IV antibiotic at home. That is clearly due to a person who has a chronic illness with an acute exacerbation and goes in the hospital or is not sick enough to go in the hospital and is put in by the community and clearly dramatically I think in terms of program expenditures an increasingly large proportion given to people who are chronically ill who continue to need skilled care or at least receive skilled care and probably benefit from it, this would imply, and that would imply that home health care is to a considerable degree and an increasing degree from a cost point of view a long-term care benefit.
Thank you.
DR. IEZZONI: Thank you, Dr. Rabin.
Any really quick questions of clarification?
Okay, Dr. Nancy Miller from, where are you from in HCFA? Can you name your organization?
DR. MILLER: I know quite well where I am. I am in the Office of Strategic Planning in HCFA.
I guess I am really kind of the demonstration component to this research and demonstration panel, and actually what I am going to do is talk about kind of a design project that we have.
The work is actually being done by Bob Caine at the University of Minnesota and several of his colleagues there. If you think back to the first panel that we had, Tom Hoyer mentioned that within HCFA there is kind of a short-term strategy and a long-term strategy to thinking about how we are addressing kind of the post-acute care services and beneficiaries who use those services. We spent a lot of time on that first panel talking about the short-term strategy, and this is really, well, Tom kind of describe the long-term strategies in terms of a 21-year-old kind of thinking about his or her retirement that we kind of know is out there, and we are kind of clueless about how we get there, but this project is hopefully designed to help us start thinking about what we might want kind of a longer vision of like a post-acute care system to look like within HCFA.
It clearly addresses or hopefully addresses one of the things that I think has, also, been brought up this morning and the way the post CQ care system works right now, it is very kind of benefit and provider driven. Your eligibility and coverage criteria differ by benefit. Your payment systems differ by benefit, and it is not clear that people do with different conditions do more better or worse in different types of post acute care settings.
It is a system that right now is not at all centered around a particular patient and that particular patient's health care needs nor is it in any way particularly centered around what their preferences might be for a certain setting and particular outcomes, and so, this work is really intended to think about how we might start creating a post acute care system that is much more focused on a patient, the patient's health care needs and the preferences of that patient in terms of where they are receiving their services.
Another thing that has been mentioned that came out clearly in the research studies, and it was mentioned a little bit earlier, also, is that there is clearly a relationship between Medicare post-acute care services and the use of Medicaid long-term care services.
If you look in the post-acute care world about 16 percent of beneficiaries who are eligible for Medicare are, also, eligible for Medicaid, but about 35 percent of the post-acute care expenditures are kind of attributable to people who are, also, eligible for Medicaid. So, clearly as we think kind of down the road to kind of a more integrated Medicare system we, also, need to be thinking about what the relationship is between kind of the Medicare and the Medicaid system in the long run.
In this particular project we are focusing, and we did this primarily because we kind of needed a starting point in realizing that it is just a starting point is we are focusing on post-acute care that is care that is really post-hospital care, and we are focusing on care that is provided in four settings, skilled nursing facilities, home health agencies, inpatient rehabilitation facilities and long-term care hospitals.
We would down the road basically like to move that into other settings so that we are picking up some Part B services and outpatient services as well as to begin addressing post-acute care that can start in the community relative to a hospital because about 40 percent of home health care actually is initiated in the community setting, and we are really kind of missing out on that piece at this point.
This is really design work for a demonstration and there are basically four pieces that Bob Caine and people are going to be working at the University of Minnesota in kind of putting this project together for us.
The first thing they are going to be working on is basically an assessment tool that could be used to identify patients within a hospital who may have a need for post-acute care services and conduct an assessment that would determine the types of services they might need and help us think about what the costs of those services might be as well as again to more actively engage patients and their families in thinking about where they want to receive those post-acute care services.
In this activity we are going to be closely coordinating with some of the work that you heard discussed earlier in terms of both building from the uniform needs assessment instrument that was discussed this morning as well as trying to coordinate the activity with the work that is being done to develop kind of the minimum data set, the post-acute care piece of that which is targeted on sort of the short-stay patients. So, to that effect we have already had kind of an organizing meeting between Bob Caine and other researchers who are here today working on different pieces to kind of figure out how we might coordinate these activities.
The second piece that they are working on is basically what we are calling a beneficiary needs based payment system. If this were 1992 or 1993, we might have called it a bundle payment system, and that is how Tom Hoyer referred to it this morning, but basically what we would like to do here as you are aware and it was fairly clear this morning, and it is clear coming out of the Balanced Budget Act, the payment systems right now very much kind of benefit specific and even though we are moving to prospective payment systems, we are moving to prospective payment systems right now that look fairly different across those. So, the skilled nursing facilities are per diem.
Home health will be some yet-to-be-defined episode, and we are not clear what rehabilitation and long-term care hospital prospective payment systems will look like, but they are very much tailored to kind of a benefit in the setting.
What we would like to move to in the long run is a payment that is somewhat, well, it is not tied into a particular setting, but it is really tied into a patient and the patient's kind of health and functional needs and to determine kind of based on information like that basically kind of a dollar figure or a budget or something that could be then given to the patient and then some decisions made with that set of money where might this person want to be receiving their services.
So, actually there is a lot of work to do there in terms of some thorny issues and figuring out things like when we talk about kind of this beneficiary payment-based system what is the episode of time that we are talking about; are we going to be doing payment that is based on kind of what you would pay for like optimal care that a patient might receive; are you going to do payment on what would be more kind of an average basis of what people are typically getting; do you want that payment to be risk adjusted in any way, and if you are doing a risk adjustment is that an individual or group level. There are lots of issues to work out there.
The third piece to this is we feel pretty strongly that there is a need for kind of a case management component in basically working with the patient and the family to make some decisions about the types of post-acute care services they might need, thinking about what we know about outcomes in different settings, what their preferences are in terms of where they might want to receive the care, what the costs might be, those types of things, have a case manager basically working with the person to make decisions up front and then to probably, also, to provide some kind of coordination throughout this post-acute care period however we define it.
In this activity, also, we are going to try to coordinate basically kind of the data needs for that case manager with the activity that is going on with the MDS post-acute care instrument refinement, and then the last piece that Bob is going to be working on is basically developing some outcome measures, I think to again address some questions that have been raised earlier which is that we have some kind of setting-specific outcome measures that have been developed, and we are testing now so we actually have a demonstration up with the outcome based system that Peter Shaughnessy and colleagues developed for home health care.
There is an outcome component in a skilled nursing facility, but in thinking more broadly about a patient in kind of a system of post-acute care we need to be thinking about a set of outcomes that could measure how well a person is doing throughout that system of care, and so, in thinking about that we think that that system will probably include some fairly generic constructs, things that relate to how the person does in terms of their functioning with activities of daily living and instrumental activities of daily living, whether they are living independently, minimizing symptoms, avoiding complications, those types of things and that would basically apply to any patient who is using a post-acute care service and there, also, might be some very condition-specific types of measures that would be developed.
In doing this work, ASBI has actually recently funded some work with Andy Kramer at the University of Colorado and some colleagues there to develop some outcome-based measures more for a research study focused on post-acute care, and we expect to closely coordinate with that activity, also, in thinking about the measures that we are going to develop.
Two years down the road we hope to have basically these design elements completed and then to actually design a demonstration where we could actually test the effectiveness of these components in putting together a more integrated system.
So, it is clearly a project that will take us into the millennium, and there is a fair amount of work to do before we are out there, but I think it goes a way toward helping us think about where we are going to go with post-acute care in HCFA.
To date basically the contract was awarded in September. Again, we had a coordinating meeting in January with other people who were working on post-acute care activities that relate to this. We will have a technical advisory panel meeting in April, and work has begun on case management models and the payment methodology, and the other thing that I guess I would note in passing and thinking about the demonstration, one of the things that we have asked Bob to think about again going back to kind of the interplay between Medicare and Medicaid is we thought we would like to have Bob give some thought to designing kind of a demonstration that would focus specifically on post-acute care taking on both the Medicare and Medicaid post-acute and long-term care world. We know that there are some states out there that we have had conversations with who would be interested in trying to kind of test an idea like this with us, also, and so it may be in the end that we would actually have a couple of different designs that we would be testing.
DR. IEZZONI: Great, a very interesting panel.
Barbara, any questions?
DR. STARFIELD: Let me think for a few minutes.
DR. IEZZONI: Okay.
DR. STARFIELD: How to frame it anyway.
DR. IEZZONI: Elizabeth?
MS. WARD: Nancy, thank you. What would be from where you are sitting the best way for our Committee to stay involved in your planning future activities, have representation to your technical advisory committees? I know we have some staff interaction, and that is very important, and we rely on that, and that is very effective, but there is another level of sort of advisory committee members desire to actually have a little bit more of an involvement and interaction about it, and you don't have to answer now, but that would be, I mean unless you have an absolute answer you feel comfortable with, but that is my basic question.
DR. MILLER: I think we could consider, we do have a technical advisory group who is there primarily although it is to do a couple of things, one to kind of provide kind of explicit kind of technical feedback on the work that is being done, but it is, also, to provide kind of a link to the provider industries that will eventually be affected by this, but it is certainly something that we could consider bringing a representative onto, and then I think the other way would be to kind of share basically kind of design reports and things as they come out, also.
DR. IEZZONI: Are there Subcommittee members? Simon?
DR. COHN: Nancy, first of all I want to congratulate you on the project. It seems very appropriately focused based on our discussions this morning. I find myself just how we are looking at the time line of your, the project I think such as has been described versus what we have heard of the overall time line regarding balanced budget amendment initiatives, other things to put prospective payments in place and all this, and there seems to me somewhat of a disconnect, and maybe you can comment on this only because it really seems you are looking towards, I mean it seems to me you are working on sort of really the solution to the problem, and it is sort of missing all the other time lines that I am seeing here. Do I misunderstand?
DR. MILLER: I am not certain that it is a total disconnect, but I mean it is clear that there are lots of kind of interim payment systems that are being put in place, and I mean we have been having the discussion in HCFA probably over the last couple of years about moving toward a more integrated system. Actually the Balanced Budget Act includes some very general language that says that in the long run which is 2000 and whenever we would basically move from these what are more kind of benefit-specific prospective payment systems to a more integrated system, but clearly you know by the time the design work is done on this and you do a demonstration and you find out whatever you find we will have had probably implemented and had several years of experience with kind of specific prospective payment systems.
So, in the event that we went to something that was more integrated, there is a great deal of kind of activity and effort to get those prospective payment systems up. They will have been in place for some period and then there would be an issue about how you kind of transition from those into kind of a more integrated system.
So, it is a discussion that we have about kind of how well they work together. Some of the things we are trying to do to at least ease that along again are like kind of coordinating on kind of the instrumentation so that the instruments that are developed for like the inpatient rehabilitation, the refinements to like the MDS and things might be the instrument that we would be using in kind of the system that is further out, that type of thing so that we are doing things that kind of lead us there.
DR. COHN: May I just follow on that one?
DR. IEZZONI: You may.
DR. COHN: Okay, thank you. I guess I find myself, and I don't mean to push you on this one, and I know this is the panel is the panel on research, and yet I find this piece that you are working on is very much applied research, and it is probably more practically related than some of the other presentations we have had here, and I was just curious knowing that of course this is awarded; you have a process in place, but is this happening with all due speed or are there ways that, I mean 2 years to design a demonstration, then to do a demonstration afterwards puts you at least in my calculations on how things work in the federal level and state level somewhere in the year 2004, probably for implementation. Is that about right?
DR. MILLER: Right.
DR. COHN: And I am just sort of, I mean can the society wait that long to get this situation integrated?
DR. MILLER: The time line, I think for doing basically the design work is 24 months, and that is probably pretty aggressive for like kind of the work that is going to go on there. I think the question after that in terms of like kind of all due speed or whatever is it is going to be a design report, and it will be a design report to HCFA, and then it will be basically HCA's decision about whether to move forward with a demonstration and the speed with which we do that or whether we even take, I mean it is conceivable you could take pieces out of this design work and kind of skip over the demonstration phase and think that might make sense to actually implement or whatever, but anyway that is kind of where you get into a little bit of an unknown in terms of the kind of the speed with which it is done. It is kind of how people choose to kind of act on them where they want to go with like the recommendations for a demonstration.
I mean if you went straight from a design into like a demonstration, and you allow for basically site selection and things, you know, you are easily another 18 to 24 months in before you even have something up and running. So, the time line is out there.
DR. STARFIELD: I guess this is a variant of the question I have asked before. You each described post-acute care from your own perspectives, and you defined the term somewhat differently, all of you, and yet we have heard in the previous panel that there is an increasing need for linkage across because people do move.
What can we identify what the common data need are across these different kinds of post-acute care? So, looking at it from each of your vantages, you know, what is common across all of your efforts?
DR. RABIN: Function, and the functional measurements are not terribly different in these various settings, purely personal characteristics that go to financing, nature of their other insurance and certainly their home characteristics, social support, and then I would think in terms of outcome measures where really you are, also, talking about measures that are again not very different. They come back to function, and I think we might expand the function a little bit further in terms of the social functioning in addition to physical functioning within the home, social functioning in terms of maintaining independence, living environment you would like to, and then I think that really relates very closely to questions of Medicaid programs.
There is clearly, I think, a major problem in terms of who has got responsibility for Medicaid and what the nature of that program is going to be. Clearly we see increasingly with post-acute care that very, very large expenditures, particularly in the home care are associated with the Medicaid population, and at the same time we have got 50 variations of that and not a very clear understanding by state in terms of what the differences are. That is a terribly important interface to have continuous data, to have an understanding of the impact of policies and then presumably to get back to the states or inform ourselves nationally in terms of what works best along this continuum of care.
DR. MILLER: I think one of the things that we have found when we have tried to do some comparisons across some of the different instruments and things if you are looking for kind of, I don't know like a core minimum data set or whatever is that if you are looking across data the MDS and the OASIS measures that have been instruments that have been mentioned this morning and things is that there is probably kind of a fairly consistent like kind of common core there where we run into problems and what we have to I think struggle with are kind of some of the basic measures like measures of activities of daily living.
We may collect in each of those instruments, but we may collect them in very different ways in terms of how the questions are asked and even the person who is gathering it is very different from kind of setting to setting.
So, in some respects it is little bit less a question of like the actual data and more kind of the process of collecting it and how it is used and things.
DR. IEZZONI: Dr. Liu, I think wanted to respond, too.
DR. LIU: For those of us who are using the secondary data sources like the MCBS, basically it is that data limitation issue. I mean it is a rapid response if the data are there, and we can analyze data to get some insights on the determinants of post-acute care. On the other hand, we are restricted in many ways by the measurement of health status, for example. It is limited to the variables that are collected in the survey which is a very short set relative to the assessment instruments that have been discussed like the MDS or OASIS and so forth. So, that is a trade-off.
Another trade-off is that with the surveys, you know, you have got many variables but relatively few cases. The analysis with the claims data is just the opposite. You have got a lot of cases but very few variables.
So, in a sense the bottom line probably is that multiple efforts should be continued and maintained.
DR. STARFIELD: Uncoordinated?
DR. LIU: And coordinated, sure.
DR. STARFIELD: Oh, and coordinated, okay.
DR. MOR: I would like to ask Nancy, I understand, I think that the prospect of this post-acute challenge that you have placed basically on the entire industry will require at least the kind of time line we are talking about. There is no immediate fix that can be done by next year or the year after. These are two conceptually difficult issues to deal with, but the tasks that you have placed before your contractor are multiple, and I was wondering, given the variety of other initiatives currently in place, and we have heard this morning about the uniform needs assessment, the MDS modifications, the OASIS and then the post-acute whatever it is, the post-acute MDS as well, and then now Bob is going to be trying to put some of this together.
I mean is there an organizational strategy for adjudicating and coming up with this pan instrument and is there something that this Committee, some way in which this Committee can be useful in achieving that goal because I would assume there is going to be a huge number of different issues that come to bear.
The OASIS and MDS are different. OASIS was designed for outcome. MDS was designed for clinical care planning. Both of them have desires to extend their applications off in different areas. What will be the focus and purpose of a pan instrument?
DR. MILLER: I guess to go back to what you asked a little bit previously which is whether we kind of have like an organizational strategy, it is that this activity actually came out of kind of an internal HCFA, like a work group on post-acute care initiative and it basically was comprised of the organizations represented in the first panel. Tom Hoyer basically has oversight of the program. Steve Clauser is with the quality side and Helene Nepp was originally doing a lot of the quality work and now more of the survey work in instrumentation and things.
Anyway I guess I would think or what we have heard discussion about and it really hasn't, nothing has happened like over the last 9 or 10 months or so, but where that gets adjudicated will be very much kind of between those entities in HCFA and some kind of an ongoing work group activity. That is at least how we have tried to deal with the issues to date in terms of like responsibilities for developing instruments and decisions about which instruments to go with in different settings and things. It is kind of that set of people.
DR. MOR: The reason I asked the question is because the outcome of this process could be probably the most far-reaching implications in terms of data systems for the Medicare program that has actually ever occurred. This is not just the MDS. This is not just claims data from hospitals. This is some effort to integrate information on an increasingly large number of beneficiaries, and I think it would be very important to come up with a strategy to somehow or another say how is the relative weighting of the importance of the elements and purposes for these instruments to be integrated in designing something that works in a pan way.
DR. IEZZONI: May I ask a question about the immediate needs under the Balanced Budget Act and other congressional mandates, two of them in prospective payment and going to what Chris said about concerns about reliability and validity data gathering and what Dr. Liu said about the R squared or whatever, the ability of his models to predict costs and resource consumption? I am concerned about cream skimming, about the fact that none of your models are going to be all that good in terms of their predictive power. They are going to be based on data that are very gameable, and you are dealing with vulnerable populations in the sense that some of the people are going to be very disabled and obviously very disabled and obviously able to be avoided, and other people are going to be obviously much less disabled and able to be cream skimmed.
This is a question for anybody. How can we think about advising HCFA or thinking about how to implement a prospective payment system given that series of concerns that I have just raised about data quality manipulation and cream skimming?
Maybe that is another rhetorical question.
DR. RABIN: One of the big issues is relative vulnerability in a sense. I think one might suggest that those that get short-term home health care as an example have more biological flexibility, adaptability, whatever site they are in or indeed, they recover in the home. I think the biggest issue, the biggest concern is the group that is far out on this tail who have substantial disability to begin with and get into home health care, are predictably certainly going to have substantial disability at the time of discharge and are probably going to be very high Medicare program users.
So, I think within the development of the program I think there is a lot more freedom potentially to make an error on one end as compared to the other.
On the other hand, I think because of the fact that the end are the people who are very impaired, and the very large home health care costs they appear to have, the long-term care costs they appear to have and the move between having a state do that under Medicaid or Medicare doing it, I think that is the group that potentially we ought to have the greatest concern in terms of looking as to what happens to them in terms of death, functional outcome and unavoidable health care use.
DR. LIU: I think the survey data in general give you insights on changes in terms of whom has access to various post-acute services. The CVS is one data source. MEPS is another. I mean these national data surveys can tell you who is and is not having problems over time.
DR. IEZZONI: But we hear how long they take to gestate, and I am just concerned about that.
I would like to hear from you especially about the reliability of these data and the potential for manipulation. Those of you who remember when PPS came in for hospitals, remember DRG CREVE(?) and I see a real potential for a very analogous situation here.
MR. MURTAUGH: I think one piece of advice which I am sure they are aware of is the difference between people who are dually eligible and the rest of the Medicare, at least 65 and older population. It seems as though dual eligibility is a marker for a couple of things. In some cases it is people who have been ill, chronically ill for a long time and have exhausted their financial resources, and so, it is picking up on measured frailty, and then it is, also, like a marker, of course, for people who have always been poor, and maybe it tells you something especially in the home care arena about the environment that they live in, maybe not only their own individual housing, but, also, the supply of services, the type of physicians who might or might not be available in the community in which they are living.
So, you know, I think some caution in applying a single system across the board to both dual eligibles as well as people who are just eligible for Medicare might be appropriate.
DR. MILLER: The only thing I would say is we and I work a lot more closely with the development of home health demonstration. The nursing home demonstration was fairly far along when I came around, but we were concerned a lot about that, at least in kind of the demonstration mode, and one of the things that we did put in place that we could actually kind of look at the impacts on access and quality is that in that demonstration we are using kind of a modified version of the quality indicator groups that Pete developed to basically monitor, you know, how people are doing in the demonstration as one of the outcomes and would hopefully try to use some of that information to the extent that we see some differences there by different types of individuals and things to use that in thinking about how we are designing our broader system.
DR. IEZZONI: I am not familiar with that. Who reports that information, the patient or the caregiver?
DR. MILLER: The work that Peter developed actually comes from, it is information that is collected about patients, but it is collected by, I believe it is staff of the home health agency.
DR. IEZZONI: We may talk about that later. I have some concerns about that.
DR. MILLER: As opposed to like patient reports of satisfaction?
DR. IEZZONI: Yes, as opposed to, okay, maybe you cannot walk but you get around; you know, the physical therapist might note something very differently than the way the patients experience it in their lives, but anyway, yes?
MR. MURTAUGH: We actually are collecting I think the SF12, as well, but it turns out that the nurses are not that comfortable asking the patients. It is trying in their view.
DR. LIU: It is going to be an interesting landscape over the next 5 years or so. I mean you have got different systems going into place on a staggered basis, and I am not, I agree the sort of analogous behavior or responses like the RG-CREEP(?) is probably going to happen because the incentives are there, but it will be interesting to see what happens when SNIF goes PPS and home health is still out there, fee for service along with rehab hospitals. So, I think it is going to be pretty wild.
DR. IEZZONI: I actually agree with that completely, but let me stop dominating. Vince?
DR. MOR: One last question that I forgot before, you mentioned that in considering the demonstration process some consideration might be given to discussions with states that have dual eligible programs that they want to put into place. How far along have you gotten in that? I am involved with the New England States and their consideration of dual-eligible packaging, and I know that Massachusetts put in a waiver application for the dual eligible. It would be actually potentially interesting to link those groups up relatively early.
DR. MILLER: Right. Actually we did a solicitation not quite a year ago which was to develop demonstration projects for dually-eligible individuals, and one of the kind of illustrative models we included in there was like this integrated post-acute care system. No one that actually bid on that indicated any interest, but we actually have had some discussions.
I mean I, personally, have had some discussions with some states that I know are interested in it, and they probably may make sense to have a kind of more organized effort to go out and kind of talk with some states about doing this kind of outside of the grants announcement that we had.
DR. IEZZONI: This has been a fascinating panel, and we thank all the participants very much.
Thank you.
Okay, I think I have been told that the cafeteria here is really quite wonderful and especially given our point of comparison being the Hubert Humphrey Building Cafeteria; so, why don't we try to resist lingering over lunch and be back at one-fifteen.
(Thereupon, 12:32 p.m., a recess was taken until 1:20 p.m., the same day.)