Hubert H. Humphrey Building
200 Independence Avenue,
S.W.
Room 325-A
Washington, D.C.
DR. IEZZONI: Let's get started. People remember that at the meeting on, what was it, October 29, that we decided to wait until we had kind of an outline and a draft of the Medicaid managed care report before we all sit down and do the hard work of coming up with the recommendations.
Anne Marcus from GW was supposed to have an outline to us today, but there is a problem with the contract, and she is not working until the contract has been finalized.
So, we don't have an outline for anything from the Medicaid managed care report to do today. Carolyn, when do you think we will be able to have her start working?
DR. STARFIELD: Can I just ask a question about that? There was something on the e mail yesterday about a conference call to deal with the contract specifications, or at least that is the way I read it.
DR. IEZZONI: That was part of the original contract.
MS. RIMES: That was part of the original contract. I haven't looked at it. If it came late, I haven't looked at it. That will be a conference call to discuss that one six-page document that they sent out.
DR. IEZZONI: That we talked about in September in our breakout session.
DR. STARFIELD: It wasn't clear that that is what it was about.
MS. RIMES: I can re-send you the document, if that would be helpful. On the other hand, it will take a while to process once contracts gets it down here, but I don't think it will be a long time.
Anne knows it is coming and I am pretty sure that we will have something by December.
DR. IEZZONI: We have got a bit of a problem. She is leaving for a month to go to Switzerland starting December 23, and she is gone for the whole month of January.
We had kind of hoped that we would actually have a draft final report by December 23. Then we would, through conference calls, come up with our draft recommendations, so we could talk about the draft recommendations at the February breakout session.
It is now looking decreasingly likely that that will happen, which is too bad. If we don't present our recommendations to the full committee in February, we will have to wait until June. So, just so people know.
DR. NEWACHECK: Couldn't she start with the faith that we will give her the contract?
MS. RIMES: GW has their own style of working. I am pretty sure that they are going to start, once we are sure that the contract is in.
MS. ARAKI: We had some administrative staff on our end which is the problem. Actually, Carolyn did negotiate with GW and we had agreed on a rate. We tried to speed it up but sort of didn't.
I was just having a side conversation here with Dale. He should have received a FedEx today, but he hasn't gotten it.
Would they, Carolyn, accept a xerox copy of the part with all the signatures? As Dale said, they still have to come back with a written proposal.
MS. RIMES: She knows that. I sent over what I had written for the scope of work revisions yesterday.
MS. ARAKI: So, she could already theoretically begin it.
MS. RIMES: I told her to begin it and I told her how to do the budget.
DR. NEWACHECK: But this is stuff that came through somehow the government contract.
MS. RIMES: No, because this is all wrong.
DR. NEWACHECK: What about going through another route?
MS. RIMES: We are doing that. It is just a matter of -- all we are doing is closing the loop and I think everybody is getting sorted.
DR. IEZZONI: In the meantime, Carolyn or whoever is going to start scheduling some conference calls for us to talk. Carolyn, I think we should try to do that.
As we talked about when we met on October 29, this kind of conference call will have to be announced in the Federal Register.
I think Marjorie is thinking of having 10 extra phone lines probably available, first come, first served, if anybody chooses to come on. You notice that we have a large audience watching today, which might give you a clue as to how many people will come into a conference call.
Nonetheless, that is part of the open sky, fresh air, sunshine, national advisory committee type of regs. So, we need to start trying to schedule those conference calls.
MS. WARD: Please, when you do the call, make sure it is eastern time.
MS. ARAKI: Can I ask, the one with Anne Marcus, that is going to be considered a working session and not a data gathering thing.
DR. IEZZONI: It will be a working session with her. Hopefully, we will have a document in our hands that we will be reviewing.
Then we will also have to spin off ourselves and start talking about recommendations based on it.
MS. ARAKI: I am just wondering about the mechanics of it, whether or not that was also going to be an announcement with extra lines.
MS. GREENBERG: Normally, if time permitted, she would come here and it would be discussed in an open meeting.
If you are going to be deliberative at all about what the report should contain and particularly recommendations, I think we should.
If you are just literally talking to you about her outline, that is different.
DR. IEZZONI: No, we need to have a more substantive conversation. It would be a shame to have to wait until June to present any recommendations, given the amount of work that we have already done.
It is really in the can; it just hasn't been written yet. So, let's try to have the conference call to be as deliberative as possible for us to kind of come up with our recommendations based on what Anne is able to extract and remind us about what we heard out in Phoenix and Boston and in the three hearings that we held in Washington.
The second topic also is going to have some conference calls scheduled. Dale, you are on tap for this one, and this is the insular areas meeting.
At the October 29 meeting, we got what looked like a very good start and outline from Dale and Joan Turak. Hortensia, I guess you have been kind of enlisted as the shepherd of this?
DR. AMARO: Yes, we had a little conversations. I need to kind of talk to you more what you think that will involve. I am willing to guide it along but I kind to need to know what is involved.
DR. IEZZONI: Basically, the whole committee has to help guide it along. I am hoping, Elizabeth, that you will also take a really active role.
Hortensia, basically it is just being kind of the lead reviewer, but all of us have to kind of agree to be reviewers. So, Dale, we had talked about a time table for this.
MS. RIMES: What I did was get Hortensia's schedule, so we can work around her schedule when she is available and not off with the Secretary in Israel.
I sent that down to Dale, and Barbara will do a screen based on Hortensia's schedule.
DR. IEZZONI: Will this also be an open meeting?
MS. RIMES: I am reasonably sure it will have to be.
DR. IEZZONI: So, that will be another Federal Register type notice?
MS. RIMES: Yes.
MS. GREENBERG: It may be, in fact, that the timing is such that there isn't even time to get a Federal Register notice. We will put something on the web site.
DR. IEZZONI: Again, this would be awfully nice for us to take something to the February full committee, so we can move it forward in February rather than having to, again, waiting until June.
DR. AMARO: Either now or later, but give me some sense of what is this kind of product going to look at in terms of length.
DR. IEZZONI: We had talked about 15 pages, right, Dale, with appendices, and then an executive summary on the front with our recommendations in bullet form.
MR. HITCHCOCK: Hortensia, we need you to sort of breathe some life into this. Can I pass out a new version, updated slightly?
DR. IEZZONI: A new version of the outline? Okay.
MR. HITCHCOCK: Kathy had some suggestions last time that I tried to incorporate. I didn't see the purpose of it coming through. So, I queried some members and I went through and I think I sort of failed.
I couldn't really come up with some of your language, Hortensia, for why we really got into this, why we wanted to do it. I laid out just some draft language there. I would appreciate anybody's comments back on it.
I went through and cleaned up some of the tables about what the federal agencies do. I think Joan has also done some work, but I don't have what Joan has done.
DR. IEZZONI: We had talked, Dale, at the meeting on October 29 about you going ahead and doing the background, kind of describing the geographic areas and their health systems and that kind of stuff. So, Joan was going to start working on that.
So, basically, again, this would be about a 15- page document. The Medicaid managed care, just for people to remember, would be about 25 to 30 pages, single spaced, with appendices, and appended recommendations.
So, we will have a conference call once we are a little bit further along with the writing, so we can begin to sort out what the recommendations might be.
As people read through the outline, you might want to begin thinking in your own heads what you think the recommendations should be.
MR. HITCHCOCK: We had more of a schematic outline last time, but I couldn't bring one this time, that is really kind of useful for getting through this document.
MS. RIMES: Hortensia, I mailed you that.
MR. HITCHCOCK: One pager.
DR. AMARO: I am trying to remember -- I have so many files for this committee -- that at some point you sent us the transcripts of that. So, I should have that in my file.
MS. RIMES: Yes, Dale has it, Joan has it.
MR. HITCHCOCK: It is on the web site.
DR. AMARO: It is on the web site?
MR. HITCHCOCK: Yes.
MS. RIMES: Yes, the complete transcripts are.
DR. AMARO: Okay. I think I have it in my file. If it is missing, then I can get it there. Okay.
DR. IEZZONI: Okay, so that is the insular areas item. Are there any other things on that? Dale, any more help that we can give you at this point?
MR. HITCHCOCK: At this point in time, anybody's comments or suggestions.
DR. AMARO: Are we going to have any kind of input or review from any of the major people who testified, so they can see if this is reflective of their concerns?
DR. IEZZONI: That is something that we should probably do.
MR. HITCHCOCK: I was certainly planning on doing it with federal agencies, that I am in direct contact with.
DR. IEZZONI: We had talked about that on October 29. Okay. Now, the next item, we do have a charge and a work plan that you see in your packet here.
We are going to finally, finally, finally, after many fits and starts, vote on this tomorrow as a full committee.
Hopefully, people have nothing to add to this. We kind of pounded at it on October 29, and we are hoping that tomorrow it will go without a hitch and we will finally have a work plan.
DR. STARFIELD: We don't really want to tell everybody what is happening; right?
DR. IEZZONI: It is under an action item, tab E. So, if there are any comments or concerns, let the royal us know. All right.
Then the next item on the agenda is --
DR. STARFIELD: Do we need to move for approval?
DR. IEZZONI: We did that on October 29. We approved it. We need to have the full committee approve it. For good measure, we could approve it again.
All right, I need Carolyn to be in the room for this conversation. Okay, Carolyn, our next item on the agenda is the January 22 meeting.
We talked about this at some length at the October 29 meeting. For those of you who weren't there, on January 22 we are going to come to Washington to be educated.
We are going to be educated about post-acute continuing care. We are trying to set this up as kind of an academic type of day for us.
The afternoon will also have a focus on quality based on Kathy's work group and the discussion that we had this morning around it.
Some of you weren't at the discussion this morning where we did talk a little bit about this meeting on the 22nd.
What I would like to do is, I would like to make sure that we have pediatric representation for the speakers. I would like to have at least one speaker who represents kind of continuing long time, post-acute-ish type of care for kids.
So, Barbara and Paul, if you guys could be thinking about this?
DR. MOR: Let me recommend Lou Stein? Is it Lou Stein? She has just done a paper for the Institute of Medicine committee on long-term care issues.
If she would be willing to come down --
DR. IEZZONI: Is she a pediatric focus?
DR. MOR: Yes.
DR. NEWACHECK: She is a little bit more on the medical side of things.
DR. MOR: Measurement?
DR. NEWACHECK: Measurement, chronic illness, but I think we were talking a little broader than that. I think she will be fine. I would say, first, I would go with Jim Perrin.
DR. IEZZONI: Jim Perrin from the MPH.
DR. NEWACHECK: Yes, he is on the committee.
MR. HITCHCOCK: He is the head of the American Academy of Pediatrics committee on disability and has been in this field for years, and I think has a broader perspective.
DR. MOR: Jim is wonderful.
DR. IEZZONI: Let's see whether Jim might be available. We might need to have travel funds or something like that.
MS. RIMES: We are going to need travel funds for another person, too.
DR. MOR: I can tell you, he is going to be spending four days in Washington that month already.
MS. RIMES: What days is that?
DR. MOR: I will look up now. I have my schedule. I know we are going to be together.
DR. AMARO: I know this came up before, but I am not sure what we decided. Did we decide that we are not including mental health and substance abuse in how we look at it?
DR. MOR: It is the 14th through the 17th, he will be in Washington. So, the 22nd is available, at least for me. It is on my calendar. I don't know about his.
DR. IEZZONI: Maybe you can check with Jim. I think, Hortensia, that we had kind of felt that mental health was a really important piece of this, and we felt a little less sure about the substance abuse side.
DR. AMARO: Can we talk about that?
DR. IEZZONI: Yes, go ahead and tell us what you are thinking.
DR. AMARO: I think that, as much as we can integrate mental health and substance abuse into how we look at -- as we look at issues in the health care delivery system, I think the better off we will be.
We keep leaving mental health and substance abuse out and, as a result, they lag behind in everything.
If you look at the Healthy People 2010, you see how it is so frustrating; there is so little. Substance abuse related mortality is among the leading causes of death.
Our data systems reflect sort of the second class citizenship of substance abuse as a health issue.
I just really wish that we stop doing that and sort of all of us in the field. Since it is my area of work, I particularly would like to see it integrated.
If we need to think about, what does that mean and how do we include it, I would be happy to help think about that, to make it clear how we could include it. It is definitely a chronic condition and illness.
DR. IEZZONI: Other thoughts from other folks?
DR. TAKEUCHI: I don't know how to do it. I think Hortensia probably has more thoughts on how to include it.
I would second her notion of trying to be more inclusive of mental health issues. I think estimates are about 20 percent of the kids have some emotional/behavioral problem. I think it would be an important issue to include.
MS. WARD: I didn't want to think of the disease. I wanted to think of where are people getting care, if there are some specific care places that are not going to be included, if we are not going to include mental health, then let's make sure -- I don't want a disease excluded.
DR. MOR: I think that taking a disease or condition focus complicates matters. It really is an issue of trying to understand the data requirements as they follow individuals as they move from setting to setting in some kind of trans-approach.
As soon as we get into the ambulatory care world, that becomes basically the entire health care system. It is no longer in any sense special, as we have been thinking of it.
I believe once we begin to isolate out specific ambulatory conditions which are chronic, then the challenge in understanding the differences in terms of the depth of data within each of these setting-specific kinds of things gets washed aside.
MS. WARD: When I think about board homes -- we have talked about those are one of the places where we want to say, why are they not part of it. How do we collect data.
To me, boarding homes have a lot of people with mental health issues. A lot of them that have mental health and drug abuse, some of them have Alzheimer's; some of them are diabetics.
I don't want to think about conditions. I want to think about the places that we feel are not being included in that continuum that are going to get us into trouble, because we are not figuring out how to collect data from them.
DR. MOR: It is actually true; it is absolutely correct, that the nature of the data structures in the COP systems for gathering data in methadone treatment center, CCOPs or whatever it is, those are also not part of the normal purview. It puts us in a conundrum.
MS. WARD: Maybe the conversation needs to be, what are the kinds of places that people get care, who have been totally left out of our view, and how many of them need to be staged in, and what is the priority for staging them in. I think that is where the conversation needs to be.
MS. COLTIN: As you were framing it, I was thinking about like renal dialysis centers. I mean, are you really getting that? That is a chronic care setting as well. This is getting really big.
While I think all those settings are important for us to look at at some point, I don't know whether the initiative and the work plan that we were designing for one year of what we thought we could accomplish could really encompass and give adequate attention to all of those treatment settings.
I wonder if we could lay out a path of what all of them are and then decide which ones we want to try to look into over the next year, but have an agenda, maybe, that goes beyond a year, to say what we ultimately want to do.
DR. IEZZONI: Kathy, do you want to summarize how the conversation was this morning in your work group on quality, when we started to try to define what we were focusing on? We had two very big exclusions.
MS. COLTIN: Yes, at that time we said, for this coming year -- this is not forever, just for the work plan -- for this coming year, where we thought we were going to sort of hang our hat on this initiative that we are talking about now, we had thought that it would certainly not include acute care hospitals.
I would probably, although I did this morning, include like ambulatory surgery centers in that construction also.
It would not include outpatient settings such as clinics, doctors offices, hospital outpatient departments.
There are lots of other outpatient settings, like a renal dialysis center, for instance. I was not thinking to include that in what we have been calling post-acute care up to now.
It is an open question. What we talked about this morning, I think really was focusing on skilled nursing facilities, rehab hospitals, home care providers. I may have left out something. I think primarily the focus was those three settings.
DR. IEZZONI: And home care including boarding homes and other kinds of residential settings.
DR. MOR: Home care includes people getting the care.
DR. IEZZONI: Getting the care in the community in a residential setting.
MS. COLTIN: One of the areas that comes up as a question is hospice, which can be home and can be residential. I would include hospice in that definition.
DR. NEWACHECK: The other category is homes and schools for physically and mentally handicapped kids, which is a small category, but it is real important.
MS. COLTIN: Then we can throw in long-term care hospitals, which also touches on some of Hortensia's issues.
DR. IEZZONI: Why don't we at least be educated about a piece of this on January 22. We are not going to be able to buy the whole entire thing on that particular day.
What we are going to have to do after we have been educated is regroup and say, okay, now that we have learned a little bit about this area and have some kind of principal ways of thinking about it, how do we want to structure our work plan for the next year.
We don't really have a time schedule to do that kind of thinking, do we, Carolyn? We do not. So, we were going to kind of have the meeting on the 22nd and go home.
We obviously can't do that, because that will leave us hanging. We don't have another meeting until the full committee in June.
I think we are going to have to --
DR. STARFIELD: I think we have a February meeting.
DR. IEZZONI: The February meeting, but we are kind of hoping to maybe do the Medicaid managed care, do the insular areas and territories report then. We have got a lot that we are kind of biting off here.
We should probably add -- that is a good point, Barbara. We should probably add that to our list of things to do.
MS. GREENBERG: We talked about querying people about being available for a few hours to discuss, I guess it was the quality work group.
We are talking about maybe a half day on the 2nd. The full committee is the 3rd and the 4th. The second has already been reserved for a privacy and confidentiality meeting on that day.
We have only one conflict. We thought we could work that out.
DR. STARFIELD: So far we don't have that day. At least I don't have that date.
DR. IEZZONI: Staff is going to query.
MS. GREENBERG: I could go through the dates. We gave out the 2nd through the 4th.
DR. IEZZONI: So, if we are able to find some time on the second, then we could spend some time thinking about a work plan based on this topic area.
So, that is -- I think that is all the business, Carolyn. Was there other business for the subcommittee that people can think of?
I guess tomorrow, when we have our subcommittee presentation, Kathy will present on the work group, Dan will present on the work group. I will just kind of present what I have just said, that we are in process on a number of things, and we will do the action item on the charge.
Were there other things that people felt we should spend time right now talking about?
DR. MOR: I assume we will talk a little bit further about what the day is going to look like, in terms of who is going to do what on the 22nd?
DR. IEZZONI: The 22nd, yes. Carolyn was going to get some names based on our conversation this morning, about the quality piece, and Paul, I guess we just thought that Jim Perrin would be a good person that we would contact for the pediatric piece.
DR. NEWACHECK: Will there be the inclusion of somebody on drug abuse data systems or something like that, and/or their integration or lack of integration into the regular health care systems? I don't know anything at all about that.
If that is going to be part of the agenda, this is something about which I am totally ignorant.
DR. IEZZONI: How do people feel? It is going to be a busy day. We were going to start, what, 9:30?
MS. RIMES: We were going to do the educational part in the morning. We were going to talk a little bit about existing data systems, not necessarily federal, but external to defense, and then have a section on quality.
DR. NEWACHECK: Carolyn, is there who is going to talk about nursing home surveys, like MEPS(?).
MS. RIMES: We had someone talk about MEPS in March, but we can sure bring them back in.
DR. NEWACHECK: With regard to that topic; was that in March?
MS. RIMES: In March, but I can bring some people back in.
DR. MOR: It is my understanding that our discussions on this are not going to actually pertain -- they will pertain less to issues related to survey than they do to ongoing administrative data structures. Is that correct or not?
MS. RIMES: I don't know that we have really made that determination yet.
DR. MOR: At least that has been my understanding.
MS. RIMES: I think what we were thinking about is doing sort of a general orientation, because March was pretty specific.
It was a lot of discussion about god's gift to payment systems and HCFA and those sorts of things. This, I thought we were going to do kind of an overview and start discussing the major component parts in terms of quality and availability and data.
Let me see how it plays out. Maybe we can bring somebody in from both MEPS and NCBS.
DR. MOR: NCBS, Corbin, if you will ask him to, he probably knows that as well as anybody.
MS. RIMES: I would probably have someone else come in on that. It is a good point, Paul. The other thing is that there is a lot of data collected, and parts of us have done some of the federal. Now I think it is probably a matter of doing both the private and the federal.
DR. MOR: Then you may want to have someone talk about the Oscar or the provider service files of the hospice and home health survey that is done now on a fairly routine basis.
These are surveys of the organizations, not just of the individuals, like the national nursing home survey.
MS. RIMES: The neat part is that we get to do more than one day. We may get to have a couple of sessions on this. So far, we could probably do a week in a heart beat.
MS. COLTIN: I had also mentioned, when we talked about this on the 30th, that the Picker Institute has developed a number of surveys of patient experiences with care in rehab hospitals, home care.
MS. RIMES: I think those would be very valuable. What we may end up doing is building from the 22nd for quite a few things, I am thinking.
DR. MOR: You mean, like adding another day?
MS. RIMES: No, not then, but like next, kind of like we did the Medicaid managed care. We will just do like an easy orientation, trying to figure out where we want to be.
DR. IEZZONI: It sounds to me as if it is a full day. Hortensia, many of these data systems have also been traditionally outside of the mainstream.
I mean, basically, mental health is also outside the mainstream, but so is home health. I mean, home health has been way out.
I think that there is a learning curve here that will be confusing, at least to me, if I was introduced to too much new stuff in a single day.
So, I think that we should probably try to cast our day as we have been framing it thus far, because I think it is going to be a very full day.
I think that mental health issues are certainly going to pop in. As Paul has already said, many of the kids in these kinds of settings have many kinds of behavioral health issues.
Kathy's question about, are we including renal dialysis centers really pushes the envelope on this.
DR. MOR: Or surgery centers.
MS. COLTIN: I mean, I would recommend no for this year. I think it is important ultimately.
DR. IEZZONI: Any other items that people need to talk about? I see hopeful faces around the table. We could go on for another hour and 15 minutes, because that is how we are scheduled. I don't think we will. Does anybody want to recommend adjourning? All right.
[Whereupon, at 4:15 p.m., the session was adjourned.]