[This Transcript is Unedited]

National Committee on Vital and Health Statistics

Workgroup on Quality

March 3, 2004

Hubert Humphrey Building
200 Independence Avenue, S.W.
Washington, D.C. 20201

Proceedings By:
CASET Associates, Ltd.
10201 Lee Highway, Suite 160
Fairfax, Virginia 22030
(703) 352-0091


Subcommittee Members:

  • Robert H. Hungate, Chair
  • Peggy B. Handrich
  • Justine M. Carr, M.D. (via telephone)


  • Debbie Jackson
  • Julia Holmes
  • Marjorie Greenberg
  • Stan Edinger


Call to Order and Introductions – Robert Hungate, Chair


P R O C E E D I N G S [2:35 p.m.]

Agenda Item: Call to Order and Introductions

MR. HUNGATE: There are four of us here now. I will just let people go around. I don’t think you have met either Julia or Peggy, Julia Holmes or Peggy Handrich. I think you have met Debbie Jackson last time. Is that right, Justine?

DR. CARR: Sorry I can’t be there. I will be down tomorrow morning, though.

MR. HUNGATE: Why don’t you go ahead and tell the folks here a little bit about you and then I will have them do the same and then we will know each other a little better.

DR. CARR: Thanks. I am a physician, a hematologist at Beth Israel Deaconess Medical Center. I have been here for 25 years. My last five years have been in health care quality. A lot of what I do is work with physician support, using administrative data sets to track outcomes and performance of — improvement of quality improvement projects.

I also work closely with medical records as, you know, when we are looking at coding and proper documentation and so on. So, I am pretty knowledgeable about ICD-9 codes, DRGs, things like that. We also have — we are a very electronic hospital. Nearly all of our medical record is on line, not the narrative, but all of the data elements.

So, also as part of our health care quality program, we work to track data elements that are captured in various electronic venues. We have provider order entry. So, for example, we look at appropriate use of blood products. When a doctor goes to order blood products, there are four indications for red cells, a couple for platelets and FSP. If someone orders something and the hematocrit is high, the computer tells them that. If they override it, we capture that as an override. We go back and look at the end of the month on what were the overrides and who were they, what were the rationale. We have been using that to target — we feed that back to our QI directors and then we get themes and try to work on themes.

So, I have used data in a lot of different ways and I, you know, have been very involved in a large array of quality performance improvement initiatives.

MR. HUNGATE: Terrific. Thank you.

Debbie, why don’t you go ahead.

MS. JACKSON: Debbie Jackson, staff for the National Committee of Vital and Health Statistics. My background is working maybe 15 years in National Committee work, between this, the Council on Graduate Medical Education and the Committee for Women’s Health Research and I am just happy to staff the subcommittee and provide assistance where I can.

MS. HANDRICH: I am Peggy Handrich. I am from Wisconsin and I served as the Medicaid director under then Governor Tommy Thompson. Now we have a new governor and I am an associate administrator in our Department of Health and Family Services, responsible for Medicaid and also we oversee the part of the department that collects and analyzes and distributes health statistics and vital records for the state.

MR. HUNGATE: Thank you.

I am Bob Hungate. We have talked and these people know enough about me that I am not going to say anymore.

So, Julia.

MS. HOLMES: I am Julia Holmes and I am from the National Center for Health Statistics and I work in the Division of Health Care Statistics, where we run the establishment-based surveys, such as the National Hospital Discharge Survey and the National Long Term Care Survey.

My primary duties at NCHS over the past two years have been working as a liaison between NCHS and the Centers for Disease Control and Prevention on the AHRQ’s National Health Care Quality Report and the National Health Care Disparities Report. Prior to working at NCHS, I worked at Blue Cross/Blue Shield of Michigan in the area of quality assessment and, thus, cognizant of working on measurement of quality using claims data as well as survey data, which is obviously what we use at NCHS.

Agenda Item: Discussion

MR. HUNGATE: Good. All right.

We have a couple of tag ends related to the existing report that is on the table. What I am going to do tomorrow in the meeting is refer to it as the third reading of the bill because that is kind of where it is. It has been revised quite a bit, but I am going to ask people to make three kinds of contributions. One is to identify any factual error and point that out, identify any wrong decisions and point that out, but not to provide typos in the context of the discussions, that I thought I would have them give them to you, Debbie. Is that an appropriate thing to do?


MR. HUNGATE: So, that is the rules we are following. So, you have got some inputs, Julia.

MS. HOLMES: Yes. On page 16, lines — actually it is just line 274. The sentence begins on line 273. It says, “The recent National Health Care Quality Report documents wide variation in health outcomes among states, health plans and hospitals.” That is not correct. That makes it sound as though the reporting is at the level of health plans and hospitals and it is not.

Measures are reported at the national level and at the state level and that is it.

DR. CARR: — and the one that went out with the

— has different line numbers.

MR. HUNGATE: It is page 18, line 288. I had the same trouble, so I had to find it. So, that is where it is.

MS. JACKSON: So, the correction then would be what, Julia?

MS. HOLMES: I think the correct should be “documents wide variation in health outcomes at the national and state level” because that sentence makes it sound as though the measures are reported for specific health plans and hospitals. That is grossly incorrect.

MR. HUNGATE: Good correction.

MS. JACKSON: So, it will be in health outcomes at the national and state levels and then continue with the line, such as health plans, et cetera?

MS. HOLMES: No, no, no. Take out health plans.

MR. HUNGATE: After comes, you strike among and put at the national and state levels. Then health plans and hospitals is struck.

MS. JACKSON: Then pick up as well as in the extent.

MR. HUNGATE: I read that and wondered.

Is that it or —

MS. HOLMES: That was it. I thought it was terrific.

MR. HUNGATE: Did anyone else find something that they bumped into?

MS. HANDRICH: I have a question. It is something that occurred to me after reading the final version and if it is not really germane to discussing the report, we could just table the question, but after I read this through and thought about it, I had a couple of reactions. One was I just think it is a wonderful report. It is just wonderful. I think it is something that can be used for so many different purposes, as well as the report talks about a kind of launching pad for other things, but, you know, kind of thinking from the perspective of Medicaid and measuring quality in the areas that matter to Medicaid, I just felt that there — it was hard to understand how a lot of this would fit with measuring quality in long term care.

The report talks so much about primary and acute care arenas and not so much about nursing home care, home health care or care provided in the community that we commonly think of as long term care services. There is one reference to nursing homes that I found in the whole document. When you think about the Federal Government as a purchaser of health care and you think about Medicare and — which is really — the majority of spending in Medicare is not long term care, but when you combine the federal funding that goes to long term care and Medicare with the federal funding that matches state funds from Medicaid, which is the primary payer of long term care, I just started to think, well, perhaps when all of this was conceived as a report, there had been some agreement that the focus was going to be on primary and acute care and I just didn’t know that.

MR. HUNGATE: I don’t think it was an overt decision. I think it just kind of happened. At least that is my impression.

DR. CARR: But it is also a very good point, Peggy.

MS. HANDRICH: And it made me wonder whether at the end of the report there ought to be some explicit solicitation of feedback in the area of long term care. I think it is a wonderful report and we ought to get the thing rolling, but, you know, how there is a discussion at the end about the priority of convergence? Remember that? That perhaps there might be some discussion about specific things that the committee might like to hear from experts and communities and so forth about in the area of long term care. That is my first point.

My second point, which is kind of coupled with that is that in the area of long term care, there is emerging so much interest in consumer definitions of quality, consumer driven health care and there isn’t really any discussion about appropriate indicators for data.

Just to complete my thoughts about — what I was saying, Marjorie, is a couple of things occurred to me after I read this final report, which I think is so wonderful. I do. I think it is wonderful, but giving you the Reader’s Digest version, I was saying there isn’t very much about long term care quality and, secondly, there isn’t very much about the world of consumer definition of quality, particularly in the world of long term care, which I know in Medicaid is considered to be I think almost more preeminent than in the world of primary and acute care, in Medicaid purchasing, I think it has become and accepted value that you can’t just have a system where you are measuring lab tests and weights and, you know, whatever that kind of standard conservative traditional things are, but consumers get to choose what they want in their care plans and within a budget or whatever and define what quality means to them and it might mean choices that in a traditional quality world would be considered to carry with them unacceptable risk, but consumers choose to make those choices and so forth.

So, again, the thought occurred to me, not to be critical of the report and to not in any way suggest it to be held up, but if we are embarking on a round of opportunities for people to give feedback and to embrace a wider view of what quality means, perhaps we ought to talk about how we would solicit good feedback in those two areas, as kind of a future endeavor with this report.

MR. HUNGATE: How did the National Quality Report deal with long term care?

MS. HOLMES: Well, it included as one of the areas that consumers are interested in, I mean, it was kind of subsumed under end of life care, which whether it should be or not — it didn’t fit nicely into the components of quality. But, you know, we had a lot of problems coming up with quality measures for long term care if you will, whether we were talking about nursing home care or whether we were talking about home health care and we had to defer to the CMS measurement systems for —

MS. HANDRICH: And the CMS measurement systems are — they are a great start, but they are very rudimentary.

MS. GREENBERG: Although they collect it, I mean like the MDF.

MS. HANDRICH: Very extensive, but —

MS. GREENBERG: But it doesn’t really get at —

MS. HANDRICH: And it is not used to purchase for quality.

MS. GREENBERG: It is more used for care planning.

MS. HANDRICH: Right. And it is also used to do surveys of facilities.

For example, there is no standard functional assessment in the area of long term care. So, I just think this is an area that is critically important from a fiscal perspective.

MS. GREENBERG: Not to mention out-of-pocket money.

MR. HUNGATE: We have a recommendation relating to measures of functional status, right?

MS. GREENBERG: Yes, we do. But I think what Peggy is correctly noting and I think this for the next steps is that this report focuses primarily on acute care and probably even more hospitals than even —

MS. HANDRICH: Maybe the report should say that.

MS. GREENBERG: That is where it starts. Maybe we need to be more explicit about that, but, for example, I mean, last week I was at the meeting of the National Uniform Billing Committee and the consumer closure project folks were there and they support a number of these recommendations and some additional ones as well. It came out this really — what settings are you talking about and they said really at this point, their settings, their recommendations were primarily for inpatient. Now, I think these also go into outpatient in some areas, but probably they are first and foremost inpatient and then some also relevant to outpatient. But they don’t get into the long term care and nursing home and all that, where the challenges are great, as you said, but, nonetheless, where a lot of the —

MS. HANDRICH: If not NCVHS, who?


MS. HOLMES: I want to expand that issue of not accounting to long term care by adding the issue of end of life care because that is a growing area of concern and that partially goes with long term care, but not completely. It is the whole issue of, you know, pain management for people, who are dying of cancer or of other types of diseases, those are issues that probably the measurement of quality is very dicey, but something that probably should be addressed.

MS. HANDRICH: Just to be clear, what I mean by long term care is care for persons with chronic conditions. So, it is not just care for old people. It is care for people with disabilities, who have continuing, ongoing needs.

MS. GREENBERG: But who are institutionalized?

MS. HANDRICH: Not necessarily. Home health care, personal care —

MS. GREENBERG: I mean, not people with chronic conditions so much who just like to see a doctor —

MS. HANDRICH: I mean disabling conditions.

MS. HOLMES: Who have functional limitations due to their disabilities.

Of course, the folks that could probably address that the best are the folks from gerontology because there is already a lot of work, I think, that has been going on for a year in terms of trying to measure quality in long term care, broadly defined.

MS. HANDRICH: I think the same kind of approach, a scan of the challenges and opportunities with what is out there that was done here would be so great in the area of long term care. I think people would think it was so valuable.

MS. GREENBERG: Of course, the problem that we have, too, in long term care, broadly defined, is that there are different measures in each, different data sets and all that and different reimbursement algorithms in each one. And yet people go between them and among them and —

MR. HUNGATE: Let’s see what we want to say in the context of the report. It seems to me back where we are talking about functional status — it is on page 30 — there is a functional status in the left hand margin that is bolded. It seems to me that in there we should say something about the chronic conditions and long term care omissions and the importance of those for this measurement set. We can make that statement, it seems to me, just as an additional comment without changing the recommendations.

I don’t have words for that, but what do you think, Marjorie? Would that be inappropriate to add that?

MS. GREENBERG: Sure, I think — no, I think you might want to say that — see, the National Committee’s earlier report on functional status really looked at functional status very broadly, not just for people with chronic disabling and they felt strongly about that that some measure of functional status should be collected even in the acute environment, although maybe not at every encounter. You have an injury and then you recover from it. Generally, you don’t get into the — if you are in the long term care environment, it is short lived.

So, I think what you maybe want to say is somewhere that this report and the National Committee’s previous report focused more on inpatient and outpatient care or whatever, but that this recommendation or recommendations to really capture — to capture information on functional status. Equally or more important for people with chronic disabling conditions, who are cared for and

are —

MS. HOLMES: Across a range of settings.

MS. GREENBERG: Across a range of settings. Exactly. And that in — you know, that needs to be — or you could just say that.

MR. HUNGATE: I wonder if we just couldn’t add another one or two sentence paragraph at the end of what is here that says while this report tended to focus on the in-hospital first, outpatient second, it did not address the chronic care and long term care.

MS. HANDRICH: Could I just ask a question about that? Why would you make kind of a general statement like that — why wouldn’t it be in the beginning?

MS. GREENBERG: Because if you think about it, all of these things about — it is kind of across the board. But then you could also maybe — you could make that statement —

MR. HUNGATE: It seems to me you want to make the statement here. It may not be sufficient, but it seems to me that maybe we need it up early — and then maybe in the next steps.

MS. GREENBERG: Yes, you could make the overarching statement earlier in the report and then also highlight that this is an area that is particularly important for settings other than — you know, chronically disabled —

MS. HOLMES: Just say for long term care —

MS. GREENBERG: Long term care services maybe.

DR. CARR: It cuts across all settings, including community-based and —

MS. HANDRICH: All settings where people receive long term care services.

MS. GREENBERG: I just received an e-mail and I don’t even know if you all are aware of this — while I was at the other meeting, I received an e-mail that Eduardo is leaving AHRQ and going to the Veterans Hospital. He is going to be head of Informatics or something. So, obviously, he is not here.

Literally, I just got this e-mail and it was unknown to me as well. Here it is. I pointed that out because as the executive secretary, I am always saying, okay, now who is going to do this, you know. Where is the lead staff? Well, the lead staff isn’t here, but the lead staff is literally on his way out the door of the department.

MS. JACKSON: I am taking some notes but I really need some backup —

MS. GREENBERG: Maybe, Julia, you can help — unless we want to — do we want to — since there are so few of us, do we want to just come up with the wording now?

MS. HANDRICH: Why don’t we do it right now?

MR. HUNGATE: I am not a good wordsmith.

MS. GREENBERG: Let’s find the place where we were going to put it in the beginning and I don’t know that it needs to be in the executive summary. Probably not.

MR. HUNGATE: Although you could add a little bit on the functional status recommendation in the matrix.

MS. GREENBERG: Well, you could put something in the matrix and maybe to put the matrix in context, we do need something in the executive summary.

MR. HUNGATE: When does Susan get here?

MS. JACKSON: Susan is in a meeting now upstairs, but she was not planning to come to this meeting. This meeting was based on being a blue sky. But she will be in for the meeting tomorrow.

MR. HUNGATE: I don’t know how much other content we are going to uncover tomorrow. We have got the meeting tomorrow —

MS. GREENBERG: You don’t need this for your — you could just mention this when you present your report.

MR. HUNGATE: I could just cover it in my comments and if I forget it, somebody can help me out.

MS. GREENBERG: Then, I think, once Susan is here, we can figure out where to put it. But we basically want a sentence kind of up front about that the primary focus was acute care —

MS. HOLMES: It says there acute care settings.

MS. GREENBERG: Acute care settings.

MR. HUNGATE: That is fine.

MS. HANDRICH: That included physician offices, didn’t it?

MS. GREENBERG: It does, yes.

MS. HOLMES: Acute care would be like inpatient hospital care and primary care would be physician offices.

MS. HOLMES: — acute and ambulatory outpatient care.

MS. GREENBERG: Outpatient — I often think of the outpatient department of a hospital.

MS. HOLMES: Our surveys are the —

MS. GREENBERG: They cover all of the —

MS. HOLMES: — outpatient department, as well as the — and they are referred to as ambulatory —

MS. GREENBERG: — primary focus was acute care in inpatient and outpatient settings.

MS. HOLMES: I don’t think that is good to say acute care in conjunction with outpatient settings. I would say acute care, but also included —

MS. GREENBERG: Yes, that is true. It wasn’t just acute care. Acute care and ambulatory care. Acute and ambulatory care or something. Forget about the settings.

MS. HANDRICH: You don’t like the word “primary”?

MS. HOLMES: That assumes that you are only — when you are talking about physicians —

MS. GREENBERG: Family practice or something.

MS. HANDRICH: You know, in the world I come from, there are three categories; primary, acute and long term care.

MS. GREENBERG: Actually, I mean — I was in a meeting with the Lamberts yesterday. So, primary care — this is Hank and Inga Lambert, who are very, very involved in — they are Dutch — with the International Classification for Primary Care.

Anyway, speaking of primary, I had said the primary focus was on —

MR. HUNGATE: It was kind of focused on hospital and physicians.

MS. HANDRICH: Physician and lab is the way it looked to me.

MS. HOLMES: I would just say hospital and physician care services.

MS. GREENBERG: Do we want to — maybe you just say that. Primary focus of the hearings.

MS. HOLMES: Then at the end you could say — give short shrift to, you know, long term care and that future committee efforts and hearings, et cetera, et cetera.

MR. HUNGATE: I think where we have the functional status, we could say while not specifically addressed, these measures are even more important in the chronic care and nursing home care.

MS. HANDRICH: And then the thing about consumers.

MR. HUNGATE: Put that in the last part, I think.

MS. HANDRICH: That accurately measure and reflect consumer preferences. Again, I don’t think it is a shortcoming. I think this is a terrific report for the arena.

MS. HOLMES: I would like to go back — I would like to change once again, to change — just to be absolutely specific. It has to do with talking about the National Health Care Quality Report. When I said at the national and state level, I don’t think that is absolutely correct because it is better to say at the national and in certain cases at the state level because we didn’t always have measures that were presented for states. Certain measures we could only present national estimates.

Does that sound —

MS. GREENBERG: Where is the sentence?

MS. HOLMES: It is at the bottom of the page. It says — documents wide variation in health outcomes and we substituted at the national and could I say in certain cases state level.

MR. HUNGATE: Yes, I think that is fine.

MS. HOLMES: I just didn’t want to give the impression that all measures were reported at state level.

PARTICIPANT: Is Gail coming, by the way or —


At the national and in some cases —

MR. HUNGATE: In certain cases.

MS. GREENBERG: Instead of saying among state health plans and —

MS. HOLMES: Because we don’t report. That is erroneous. We do not report on health plans or hospitals.

MS. GREENBERG: Well, then that definitely has to be changed.

MR. HUNGATE: I told everybody else earlier that what I was going to ask people to do tomorrow is report factual error and wrong decisions and if they had any typos or wording changes, that they were to give those to Debbie.

MS. JACKSON: Susan will be here tomorrow. So, Susan can get all of these —

MR. HUNGATE: Should I have them give them directly to Susan?

MS. JACKSON: Yes. She will be here tomorrow.

MR. HUNGATE: I don’t want to clutter our conversation with detail —

MS. GREENBERG: Now, I can report that I did talk to Simon briefly just this morning and although he still — I mean, and he will bring this up and he is of the belief that, you know, he would have preferred if the report had, you know, gone out more — you know, you had hearings and heard from people as to what they think about the recommendations. I don’t think he is going to fall on his sword on it.

MR. HUNGATE: I think we have incorporated the content of his suggestions in what is here, except for —

MS. GREENBERG: At the end of the day —

MR. HUNGATE: — process —

MS. GREENBERG: — he feels that there are a lot of recommendations here, even though they are at a higher level and that, I guess, his comfort level would be greater if before the report was blessed by the committee, we have gotten current reactions to the recommendations.

MR. HUNGATE: And I will respond to say that this report is a useful way to kick off the —

MS. GREENBERG: We need to bring this phase to closure.

MR. HUNGATE: We need to finish this one and see where we go from there. I have no qualms about —

MS. GREENBERG: Okay. Good.

MS. HANDRICH: I have kind of a third area of questioning about the report. So, it is the long term care, the consumer thing and then I just — in the last part of the report — these are all things that occurred to me after I read the whole — the last part of the report where it talked about what is happening, did you all talk about, you know, identifying things like FACT and Leap Frog and, you know, these national initiatives that have taken such an interest in selecting quality measures and using them for very specific purposes?

MS. HOLMES: Now, one iteration I remember very vividly, Susan’s writing included a consideration of not only federal initiatives but some private initiatives, such as Leap Frog groups. I didn’t see that in here this time, but I wouldn’t think it would be too hard to find.

MR. HUNGATE: I am wondering whether that gets a little bit into the next steps in a way, too, because many of those groups are the ones that you need to have involved in updating that Simon feels we need to do.

MS. HANDRICH: But you know what they are doing is they are making choices about what data — from what is currently available is usable. They are doing that right now. It is kind of like, if you will, leap frogging the data challenges that are presented here and just going ahead because there is a sense of urgency that you have to have something that you are measuring and you can refine it as time goes on.

MR. HUNGATE: Let’s use that as the kick off for our other discussion because I think it is — this morning I was in my Massachusetts hat, chairing the Group Insurance Commission, where we are getting ready to throw the cards in the air with regard to the benefit plans and we will probably end up having 40 percent of our beneficiaries change their plan because of the way we are going. We are going to cancel some very large HMOs, replace them probably with self-insured — we haven’t decided this yet, but there is going to be a narrow spectrum of hospitals with quality and efficiency measures that are not public measures at this stage.

Yesterday, in the paper — I have got a clipping in my briefcase that came from The Boston Globe about the Blues buying a quality measurement system. This is a new quality measurement system and it has totally different hospitals than the top hospitals that were previously listed in Massachusetts. So, this whole — you know, people are grabbing things, as you said, and there is no certainty that they have any coherence. I am very worried about what is going to happen with the beneficiaries in this discussion because — and it came up in our meeting this morning.

I think that our task is to try to get some coherence to these measurement systems in a way that benefits individuals. It is the meshing of the consumer driven thing with the measurement is, to me, where the need is.

MS. HANDRICH: That is a great statement.

MR. HUNGATE: Because, you know, you could look at AHRQ’s work and it showed that the release of the hospital mortality data made no effect on market share. I have a suspicion that a lot of these other measures are going to have no effect at all because they will self cancel and it will all just turn into mush and will be —

MS. HOLMES: That is confusing and frustrating to providers as well. It sends a very sure message to providers that there is no standard. There is no true measure of quality and all of our efforts to pay for performance or to measure quality are just frivolous. So, it sends a very bad message to providers as well.

DR. CARR: I would like to add to that because I spend a lot of time trying to generate the JCHO data and then reconfigure it for the Leap Frog data and then reconfigure it for —

[Multiple discussions.]

— last time that the definition of door and door to balloon times are consistent. So, to try to configure systems to capture the time a patient arrives in the hospital, in the ED, in the cath lab and whether they came from a transfer hospital or an ED to ED transfer. We have devoted endless hours to defining door and then getting our data systems nimble enough so that the door that JCHO wants is correct and the door the EPH wants is also correct. And it is enormous in undertaking and very frustrating and leaves one with the sense that there are so many different definitions that whatever definition you apply, you can take for your data.

DR. EDINGER: Actually, it is interesting, too, because the new to be head of HCFA — CMS, I am sorry — he was discussing one of his grants about quality indicators at the time. We had a long discussion. He was talking about this same very issue about how you use the various quality indicators, but he was asking about the survey certification data, the JCHO data and when — CMS used to review and do the equivalency and did a lot of surveys and stuff and he was asking me how in the world — what do you use them for. I tell him, well, it depends on who was in their survey. You know, if I went in on one day and you went on a different day, we might find totally different things in the facilities. We might come to the same overall conclusion, but we would probably have very different reports and extracting information from the sort of legalese type of survey data versus some of the Leap Frog type data and comparing them is a nightmare, but basically that is what he sort of concluded. It will be interesting to see now what he does now that he is in charge of all this.

But he has actually had a lot of hands on experience with all the various databases; I mean, going into the Part B databases, into the survey data. But that is a problem and what do you do with it?

DR. CARR: I would say that the quality that has come out of the exercise has been renewed for multidisciplinary group to go to primary data and you begin to look at things and we found things we didn’t know were there. So, I would say quality is coming out of it but it may or may not correlate with the number that you generate and somehow — you know, I find over and over, it is the exercise of actually looking at what we thought was going on.

So, there is value to it. It is not the thing that will go into — it is going to go on the web page necessarily, where it will take longer for us to get the web page numbers correct than for us to recognize the quality that is happening by merely asking the question.

MS. HANDRICH: So, would there be any value in having some statement at the end that there is a recognition that the goal is not really perfect data, but something else and something that is actually used and meaningful and accepted across a wide spectrum.

MS. GREENBERG: Maybe it the best definition in the world, but everyone is using it.

MS. HANDRICH: Right. Because there is this — a little bit of a feel of the perfect data quest, about, you know, the current indicators and so forth and to just say that that would be part of what would be sought in public hearings would be a reaction to — if all of these things happened, if all these systems got changed, presto chango, where would we be then?

DR. CARR: It will delay getting to the goal if we have all these different definitions. It is a real time waster, a distractor.

MS. GREENBERG: Actually, you know, I was looking at this thing about in support of the recommendations and I think maybe the reason that — well, Susan could tell us better why some of those things like Leap Frog and JCHO, et cetera, aren’t here is because of the way this is couched. It says a number of initiatives that are ongoing, planned or recently completed, operating in both the public and private sectors can’t affect health data systems in a manner that would facilitate implementation of the recommendations laid out in this report.

These were mainly things kind of related to — although there are exceptions, but, you know, things that would impact on kind of the capacity of health information systems to capture and use the information or the data elements that I think have been identified or some of the things that — because certainly that is true about the consolidated health informatics initiative. I mean, that is more of an enabling activity rather than — it is not specifically related to quality of care, though the whole idea is — it is the same with the electronic health record.

MS. HANDRICH: But when you get into the CMS quality initiative, you know, you are getting into —

MS. GREENBERG: But you are —

MS. HANDRICH: So, why do you stop there?

MS. GREENBERG: I don’t know. I would agree with you. Then you get back to HIPAA. So, maybe that opening statement needs to be broadened a bit and then — because I think she already has something on —

MS. HOLMES: She did. She had some verbiage about Leap Frog Group and JCHO and those types of initiatives.

MR. HUNGATE: Gail is traveling or is she available? She had that section, right?

MS. HOLMES: This was from a long time ago. This was Susan.

MS. GREENBERG: Is Gail going to be here tomorrow?


MS. GREENBERG: So, everyone will be here tomorrow.

MR. HUNGATE: So, Susan can add something in of that —

MS. GREENBERG: And, in fact, I mean, probably what you can say to the committee on those is that we are just going to add something about those. I don’t even think that they need to — what I kind of anticipate happening unless there are members who feel real strongly about not getting — of not approving this report and that is why I spoke with Simon because I kind of wondered where he was coming out on that, but if that is not the case, then there will be some suggestions and some of them you will be able to accommodate on the spot and then they will ask you to finalize the report with the Executive Subcommittee.

And then have it approved, have it approved at the meeting for finalization by the Executive Subcommittee. I think it should be the goal.

MR. HUNGATE: You and John Lumpkin are the institutional memory relating to the process.

MS. GREENBERG: Going back to 1903 or —

[Multiple discussions.]

MR. HUNGATE: I think at some time it needs the endorsement of the two of you in some way to say that this really does say what we did.

MS. GREENBERG: You know, I think both John and I are in favor of getting this thing to bed. I think it is in good shape.

MR. HUNGATE: I think it is better for you to make that point strongly than for me to make that point strongly, although I am happy to —

MS. GREENBERG: — for John, since I am not actually a member but if asked, I will say so.

MR. HUNGATE: I am just trying to stack the deck as well as I can.

DR. EDINGER: Or next year we will be here still discussing this —

MS. GREENBERG: In self-defense, I would happily say that.

MR. HUNGATE: Okay. Are there any other pieces relating to the report or can we now use that as the kick off for the longer discussion?

MS. HANDRICH: What do you hope to accomplish in the longer discussion?

MR. HUNGATE: Well, the agenda is as I put it, what do we need to accomplish first, how will we do it —

MS. HANDRICH: Vis-a-vis the report or —

MR. HUNGATE: The work of this committee.

MS. GREENBERG: Assuming that the report is put to bed.

MR. HUNGATE: And that the report also is a stepping stone to what — I started to outline the problem as I see it, which says the problem that I think we need to address is the reconciliation of the language of quality between the consumer, the user of health care services, the provider of health care services and the external study of health care services.

To me, that is measuring health and the relationship between the health care provided and the health achieved, which is the process, outcome, tension. My sense is that — and you have got to understand where I come from because I am a product of my experience and I think we are developing a new product. There is not a quality measurement system that is extant and works. So, we are designing a quality information system in a way.

Now, that is different than looking at the specific measures of how much time, what is start and what is the end. Some things, the National Library of Medicine is better at and some things, standard settings organizations are better at. I think our specific task really is in thinking about how should the system change, the information system. Now, that will get played out, I think, in individual demonstrations.

Let me back up. In designing products and my experience was Hewlett Packard, we had a process where you had an idea and then somebody demonstrated that they could actually make that idea happen. They did a prototype and then you did a little better one and then you found out if you could build it in an economic way and after you have taken about four iterations of that, then you introduced it to the marketplace and you found out whether they bought it or not. They never bought it as much as you thought they would. So, you would have to go back and change it again.

You kept changing. That is the process of developing a customer workable product. I think we should have for this workgroup a two year goal, which has in mind a 20 year goal because I think it will take 20 years to develop a measurement system for health care that does what I described between consumer and provider and external assessment. That is my model.

The thing it seems to me that we do in thinking about the two year thing is saying are there some demonstrations that we could figure out, some ideas that can be articulated and tested that might lead people in the direction of a 20 year objective. I am talking at a pretty abstract level. I am an idea person, an idealist. I expect others to correct my idealism to realistic objectives.

We need to assess what is going on, you know, as you did with Leap Frog and FACT. There are things going on in places. We need to say where do we fit in that spectrum. The IOM has identified priority conditions, for instance. Now, I could argue that what we need to do is pick a couple of priority conditions and say we have got a model in our mind of what we think we want to do.

When I came to Washington and worked on health policy and wanted to answer questions for myself, I went around and talked to everybody to find out, you know, what people thought and I could synthesize that into an answer that I thought was a good answer. We do that here in a public way. We don’t do it to find out for ourselves. We do it to inform the public, inform the decision-making group, if you will, at large about the issues and how they might be addressed.

So, that is partly objective in terms of where I think we need to go and it is partly process. But I think we should consider trying to narrow to a couple of priority conditions so that we are building off the vector that IOM has created. We should think about how we align what we do in ways that help what everybody else is trying to do work better and achieve what we think might be needed.

DR. EDINGER: Actually, I had a long discussion with Janet Carson(?) when they were doing that report. I and Greg Meyer, who was at the agency, actually had a discussion off line and one of the issues we were raising was if you do 15 priority conditions, what happens to the ones you don’t deal with. Each one have had very strong advocacy groups. Each one has people with very strong feelings about why their condition or area is more important than another. Take, let’s say, diabetes. There are other groups that feel their condition is probably equally important or more important, have used that as a model.

It doesn’t necessarily carry over to others when you do it by disease conditions, because sometimes the factors that relate to one disease condition may or may not relate to others.

We got into this issue, too, about cancer. There are so many varieties of it, each with a subconstituency group. That is why we picked some of these broad categories because cancer has so many connotations and groupings that the prostate and the breast cancer and everybody has their own indicators and quality. Sometimes it is very difficult, just for political reasons. It may not necessarily lead to a broader system when you go to specific, to one individual condition. I mean, I don’t think there is a clear answer to the question, but I am not sure necessarily when you go to a condition, say diabetes, that that necessarily applies or solves all your problems.

MR. HUNGATE: Let me try another bias on it. We had a lot of different managerial styles at Hewlett Packard and classic way you do things is kind of a ready, aim, fire and we found that we had some managers that were fire, fire, fire, fire, fire, fire, just shoot, just keep going and then follow what worked.

We had some that we referred to as aim, aim, aim, aim. Those usually were headed by committees. So, I think we need to pick something we can do in two years that can show a different way. Now, I don’t know whether it is specific disease. I am a little inclined to believe the narrower we make it, the more likely we are able to get something together that can give a good answer for those patients that have those conditions that help them.

If we do our process right, if we use a process that works, that others could replicate the process. In that argument, I am saying what we want to do is test the process.

DR. EDINGER: — 100,000 conditions, you go one at a time, you know. Our grandchildren —

MR. HUNGATE: We are not making any progress the way it is.

DR. EDINGER: Doing nothing.

MS. HOLMES: I thought one of the next steps that we have kind of outlined at the end of the paper was to pursue at a more general level the viability and feasibility of some of the recommendations that had been made. Am I not reading that final —

MR. HUNGATE: No, that is correct.

MS. HOLMES: So, I mean is this a kind of a two-part approach then that —

MR. HUNGATE: Yes, it is. I think that is an implementation step in the other model that I am articulating.

MS. GREENBERG: You are going to have hearings and I think — I mean, someone like Simon, if they are not going to have hearings before this report, he certainly would expect that you would after and I think we really should because it is also a way to engage then people around it. The reason, I think, not to have the hearings before you finalize it is there is so much in here, you know, and everyone will have a different view to some degree and then you — the report might unravel.

So, my sense is your best effort based on years of hearings, et cetera, I think it is good to go, but if you organize a series of hearings, it could be around, first of all, you know, the people — hearing from the people who — payers, providers, standard development areas, whatever, would be — would have to make these happen. But also you could hear from those same people, as well as others about some of these — you know, these other ideas. So, in a sense you could, you know, do both.

MR. HUNGATE: I have seen probably three times Brent James presentation of appropriate use of antibiotics in prevention of deep wound infections. Very clean, nice study, well documented, right? They have done things within their organization —

MS. GREENBERG: Intermountain?

MR. HUNGATE: Intermountain Health Care — to control that piece of quality. Some of the data pieces that are needed to do that are part of what is in this recommendation. I would be kind of asking what — suppose we set up that deep would infection management challenge and say all right, what do we need to do in the information system to assure that that specific has the same information for the provider of the patient.

MS. HANDRICH: Would you be soliciting in the public hearings people’s suggestions about areas that that kind of information is needed, that are priorities to them?

MR. HUNGATE: I am open to discussion. This is one that has been around for awhile that has, you know, a following, it seems to me. People believe it and I know that when I had surgery, they administered antibiotics and I tried to track to see whether they did it in the right window. I didn’t get any infection.

But, you know, we are putting some emphasis on consumers to pay attention. A lot of these quality measures, you know, are things that a patient is going to worry about whether they got aspirin or not. They are not going to know whether their indications are right or not. So, I am trying to think about the generic problem of getting a measurement system that fits all the needs and ways to demonstrate it in specifics. Because I think the abstractions and the generalities just get lost. I mean, they have no compelling action.

DR. EDINGER: Why don’t patients use them? I mean, there are a variety of reasons they don’t use them, including ourselves. You know, when my doctor uses Hospital X and they said Hospital Y is better, but I go to my doctor. He is there. Hospital X is across town. I can’t get there. I mean, there are a number of reasons. I didn’t understand what the measures were or you know, my Aunt Matilda went there and said she had a good result. So, I believed that and I went to that hospital or my HMO told me I got to go to this hospital.

That probably should be an area we should look at as to why consumers don’t basically use or can’t use the information and what may need to be done to make it useful to them.

MR. HUNGATE: It is not valid information for the decision you make. It is not procedure specific. It is generic. You know, it is so easily defeated. It just doesn’t help.

DR. CARR: I think that I would like to underscore the importance of what was just said because, you know, in terms of identifying what we will achieve by this — I mean, one thing is quality care, but the consumer role, I don’t know how much flexibility any consumer really has with managed care and other sort of historic things that focus on that. I think that is — it is important to either say it is a driver or it is not a driver. This is still the right thing to do but how much of a driver is it with consumers?

MR. HUNGATE: The only place that I see a consumer having any choice is at the level of undergoing a procedure or not undergoing a procedure. As I see our tiering of networks likely to move in Massachusetts, there may be conditions where a high risk patient should be going to one hospital and a low risk patient should go to another hospital. But that has to be up front and clear and the person that — the low risk person that goes to a different institution has to have enough evidence to believe that they are still being well treated for it to be a reinforceable system.

DR. CARR: Just regarding emphasis on Leap Frog, you know, I wonder if there is any data on how that affects patient choice and if it affects it because you were saying, no, the only choice a patient has is whether they are going to have the procedure, but — I mean, I think there is the publication of the Leap Frog data right next to health grades data is the impression that it is going to be used by consumers in some way.

MR. HUNGATE: Yes, but I think what I see happening with purchasers is that they use the Leap Frog in many cases to make a differential decision to say that you get this kind of a benefit at those that are Leap Frog approved and a different benefit at those that are not.

MS. HOLMES: Let’s remember, too, about Leap Frog that they themselves admit that volume, which is their indicator of quality now, is not in and of itself a good quality measure. It is an interim measure. And until better indicators of quality are developed, they will contract or pay differentially based on the volume criteria, but that they acknowledge completely that in and of itself it is not a good quality indicator.

[Multiple discussions.]

— you should go to a hospital that has a certain volume, but there is a great deal of debate even within the health services community because some people say it is not the volume of the hospital, it is the volume of the physician or it is an interaction between the volume of the physician and the volume of the hospital. So, even though we talk about it as though it is kind of a done deal, it is not.

MR. HUNGATE: No, it is not and I agree.

MS. HANDRICH: You know, if what you are — one reaction that I have to what you are talking about is that I think one of the things that you are saying is that you think it would be an appropriate role for this group to think about the practical applications of quality measures in some way and that — that is point 1.

Then point 2 is that you are thinking that it would be really good if that practical application could somehow address the needs of consumers, health care of consumers and that regardless of whether or not in our current health insurance environment, people make choices about where they seek health care based on quality measures. There is this issue of people understanding the quality of care they are receiving, regardless of whether or not it affects the market. That is like maybe a thing to explore.

If that were something that people thought would be a good practical application of good as it relates to quality, as it relates to consumers, is it known or would it be a good thing to explore what it is consumers themselves with some education would feel to be useful information for them? I think work has been done on that, but nothing that I am aware of that is kind of the definitive statement.

If we were to take this report, let’s just say this report in the primary and acute field and hypothetically make some progress in all of this and explore with consumers — now, if you had all of this available to you, what would be meaningful to you? What would help you feel comfortable that the care you were receiving was, you know, at a minimum, adequate? And then think a little bit about what those measures might be and whether or not there has been enough focus on the collection and dissemination of those measures so they have kind of a consumer focus. I think that would be really neat.

MR. HUNGATE: My conclusion from some work in that direction is that you have to get to specific conditions. You have to get to backs or knees or hips or hearts, but it has got to be specific to the issue.

MS. HANDRICH: But what I am reacting to that you said is — you know, when you started off talking about like wound infection, you could have a very kind of technical physician, hospital oriented report that would be the perfect way to treat this. But if the focus were going to be on what consumers need to know about specific conditions as they go into — that is very different, I think.

MS. HOLMES: I think we want to be careful that we are not getting into the — we are creating quality guidelines.

MR. HUNGATE: We don’t want to do that.

MS. HOLMES: I mean, this could very easily kind of veer off into that and what quality guidelines would be for a health care provider versus what quality guidelines would be for a consumer. I just want to make sure we

don’t —

MR. HUNGATE: I come at it from the standpoint of wanting to get to risk adjusted outcomes. You have heard me say that before, more than once. I think that has got the support of the Executive Subcommittee. It hasn’t been talked through at the full committee. Am I right? Is that — is my reading correct?

MS. GREENBERG: I think there was a recognition of that, importance of it, also of the difficulty of it and that it really — at least I know Ed Sondik said he thought it was still very much of a research issue, but that —

MR. HUNGATE: But that you see is —

MS. GREENBERG: — doesn’t mean the research doesn’t have to be done.

MR. HUNGATE: But the research is aim, aim, aim. We have done a lot of research on a lot of things and a lot of things haven’t changed.

MS. HOLMES: Well, some of that has been done with some cardiac procedures. They have databases that have risk adjusted outcomes. I mean, not passed probably initial hospitalization and maybe six months later, but it is certainly only in very specific areas and once again it is focused on hospital risk adjusted outcomes.

MS. GREENBERG: I think we sort of need to be on two tracks, but they can come together, but —

MR. HUNGATE: I think that may be true.

MS. GREENBERG: I think in regards to this report — and as I look at the recommendations, they are primarily — and I guess I said that earlier — they are kind of enablers. There are a number of ways both in a systems way and a data content way that one could — been identified as a high priority activity that would improve the data on which I think maybe purchasers, not so much consumers but more higher level purchasers could assess the quality of care.

They could also, I think, maybe provide the foundation for being able to get at what is important to individual consumers. I mean, you know, the functional status, some of the issues about special populations, et cetera. But consumers, even — well, consumers really don’t focus on whether, you know, data elements or they don’t focus on, you know, whether it is an electronic health record. I mean, it is only the most sophisticated that would even realize — I mean, if you kind of present this and say, you know, right now your information is all over the place and you are having all these duplicate tests and all this and this is — but I mean that is not what they are focused on.

They are, I think, primarily focused on —

MR. HUNGATE: Outcomes.

MS. GREENBERG: And to some degree, process. If you are in a chronic care situation where maybe they know — certainly the cure is not an expected outcome and certainly in long term care, too, there is a process thing where, in fact, you know you are going to live with this condition maybe until some miracle happens or maybe you are even going to die within, you know — and there is where the process of care, the end of life or the — those are the things, I think that people care about. Some of that is in here.

MR. HUNGATE: Some of that is there.

MS. GREENBERG: This is not the focus of this. But having — but there is a feeling that this — what is recommended here from what we heard and from what people have digested and come out with in this report, would improve the infrastructure for assessing quality. So, I think we need to validate that with some hearings.

MR. HUNGATE: I agree. I don’t disagree at all.

MS. GREENBERG: But I think in doing so we could also engage these people and then some additional people, and I think I am repeating myself because I probably said this ten minutes ago, on how to get from just to the sort of infrastructure, which is more related to population-based data, et cetera, to meeting the needs more of consumers. But, hopefully, purchasers — of course, they are concerned about cost, too, but, hopefully, purchasers have the same goals for consumers that consumers have for themselves.

[Multiple discussions.]

MR. HUNGATE: There is an old joke about the difference between the pig and the chicken and breakfast. The chicken is involved by providing an egg. The pig is committed. The patient is committed. The employer or payer is not.

[Multiple discussions.]

MS. GREENBERG: The employer is committed fiscally because I think that —

MR. HUNGATE: Like the pilot on an airplane, you know, the pilot is committed the same way the passenger is in the progress of that flight because he is also a passenger. But neither payer nor provider has the same commitment in health condition that the patient has.

DR. EDINGER: — patient safety. What if a CEO from a hospital got up and said can you tell me how it saves money, it saves money for Aetna. It doesn’t necessarily save money for me. He said it is wonderful that Aetna is saving money but that doesn’t translate to my bottom line in my hospital when I have to face the board of directors.

I think all three of them have different concerns. Maybe one of the things even with the patient is not so much how many data elements I as a patient would receive if I go for my knee replacement, I would probably be more concerned if somebody told me that — does great cardiac work, but you are right. If I go in for a knee replacement, I don’t care if he does great cardiac work. I want to know what the hell is going to happen to my knee when I get out of there.

If the greatest knee surgeon is over there and the greatest cardiac surgeon is here, I would rather go where the great knee surgeon is, not the hospital where everybody else is wonderful except the knee surgeon. But maybe the publicity of it — you know, if I was reading in a hospital the hospital across the street was killing — the mortality came out — the hospital across the street was killing people by the truck load, I as an individual may not be able to do anything, but I think the collective concern of both the public and even political people, who use the facility certainly can influence decisions to reexamine the quality of care in an institution or in a provider.

So, I think sometimes the publicity and the way it is presented, even though I as an individual may not get to do anything, collectively sometimes things can happen to them. It is not just even the quality of care, but the — introducing information systems —

MS. GREENBERG: We have a story line, though, with some of these and that is maybe would be our next step also because then just thinking like about knee surgery, okay, you want to know what your functioning level is — you know, a week out, a month out, x months out. You know, there are various things. So, if you had a unique identifier, if you had — or you want to know — somebody wants to know if they should go to that physician, if you associate the physician with the surgery, if you have functional information, if you have linked records, you know, all of those — so, I mean, there are a lot of pieces in here, but I think it is a different story line than it is for people looking at, you know, the consumer. It is a different story line than the people, you know, purchasing care.

But a lot of it works both ways and I mean and what we want to know is what is missing here and then to the extent that we have captured really the important things that need to be done, how does that happen? How do we make it happen?

MR. HUNGATE: I don’t know that we have highlighted the need for agreement between the purchaser community and the provider community of the terms of trade between them. If you look at how we have evolved in purchaser action, they tried to take the easy thing that will save money without compromising quality, shorten the length of stay. Hospitals are expensive. So, we will pay for fewer of them.

Each of those sets has had an unanticipated occurrence afterwards. So, you end up not getting to a real answer. You only get part way. To me, that is where the outcome part of it is helpful, where functional status is part of that. If the consumer is interested in outcome, if that is their primary interest, not having the deep wound infection is what they want. So, they get out of the hospital quicker. It seems to me that if we conduct our hearing saying that we need to reconcile those three, that we have a better chance of helping the macro commitment.

Simon argues in effect for using claims attachments for risk adjustment information. Others might argue for using administrative data. Both of them will improve the outcome measures.

Does that make any sense or am I just babbling?

MS. GREENBERG: Well, I am certainly not going to say the latter, but —

MR. HUNGATE: I probably pushed it too hard.

MS. GREENBERG: Well, no, I mean I think the idea of sort of reconciling what payer needs, the provider needs and the patient needs and is —

MR. HUNGATE: Is okay.

MS. GREENBERG: Yes. How you go about that, I am not quite sure, but — I mean, one thing we might want to do — we said there has been a lot of research on race adjusted outcomes, in addition to, you know, getting the feedback and following through on all this, is to actually have some people come in and present the state of the art.

MS. HOLMES: I think that is an excellent idea.

MS. GREENBERG: — in my briefcase also. Have you seen that?


MS. GREENBERG: We should get that for everybody.

DR. CARR: What is that?

MS. HOLMES: It is an Academy held publication that at kind of a high level summarizes the issues involved in risk adjustment, including, you know, the source of the data for which you risk adjust, the purpose for which you are risk adjusting and the level of analysis, say the level of — yes, the level of analysis, where you are talking about individuals, groups, states and so on, that that all affect decisions about risk adjustment.

I would like to second Marjorie’s idea. I think that the — I mean, everyone fights very bitterly and disagrees very bitterly about risk adjustment methods and, you know, it is come to blows, for example, in the long term care community with competing approaches to risk adjustment and so on. It is a very contentious issue. I think we might be doing a service to the community, whether it is acute care, ambulatory care or long term care, if we did have some hearings that were aimed specifically at risk adjustment methodologies, pros and cons, strengths and weaknesses and so on. I think that would be a very useful contribution.

MR. HUNGATE: That might be a second step beyond the first working — I think that working from the recommendations here would reveal the need for —

MS. HOLMES: Right. Exactly. For example, in choosing the measures that go in in the quality report from the National Nursing Home Survey and the home health care measures that CMS has. I mean, people literally almost came to blows about —

[Multiple discussions.]

MS. GREENBERG: I do think the committee is good at getting the different people at the table and identifying maybe not the answer, but at least a research agenda and then kind of push, you know, with recommendations, to push that agenda forward.

MR. HUNGATE: Let me throw my ore in again on the individual. When it is hung up between people on competing risk adjustment methods, the patient ends up getting nothing.

MS. HOLMES: But I think we have — if you had a very broad approach, I think that it is interesting to think about the differences in terms of a risk adjustment methodology base and whether you are talking at the level of an individual or you are profiling a physician, a group of patients or whether you are summarizing data and trying to risk adjust the different characteristics of patients or individuals in a state. You know, the methodologies differ and a lot of people don’t know that or they don’t internalize that.

I think by shining a light on, you know, these things matter in terms of talking about risk adjustment, whether you are talking about reporting on quality at the individual level at the individual physician level or at

the group —

MS. GREENBERG: Institution or group —

MS. HOLMES: — institutional level, you have to take very different approaches.

MR. HUNGATE: See, I am trying to argue that what I want to do is focus on the individual’s need and I believe that if you are going to risk adjust a hospitalization, that the risk factors that are related to that patient need to be identified on admission because they have to be managed if they are appropriate.

If they are appropriate to be managed, then the patient’s expectation of outcome has to be based on those same risk factors, has to be fed back to that individual, that those two should not be different risk factors or something is wrong with the measurement system so that if you summarized those risk issues on admission, then that would be a coherent external judgment is my mental model of how I get to where I would like to be so that it would still be enforcing.

MS. GREENBERG: One thing we could do if we had, you know, people come in and I think — if we had people come in to talk about the methods and some of the issues and what needs to be — you know, what needs to be — we could have a dialogue with them and you can say this is, you know — to people who spend their life worrying about this and fairly coming to blows about it, but, you know — and all the committee members and staff, too, who feel they are knowledgeable enough to — I mean, I have no expertise specifically in risk adjustment methodology. So, I would learn and listen — listen and learn a lot, but can then engage — I mean, you don’t just have to have people come in and provide testimony and walk out. You know, they are not members of the committee, but isn’t there a way so you can invite people back for a second time because you didn’t get enough information from them the first time.

And you could really engage them and, you know, throw out ideas, get their reactions, see whether there seems to be complete lack of agreement and where we see a little light at the end of the tunnel.

MR. HUNGATE: Should we do that in our workgroup or at the full committee?

MS. GREENBERG: I think you might start it at the workgroup. Anyone from the full committee who is really interested could be invited to come.

DR. CARR: A person might want — and I don’t know if it came up before, but Lisa Iezzoni, you know, was on the committee, of course, and this is an area that she is quite expert on, with the different modalities and what works and why things don’t work. I mean, I have learned a tremendous amount from her on risk adjusting.

MS. HOLMES: What would be interesting is to have people — have people come in who have experience at a conceptual or empirical levels, for risk adjustment at the hospital level, at the physician practice profiling level and at the — in long term care, whether it is home health or whether it is a nursing home, as well as people who have been working on outcomes — risk adjusted outcomes for individual patients, whether it is during a medical intervention or thereafter in the community and so on.

MS. GREENBERG: And they could react to these recommendations, too, and say — because I know one of the things that Lisa has been a big supporter of this diagnosis modifier because — so, you know whether something is a complicated — at least you have some idea whether it is a complication or it is a comorbidity because she founded a lot of her empirical work, but, you know, that was a real — that she was giving people credit for maybe complications.

So, I think it does tie in with this, but I also think you could engage them on some of, you know, the thoughts and ideas that you have, Bob, because they are the ones that we should be engaging on these areas.

MS. HOLMES: I think that is a terrific idea.

MS. GREENBERG: And, you know, we have — I don’t know, a lot of them are not — you know, they are on the East Coast or the —

MS. GREENBERG: You know, if we have to pay to bring them in, we can do that. We even have the capacity to — I don’t mean even, but we could engage one or more, maybe two, you know, to write something.

DR. CARR: I just was going to say we could meet in Boston.

MS. GREENBERG: We have done that. We have had a few meetings in Boston because everyone we wanted to talk to was there anyway. Now we have — you are up there. Is anyone else on the committee now in Boston? I see you down here so much, Bob, that I forgot. It would be a really easy way to Lisa, a much easier way to get Lisa.

DR. EDINGER: If we do this, maybe we should bring it down also to the level what does it mean to both the payer and the patient because basically the people who do risk adjustment talk to each other. It is a very different discussion.

MS. GREENBERG: It is always so hard to get — I mean, you know, you go to AARP to get consumer kind of perspective, but we need to think about that as well, as well as the payers. You have got Kathy Coltin up there, too. You have got Harvard Pilgrim. I mean, you have got a lot of health plans as well.

DR. CARR: I think we need to get our building blocks, you know, on sort of firm standing to begin with because this data is supposed to direct quality improvement. If it is flawed data, it is not going anywhere. So, the starting point is understanding what needs to be risk adjusted and what is the development of the risk adjustment processes for that particular type of care.

I think once we have confidence that we have a methodology that would work, then I think — then sort of running it through the various, you know, payer, consumer or whatever, they would then be responding to not, oh, that doesn’t accurately represent whatever, but rather, okay, starting with the assumption that it is okay, now how would you use it or what would it mean.

I think talking to the experts about risk adjustment would be a good first step.

DR. EDINGER: I think when you get done with it, having — I guess Julia has had the same experience having worked on the Hill for somebody for awhile — if you can’t explain it to somebody else, whether it is a member of Congress or —

[Multiple discussions.]

— and you tell me about risk adjustment and we have this model and we have that model and they say, well, okay, I have got my knee problem. What the heck does that mean for me. I think if you can’t bring it down to that level, after the discussion is done, two roles. One is why you need the good data and secondly what the heck does that actually mean in practice to me.

MS. HANDRICH: If we were to do this, I think a very important thing to do would be for us to all agree on what is the question or what are the —

[Multiple discussions.]

— and to be really clear. This is a huge — and maybe we ought to talk about that a little bit more.

DR. CARR: You know, can we go back to the two questions that were raised. One is what is risk adjustment and the second is I am not sure that our goal is for a consumer to be able to say what does it mean to me. I think it is more for a provider to say what do I know today that I didn’t know yesterday and how can I deliver quality. Because I think our focus ought to be on the deliverer of quality care, what the consumer hears and does and how it affects them, we have already decided they don’t have that many choices and they are not sure what to do with it anyway.

I would focus not so much on what the consumer does with it, but what the provider does with it to improve care.

MS. GREENBERG: You are not here to defend yourself. Spoken like a true provider.

DR. CARR: Care should get better at the end of this and people should be aware, but, you know, the public information that is out there, it takes a lot of managing because it is so sophisticated and not all consumers have the same level of sophistication. So, to Bob’s point of the aim, aim, aim, I would not spend time worrying about, you know — I wouldn’t use the consumer as the first — the customer of improved care, but the consumer, he should be getting good care and then be able to figure out when they are getting good care. But it is just confusing for a consumer to be, you know, looking stuff up and making decisions.

I mean, I think, you know, the process we want to happen is that we reflect back good information and care is now going to be adjusted to make it better.

DR. EDINGER: Let me take the devil’s advocate side. As a Nobel Prize winning physicist once said, the reason that you can’t explain something simply to somebody is probably because you don’t understand it yourself and to some extent that is not well enough understood to be explained simply.

DR. CARR: No, I want it to be understandable to the consumer but at the end of the day, the consumer is going to go where their health plan, physician and aunt tell them to go. So, I think a goal of ours shouldn’t be to — you know, to match consumers to the hospitals. I am just saying —

[Multiple discussions.]

— before that we are not going to change that much about consumer choice, but we certainly can change the quality of care and consumers can understand it and advocate for their opportunity to choose.

MS. GREENBERG: — because it sounds like we just don’t want — we want a way to all be able to avoid the — raise the bar.

MR. HUNGATE: The choice that I am trying to get at is not the hospital choice. It is the choice between angioplasty or CABG. You know, it is the choice that is the real decision that the patient makes.

DR. CARR: Fair enough.

MR. HUNGATE: I think that that has been left out and I know that when I had surgery, my surgeon could not answer the questions I wanted answered because he didn’t know the answers. But I had better information from other people who had had similar but not the same surgeries because their results were somewhat different. This was a simple hernia. But there is more than one way that a hernia is treated.

MS. HANDRICH: Here is a naive question. I am asking this because I know this risk adjustment area is fraught with peril. It is. If we go this route, it will be very controversial, whatever we do. Not to say that is not a bad thing to do, but given that, I am looking at the charge to the committee and just going back to the charge and thinking about what we are talking about —

MS. GREENBERG: You are talking about the overall committee.

MS. HANDRICH: The overall committee, right. Is there a charge to the workgroup?

MS. GREENBERG: There was once.

MR. HUNGATE: I didn’t find it useful. I think that is very useful. I have done the same thing.

MS. HANDRICH: Well, the National Committee is the department’s statutory public advisory body on health data statistics and national health information policy. It shall serve as the national forum on health data and information systems. It is intended to serve as a forum for the collaboration of interested parties to accelerate the evolution of public and private health information systems toward more uniform shared data standards, operating within a framework protecting privacy and security.

The committee shall encourage the evolution of shared public/private national health information infrastructure that will promote the availability of valid credible timely and comparable health data. With sensitive policy considerations and priorities, the committee will provide scientific technical advice and guidance regarding the design and operation of health statistics and information systems and services and coordination of health data requirements.

Then it goes on to talk about HIPAA and shall inform decision-making about data policy by HHS, states, local government and the private sector.

MS. GREENBERG: That is consistent.

MR. HUNGATE: To me, health data needs are outcome measures. Those are health data.

MS. GREENBERG: Well, outcome measures are one of the health data needs. And the idea of standards is that, you know, you can make decisions on things because the data are comparable and all that. So, I think, yes — I mean, I think we don’t want to get — we don’t want to get into, you know, measures, setting performance measures or favoring one performance measure over another. But what we are talking about, I think, is information policy and methodology, of course, is part of information policy. So, I think it is consistent.

DR. EDINGER: I think even though risk adjustment is controversial, we are not picking one model and saying this is —

[Multiple discussions.]

MS. HOLMES: I thought when I read it, it was, too.

DR. EDINGER: I think that is what we are trying to get at.

MS. HANDRICH: You know, you are taking this in a new direction. So, it is —

MR. HUNGATE: No, I think it is consistent. I think it is well to look back and —

Justine, anymore comment?

DR. CARR: I am reflecting here trying not to be a provider.

MR. HUNGATE: It is now 4:15. I promised everybody a break. We are going to reconvene at 4:30 for an hour and then we will quit.

[Brief recess.]

MR. HUNGATE: So, we need a hearing to deal with the recommendations, especially in the first section. Right?

MS. GREENBERG: You mean all the data elements affecting health care and health outcomes.

I think that is — because although I think building the data infrastructure, there are some things in there, too, and reducing disparities.

MS. HANDRICH: There is a ton of stuff in this report and —

MS. GREENBERG: We don’t really need a hearing on — well, maybe starting on, you know, like functionality for EHRs. I think that is kind of a different —

MR. HUNGATE: Part of the reason for this structuring was to try to narrow the focus a little bit so that we have got — in the specific findings we have got the four categories, assessing health care and health outcomes, reducing disparities, where we are expecting to populate — to work with Populations on that issue.

Where building data and information infrastructure is work with NHII and Standards and Security and balancing patient interests is work with Privacy and Confidentiality. That is the — so, the one we want to work on is the first one.

MS. GREENBERG: The first set, which wouldn’t necessarily be with any of the other subcommittees.


MS. GREENBERG: Although interested parties.

MR. HUNGATE: And we will welcome their participation.

MS. GREENBERG: Because it does have to deal with some standards issues, which are relevant to Standards and Security and some survey issues, which are relevant to Populations, as well as race and ethnicity.

MR. HUNGATE: Now, we have the job of planning that hearing. We have also articulated another hearing on risk adjustment. So, we have two work tasks for us and as near as I can tell, we have no staff to do it.

MS. HOLMES: Maybe I am confused but when you say hearing, you don’t mean one meeting. You just need a hearing as a collection of —

MS. GREENBERG: It could be one or more. It depends. You have to decide whom you want to hear from.

MR. HUNGATE: I am not trying to bound it. I am trying to identify topically —

MS. GREENBERG: Two days or — I don’t know whether one hearing or one two-day hearing would be sufficient or you would need to have more than that on the first round.

Well, as for staff, as soon as I saw that e-mail from Eduardo, I forwarded it to Jim Scanlon and I said we need a new lead staff person for the Quality Workgroup. So, we will pursue that. Did we get any new people for the Quality Workgroup? I mean, we still have Stan and Julia and Gail, but we need somebody who could certainly help with the hearings, but we need a lead staff person to take responsibility for them and — let me see. Quality Workgroup, there were — oh, and we have got Trent and Sara Lynn Marks, do you know her?

MS. JACKSON: Yes, I work with her in Women’s Health. Sara Lynn had been a fellow for years and now I guess she is really branching off into other areas in the federal service.

MS. GREENBERG: She is in the office that Mary Jo Deering is in, I guess, the Office of Public Health.

MS. HOLMES: Is she at NCHS?

MS. GREENBERG: No, no, no. She is here in the — you know, when they abolished the Public Health Service, this was kind of what was left, a small office. They are responsible for Healthy People 2010 and then — I am hoping she will come tomorrow.

MS. JACKSON: She has got an outgoing message. She is not in this week.

MS. GREENBERG: She is out entirely, but in any event, this is — Jim has the lead in identifying staffing and he will need to get back to Carolyn Clancy, given

that —

MR. HUNGATE: It is my sense that given our agenda, that the approach that has been taken by the CHI of the federal initiative to standardize systems and so on, is applicable to the resolution of conflicts around risk adjustment. If the VA, DOD and CMS used equivalent, the same, risk adjustment methodologies for assessment of quality, we would have a big step in commonality in the system. Now that is a possible result down stream from our work if we had people participating from VA, CMS and DOD that were involved in these measurement issues.

We have someone from CMS. We have the potential of someone from VA.

MS. GREENBERG: No, he is not at VA. He is going to the VA hospital.

MR. HUNGATE: A single VA hospital.

MS. GREENBERG: He is going to the — we have lost him. He is going to be actually in charge of — let me see, he is going to — beginning Monday, he will be working at the Washington, D.C. VA Medical Center, the local VA hospital and clinics, not the VA central office. He is going to be associate chief of staff for informatics and director of clinical informatics and decision support. We can always have him come back and give testimony, but I wouldn’t count on him being available to staff the committee because he is not with the VA. He is with this hospital. So, he is not even a federal employee anymore, I think.

DR. EDINGER: Oh, he is.

MS. GREENBERG: In any event, I wouldn’t completely discard that as a possibility, but I think we need someone in the department to still be the lead staff.

MR. HUNGATE: Yes. I think we have a lead staff need. We also have staff participation needs, I think.

MS. GREENBERG: What you are saying is you would also like to have staff from DOD and VA —

MR. HUNGATE: Yes, I would.

MS. GREENBERG: — as we have with the Standards group. I know we have just identified someone from the Bureau of Census, I think, for Populations. This is something we can do also. So, these are needs that need to be conveyed to Jim Scanlon. I would think we might — in the hearing that we have on this first set of recommendations, we probably would want to try to get someone, who is involved with quality stuff at VA and at DOD to react.

[Multiple discussions.]

— a staffer but I think we want to engage them.

MR. HUNGATE: Right. I agree.

So, will you address that with Jim? Should I?

MS. GREENBERG: Yes. I have written that down. I have already — and I will follow up. We will see him tomorrow at any event.

MR. HUNGATE: If I had my druthers, the person who staffs this committee would have a job that is germane to the content we are working on.

MS. GREENBERG: Absolutely.

MR. HUNGATE: So that they get a return in their own job from this work.

MS. GREENBERG: That is always, I think, a win-win, that we would like.

MR. HUNGATE: Me, too. That is why, I think, we have had the lead staff be from AHCPR or AHRQ because they have the lead on the Quality activities. Interestingly enough, I was — I am not saying that they are going to be available to do this, but I was in communication last week with Roxanne Andrews, who — you know Roxanne — she is on the HCCUP staff, which is the Health Care Utilization — Health Care Cost and Utilization Project. That is where they have the state hospital databases.

MR. HUNGATE: Within which organization?

MS. GREENBERG: AHRQ. They are beginning to look — they collect — they have these state hospital databases and she was at AHRQ. Then she went out to California and was with OSHPOD, which is the Office of State Health Policy, whatever, the people who do the state hospital discharge data, encounter data and then she came back to the area and she is back at AHRQ, working on HCCUP, but she was telling me — she was totally unaware of this project and this — and she is certainly aware of the National Committee. Years ago, she was actually staff from AHCPR as it was then, I guess, to Standards.

What she was communicating with us about was that they are looking from the point of view of HCCUP as to what data elements — you know, what are the high priority data elements and how could they get them collected, for quality. So, I said, well, you know — I sent her actually a copy of the report and I said I think, you know, it would be good for you all to meet with this workgroup because let’s hear, you know, both how these recommendations tie in with what the agency is thinking about doing and what the agency is doing.

So, I think, you know, that is another — and there maybe so many people that we need to hear from that it can’t be done in one hearing.

MR. HUNGATE: That is my guess, that it is more than one.

MS. GREENBERG: So, just from the fed’s point of view we have said the VA. We have said DOD. We have said AHCPR and there are probably a few different people at AHCPR because there are the people who are responsible for the quality —

MS. HOLMES: Fred Kelly.

MS. GREENBERG: — report and he, of course — some of this report is based on earlier testimony from him, but also these HCCUP people, since they are really dealing with improving inpatient data and actually their interests are beyond inpatients, also emergency departments, ambulatory surgery, you know, and ultimately just, you know, physicians, but they don’t have that data.

Who else in the department do you think? Is there any need for NCHS?

MS. HOLMES: Well, to the extent that you are going to talk about data on race/ethnicity —

MS. GREENBERG: So, maybe it is going to be separate with —

MR. HUNGATE: Populations, I think, is the right place to get that discussion underway and I basically agree with Vickie, to cooperate in that —

MS. GREENBERG: — separate hearing or whether Populations should join in with this.

DR. EDINGER: What about Indian Health Service? They do a lot of work on their own population. They do a lot of work in collecting health data and analyzing it.

MS. GREENBERG: So, you would have these federal folks. Then you are going to want to have providers.

MS. HANDRICH: Kind of one strategic way to think about this is who are the key players that get these recommendations implemented.

[Multiple discussions.]

— touched on the feds, but in terms of the private sector.

MS. HOLMES: The state folks as well.

MS. GREENBERG: To the extent that the recommendations would require changes and enhancements to administrative data, like the encounter data, encounter/claims, those are what we — talking about this being a DSMO room, those are the DSMOs. It stands for Designated Standards Maintenance Organization. So, it is NUBC, NUCC, X12, HL7 and there are the pharmacy and dental groups. But I am not sure they are so relevant at this point. Pharmacy may be, but certainly those four.

MR. HUNGATE: This will probably be a joint hearing with Standards and Security, is my guess.

MS. GREENBERG: I was thinking that maybe — first, you want to get the Quality people, which is providers and payers, the part of the payer organization that isn’t dealing with quality or —

[Multiple discussions.]

— as opposed to the — administrative standards and validate — do some more validation on just these recommendations. Then on prioritizing them. Then you bring in the people who could make it happen if the business case can be made.

MR. HUNGATE: Why not bring them in at the same time.

MS. GREENBERG: We could do that. But I mean I think you have got to hear from the others — you have got to hear from the quality people first because I am just thinking if in the process of getting that feedback, you find out that some of these things maybe don’t make sense or certain of them are really the highest priorities — there is a lot of consensus on that — then you want to focus your conversation with the Standards people on those that you have got —

MR. HUNGATE: I am just not sure whether we need to be the intermediary. Can’t we get the debate to take place in the room?

MS. HANDRICH: In my experience of things like this, you know, part of what somebody might say is that is a great idea, but it can’t be done. It is the technical considerations and then you have — you don’t have everybody in the room to talk through whether that is the case.

MS. GREENBERG: Try to encourage people to be there both days. It is going to have to be two days, but I would at least on the agenda hear from the payers, the quality folks at — payers, providers —

MR. HUNGATE: I am comfortable with that.

MS. GREENBERG: Maybe Leap Frog and JCHO.

MS. HOLMES: American Hospital Association maybe.

MS. GREENBERG: Well, they are also tied up with the standards process because they chair the NUBC.

MS. HOLMES: If, for example, they came to the hearing on the National Quality Report and had quite a lot to say about it and —

MS. GREENBERG: I think you are right about that. I have some of these — some of these efforts that are highlighted in No. 4, I would have those folks come in.

MR. HUNGATE: I agree. It gets to be a lot of folks.

MS. GREENBERG: That is what I was wondering. I mean, even if you could do it all in two —

MR. HUNGATE: I am not sure — do we ever sponsor workshops where, you know, you get those people together and say come out with something that makes sense around this —

MS. HANDRICH: Inviting people to submit written responses, too, and we collect both what people say and — everybody has to come and say what they would just write.

MS. GREENBERG: Well, you can do that as well.

DR. EDINGER: The other thing is you want some of the people — like the CMS’s because some things are legal problems, some are technical problems. Besides in their role as testifiers, also there are reactors, I believe, probably the CMS type people as reactors to what some of the others are saying and actually have them more than just sit there, just react to some of the problems they may perceive and — some of these approaches.

MR. HUNGATE: In our last discussion, we started working on two different matrices of current data systems and future data systems and how easy those things would be.

MS. GREENBERG: With feasibility and — desirability and —

DR. CARR: Achievability, as you know, easy to implement, hard to implement, big return, less big return.

MS. GREENBERG: Right, right.

MR. HUNGATE: Justine was nice enough to share her notes. There they are.

MS. GREENBERG: So, I think what you need to do is decide, you know, what would be the questions you would want to ask these people, as you were saying. Have a clear set of — and ideally, they will provide written testimony as well as —

MR. HUNGATE: And it could be that we could take this kind of a matrix approach and send it to those that were interested in having — provide testimony and ask them to fill out their judgment.

MS. GREENBERG: Kind of like we did with the committee?

MR. HUNGATE: Right. And see if that helps us in the prioritization. But then give some feedback back to others, relative ease, feasibility of individual judgments.

MS. GREENBERG: We have a little more leeway than you do — don’t want to get too much like a structure, although it has got to be in the context of their testimony. Otherwise, we are like surveying people, which we don’t really — can’t really be doing.

MR. HUNGATE: Is that right? We are limited on that one?

MS. GREENBERG: To some degree. I mean, the agencies are very much limited without clearance, but — you

can send out the report. You can ask people to provide feedback. You know, you can do all that and you can certainly provide them with questions that you want answered.

DR. EDINGER: I was just wondering one thing, too. If you sent like — you sent to the people in the Washington office, they probably have a very different view of this versus the people in the hospital. So you actually have to implement it. So, you might get very different answers, depending on which group of people you ask, just because of how they view life.

MR. HUNGATE: A lot of this is going to take staff work. So, we have got a time frame here of what is doable. When could we even think about having — because we have to put some dates on a calendar someplace because if we don’t get them on a calendar, they don’t happen. What is reasonable —

MS. GREENBERG: And the Standards and Security Subcommittee has taken everyday between now and December.

MR. HUNGATE: Well, if we go to Boston, we could bypass that limitation.

MS. GREENBERG: And you have got to give people enough time so that they can both — that they can spend some time at it, at putting together their responses, depending on —

MR. HUNGATE: The thing that I notice is that there is work going forward, you know. People are doing things. It is not even sitting there waiting for us. So, you know, if we want to do anything about it, we ought to do it. And not having staff to do it means I am stuck.

MS. GREENBERG: We have to address that. I mean, we have just found this out today —

MR. HUNGATE: I understand. I didn’t expect an answer today. Is a month a reasonable time to get a name or is it —

MS. GREENBERG: I would think we could get a new lead staff person on board. I think that should be the — certainly, that is reasonable. But the earliest that you could have this hearing, even May seems a little early.

MS. HOLMES: It sure does.

MR. HUNGATE: May is just around the corner.

MS. GREENBERG: If someone started working on it today, that late May might be realistic, but since we really don’t have the infrastructure right now to start working on it today or tomorrow or Monday, then I think May is too soon. The question is — because I have found that summer doesn’t matter anymore. Life just keeps going on. So, it is possible it could be during one of the summer months. I don’t know whether August is is particularly bad. I mean —

MR. HUNGATE: August tends to be bad. People don’t like to come to Washington in August.

MS. GREENBERG: Or it could be September. Maybe the goal should be to have this in September. Now, one possibility is to have a preliminary meeting on this risk adjustment hearing from the experts and having the kind of discussion we talked about up in Boston, that could take place earlier.

MR. HUNGATE: I can argue for doing that before the others.

MS. GREENBERG: That could be done earlier.

MR. HUNGATE: Because I think it would help inform the discussion —

MS. GREENBERG: And that isn’t going to take as much —

MR. HUNGATE: That is easier to come by.

MS. GREENBERG: Much easier to organize.

DR. CARR: We would be more focused and informed, right? We could anticipate where the pushback would be coming from.

MS. GREENBERG: Does anyone disagree with me that it would be easier to organize?

MS. HOLMES: No, I just was saying that I think we need to be very careful about who we invite in order to get the broad spectrum of people working in different settings of care and different levels of intervention, shall we say.

MS. GREENBERG: Is this something you could spend a little time on, Julia?

MS. HOLMES: I could ask around — to get names, you mean?

MS. GREENBERG: Yes. Maybe Justine, you could talk to Lisa?

DR. CARR: Actually, Lisa and I are meeting next week. So, that would be great.

MS. GREENBERG: That will be wonderful and see whom she would suggest, both people who agree with her and people who don’t. She is good that way.

DR. CARR: She will articulate and she will draw a line in the sand.

MS. HOLMES: But we want people who have experience or a conceptualization. Who are the folks that worked on this — I will leave mine with you. I am sure we have more at the office. I didn’t —

MS. GREENBERG: The lead authors here are Kathryn Martin, Deborah Rogall(?) and Sharon Arnold.

MR. HUNGATE: I don’t know any of them.

MS. GREENBERG: I don’t know them.

MS. HOLMES: So, you know, we could talk with Academy Health and get some names of folks because I think we need people who risk adjust for quality care at the hospital level, at the physician level and for, you know, the risk adjusted individual patient outcomes.

MS. HANDRICH: I think they had a thing, you know, where people come and hear speakers over a two day period.

MS. GREENBERG: Yes. Kaiser Permanente once did for health policy, cosponsored the working meeting.

[Multiple discussions.]

Robert Crane, Murray Ross and Laura Tolan(?), well, for the meeting. The following individuals also provided valuable input; Robert Barenson, Bruce Bowen — gosh, I know him from 30 years ago. Let’s see if there are other names that I know here. Jeanette Fowles(?), she has been here.

MS. HANDRICH: But isn’t it important to have in mind what our questions are before we select them?


MS. HANDRICH: There are a million experts and some of them come at this from an actuarial perspective, not a quality perspective.

MS. HOLMES: For example, you think about someone like Rosalie Cains(?) from Minnesota, who has done a lot of work in terms of quality of care.

MS. HANDRICH: Who is in herself a controversial person.

MS. GREENBERG: Well, if you really do work in this area, you are probably controversial.

MS. HANDRICH: There are probably other people that would look at her work and say —

MS. GREENBERG: Dick Summit(?). He was involved in the 21st Century —

MS. HANDRICH: He is kind of like the Medicaid risk adjustment god.

MS. GREENBERG: You would certainly want him.

[Multiple discussions.]

— is to identify the questions and then maybe like run the questions by someone like Lisa or —

[Multiple discussions.]

— are these the right questions, are we missing something. So, even like, you know, sort of like what would have to be — maybe like a few paragraphs about the workgroup, about what it is about, what it has done. This report is background, for what it is looking to do now in the future and then these are sort of put in the context and then these are the things that we would like to engage you on. I remember when the Privacy Subcommittee, instead of a hearing format, they kind of convened a one day —

[Multiple discussions.]

— kind of like a seminar. They brought in people from public and private sector around the issue of — I think it was record linkage and people made comments. But then they also talked. So, everyone was at the table.

MS. HANDRICH: Then you need a facilitator or someone to guide the discussion.

MS. GREENBERG: It might be good to have a facilitator and we could do that. Someone like Larry Bartlett(?), of course, is wonderful. He is a — what is the name of that group.


MS. GREENBERG: No, he is not at Lewin — well, Larry Lewin used to be a very good facilitator. I don’t know if he has retired or —

MS. HOLMES: No, but, you know, his wife — I don’t know about him, but his wife is a very good facilitator.

MS. GREENBERG: Marian Lewin?


MS. GREENBERG: We don’t normally use facilitators for the committee meetings, but we could. This might be a place, particularly someone who kind of —

MS. HANDRICH: If the focus is on learning together.

MS. GREENBERG: I agree and so also I think that would free you up, if you end up having to chair it, you can’t really be engaged so much in the — the facilitator idea is a nice one.

Of course, if we were going to do this up in Boston, I mean — I am sure there are a lot of good facilitators up there. Because the people I know are down here.

MR. HUNGATE: Arly Nash has done a lot of the work around the — and Randy Ellis is also there and worked with her on that. That is another risk adjustment person in Boston.

MS. GREENBERG: But you don’t want the facilitator to be — you want them to understand the issue sort of but not to be invested in it.

MR. HUNGATE: The Mass Health Data Consortium recently hosted a meeting.

MS. GREENBERG: Yes, I think I had told you about that.

MR. HUNGATE: I did attend and the R&D person from MediQual spoke also and they do risk adjustments. So, there was a good discussion there.

MS. GREENBERG: Are they producing something out of that?

MR. HUNGATE: I am not sure that there is a hard product to come out of it. But the Mass Health Data Consortium could maybe facilitate, someone there — Elliott does that sort of thing. So, we could probably find someone in Boston that would help with this discussion.

MS. HOLMES: But we are not relegated to bringing in people that are in Boston.

MS. GREENBERG: At the end of the day we might say, you know, maybe this doesn’t make sense to have it in Boston if we have got four people from Boston, but we actually have ten people from elsewhere. But it does seem like — I mean, we have got at least two members in Boston. You have got a number of key people up in Boston and —

MR. HUNGATE: There is a lot of experience around risk adjustment and CABG and some of that experience is in Boston. Some of it is other places.

DR. CARR: We are now using mandated — we are using STS and DPH is generating data and we also have ANNE(?) risk adjustment.

MS. HOLMES: I don’t know what those terms mean.

DR. CARR: I have finally got some abbreviations you guys don’t know. A miracle.

[Multiple discussions.]

MS. GREENBERG: — remember when we were in a car and —

DR. CARR: It is Society for Thoracic Surgery has a national database of cardiac surgery patients. It is elective in terms of whether a center wants to join it or not, but when Massachusetts decided to publish all cardiac surgery outcomes, they decided to use the STS database. So, all hospitals in Massachusetts now belong to that. So, we submit into STS and DPH also harvests the data in that format.

There is another group that has been very innovative in quality improvement, going back for some 20 years now. It is called the Northern New England Cardiovascular Study Group and it is spearheaded through Jerry O’Connor and folks at Dartmouth and it represents, I think, seven New England hospitals; Dartmouth, Portland, you know, some smaller hospitals and Deaconess used to be a part of that. Then after the merger, Beth Israel Deaconess continues to be a part of that. But they are notable in that they collect the data, but they publish — it is all in the spirit of performance improvement. But part of that has been them identifying risk factors and, in fact, we used those risk factors to tell patients what their risk is.

MS. GREENBERG: The Northern New England

Cardiac —

DR. CARR: — Cardiovascular Study Group. Jerry O’Connor is the — he is not an M.D., but he is like public health or something like that, but he has been a national leader for many years.

MR. HUNGATE: I think we could well devote a morning to various approaches on a generic sense.

MS. GREENBERG: Right. That is what I am thinking and then maybe —

MR. HUNGATE: And then move to CABG for the afternoon. It is the one that is farthest along and there maybe no others that ever are like it. But we could see what differences — ask about differences between approaches and see if there is something there. Justine just said how they were informing their patients using the risk factors. I would like to hear that from others as well.

DR. CARR: Jerry O’Connor might be a good person to include. I mean, he is very savvy, very active nationally, as well as in New England and has really doing this for I think it is 20 years.

MR. HUNGATE: It is a long time.

DR. CARR: He is in New England, not Boston, but he is close enough.

MR. HUNGATE: Is May a reasonable time to think about for that? Or is that still too soon?

MS. GREENBERG: I don’t know.

DR. EDINGER: You have Memorial Day weekend. You need facilities and places to hold it in hotels and —

DR. CARR: Graduations up here are around that time.

MS. GREENBERG: May is just such a rough month. I actually have a lot of travel myself in May, but —

MR. HUNGATE: Does June feel more likely? Does June feel better?

MS. GREENBERG: Maybe late June.

MS. HOLMES: The beginning of June is the Health Services Research meeting, which a lot of the folks will be attending.

MS. GREENBERG: And graduations then, too. The National Committee is meeting mid June.

MR. HUNGATE: I thought that one was uncertain.

MS. GREENBERG: That one is definite. It was the fall ones that — I think they have all been rescheduled, though. We have our dates.

MS. JACKSON: The dates are in the agenda.

MS. GREENBERG: They are right in the book at the end of the agenda.

Then NHII meeting now I think is not until mid to late July.

MR. HUNGATE: Have they picked a date?

MS. GREENBERG: July 20th to 22nd is what I had heard. So, late June might be a good target for this.

MR. HUNGATE: One day would probably be enough, right? Shall we try to use the window of the 23rd to the 25th of June as a possible work around time?

MS. JACKSON: The following week starts getting close to the July 4th —

MS. GREENBERG: July 4th is what day?

MS. JACKSON: The 4th is a Sunday.

MS. GREENBERG: I had had the NHII meeting the end of June, but it is not anymore.

MR. HUNGATE: I have booked in advance and paid for a salmon fishing trip in British Columbia.


MR. HUNGATE: July 19th through 23rd.

[Multiple discussions.]

MS. GREENBERG: I think we could talk about the week of June 21st maybe.

MR. HUNGATE: I used 23rd through 25th, because I have got problems on the 22nd, personally. 21, 23, 24, 25 work fine for me. I don’t know about others.

DR. CARR: That is fine for me.

MS. HANDRICH: I don’t think that any Friday in the summer is a good idea.

MS. GREENBERG: Unless you just wanted to go right from the hearing to the Cape. So, forget the 25th.

MR. HUNGATE: 23rd or 24th.

MS. GREENBERG: 23rd or 24th. Or, you know, it might be we would want it to be a day and a half.

MS. HOLMES: I was going to say why don’t we — I just think one day to hear all these things, multiple people is difficult.

MS. GREENBERG: So, maybe the 23rd, 24th. Of course, that is my wedding anniversary, the 23rd.

MS. HANDRICH: Mine is, too.

[Multiple discussions.]

Nothing is going to be perfect for everybody.

MS. GREENBERG: Okay. That is possible.

MR. HUNGATE: So, 23rd and 24th, half day nominally on the 24th is the thinking.

Okay. Is that settled?

MS. JACKSON: Are you committed to that locale or does it depend on who you get as speakers?

MR. HUNGATE: Well, if we can’t get anybody that we want to listen to on those days, we have got a problem, but we have to start someplace. So, let’s see what happens.

MS. JACKSON: In terms of being in Boston —

MR. HUNGATE: Let’s plan on Boston. We can find an appropriate facility I am sure.

MS. GREENBERG: Since my husband and I met in Cambridge, maybe I will get him to come too.

MS. HANDRICH: What is that nice hotel in Cambridge. The Charles —

MR. HUNGATE: Charles Hotel. That is a nice hotel.

MS. HOLMES: We can each try and think of four or five questions that we think would —

MR. HUNGATE: Good idea.

MS. HOLMES: Start us off or focus the discussions. I mean, I don’t think we need to sit here and try and come up with them today, but —

MS. GREENBERG: We are running down —

MS. HOLMES: Individually we could try and come up with four or five questions about risk adjustment that, you know, would be useful to focus the discussions.

MS. HANDRICH: We could talk about that tomorrow, too. Won’t everybody be there tomorrow?

MS. HOLMES: I won’t be here.

MS. GREENBERG: Can you participate by phone?

MS. HOLMES: Tomorrow afternoon? I think so.

If you are not starting until 4:30, I am not sure I will be able to join you. I am actually going out of town on Friday.

MS. GREENBERG: That is kind of late. We can have a conference call. We can schedule a conference call.

MR. HUNGATE: As soon as you get a staff person, let’s schedule a conference call.

MS. GREENBERG: I am just wondering if this we need to get started on a little sooner.

MS. HOLMES: I am willing to make some calls and look into who might be a good person to invite and also, you know, look into coming up with some, you know, questions to focus the discussion.

MS. GREENBERG: That would be great and then, Justine, if you can talk to —

DR. CARR: Lisa, yes, I will.

MS. HOLMES: You might want to continue to ask about long term care, you know, for the folks who do risk adjustment, who have been working in that area, both conceptually and empirically. I mean, I understand Rosalie Cain is kind of a —

MS. HANDRICH: I didn’t mean to dismiss her, but

I —

MS. HOLMES: I understand exactly what you are saying. I have worked with her before and she is sometimes — well, we will leave it at that. Very strong in her opinions.

MR. HUNGATE: How much are we going to bump into the issue of functional outcomes, when we start talking about risk adjustment?

MS. HOLMES: I think we are.

MS. GREENBERG: That is all right. I mean, this is exploratory sort of and I don’t see any recommendations coming out of this day and a half, other than maybe for future steps. But the thing is if we can kind of agree on these dates and this topic and this place, then we can actually get our contractor working on finding a place, a hotel —

MS. JACKSON: We can get started on that and start exploring that.

MS. GREENBERG: I don’t want to wait. Then I think Julia’s suggestion of people, you know, just e-mailing — maybe people could e-mail their questions to you. You could put them together.

MS. HOLMES: Sure. And I will send them out to everyone and we can say what questions do you think are the critical ones.

MS. GREENBERG: Then you can add your own, obviously. We can get this started, I think.

MR. HUNGATE: Okay. Then based on the questions, we can see whether we need conference calls to do some more work. Probably not worth it to try to set a time for that yet.

MS. GREENBERG: Do you want people to send you their questions? I would say send her both questions and then names, too, if you have people — by Monday or something. The Ides of March, the 15th?

MS. HANDRICH: I do know in the — I wasn’t kidding before — in the world of Medicaid, Rick Kronik(?) is considered a preeminent —

MS. HOLMES: We don’t want somebody, who is too technical.

MS. HANDRICH: He is very technical.

MS. HOLMES: I don’t think that we want to have a quantitative —

MS. GREENBERG: No, no. But is he conceptual, too?


MS. GREENBERG: That is why I think we have to think about the questions, too. If he is the same person — how could there be two Rick Kroniks? Is he out in California? He is a policy person, too. He did a paper for the — when we had the workshop at the National Academy of Sciences around the 21st Century vision for health statistics, he did a paper on what was it we needed to know and didn’t know in order — when we were trying to do the health insurance reform.

MS. HOLMES: To me, that is a terrific question. What don’t we know about risk adjustment and what do we need to know?

MS. GREENBERG: He is not just a numbers cruncher. But anyway, I would say send names of people and questions that you want addressed on this topic to Julia by March 15th or something.

MR. HUNGATE: The Ides of March.

MS. GREENBERG: We will all get into our togas.

MS. HOLMES: Is the Ides of March the 15th?

MS. GREENBERG: The Ides of March are upon us. My Latin teacher in high school, she would have a party — we would have a party at their house on the Ides of March and we would come in togas and —

MS. HANDRICH: What is that movie where the teacher does the Roman thing? It was so good.

MR. HUNGATE: Latin teachers are a unique breed.

MS. HANDRICH: Is your name on here, Julia?

MS. GREENBERG: Julia, what is your e-mail address?

MS. HOLMES: Okay. It is JSHolmes@CDC.Gov.

MS. HANDRICH: Okay. Thank you.

MS. GREENBERG: Good. We have got a plan.

MR. HUNGATE: The second hearing would be likely to be September.

MS. GREENBERG: I think so and then we really need a lead staff person.

MR. HUNGATE: Lead staff and I think also need joint work with Standards and Security to be effective.

MS. GREENBERG: Have they set up something in September?

MR. HUNGATE: It should show in here, shouldn’t it?

MS. JACKSON: Yes. Nothing is confirmed.

MS. GREENBERG: I think they are just working on that right now because I think Simon had only scheduled meetings through the first half of the year because he didn’t know if he was going to be continuing.

MR. HUNGATE: It only shows March and May. So, I will mention to Simon that we are talking about that. We will see where that goes from there.

MS. JACKSON: As well as your other two workgroup members and get the buy-in with — I assume Dr. Steinwachs is coming to the meeting, you know, checking in with them.

MR. HUNGATE: So, we will have some time to cover that tomorrow, I would assume.

MS. HANDRICH: Has Kathy retired from being —

MR. HUNGATE: She will be on the phone tomorrow.

MS. GREENBERG: She was never planning to be on the phone today.

MR. HUNGATE: She has done a great job on getting it to where it is.

MS. HOLMES: And she certainly hung on long after her tenure had presumably ended.

MS. GREENBERG: We had a professional arrangement with her, but it went well beyond that, but I think she professionally was — you know, having spent so much time on the committee wanted to see it come to closure.

MR. HUNGATE: I think that is a process issue that we should think about in terms of our workgroup. You know, where do we want to have an output from what we do as opposed to just do things. Should we after we do something on the risk adjustment have some statement as a result of that? You know, I don’t know. What are we doing for our own benefit and what is the broader benefit?

MS. GREENBERG: I guess it is sort of after this educational session or whatever, discussion session, then we would to decide, I guess, what the next steps were and if you wanted to get something that you actually wanted to say at that point about research that was needed or work that needed to be done or if you wanted to hear from other people. So, it is kind of hard to say. We will have transcripts and all that so that even if we bring someone into it a little later —

MR. HUNGATE: The way the workgroup operated prior to now was largely before the full committee.

MS. GREENBERG: That is true.

MR. HUNGATE: Where what was done at the workgroup was really to plan the activities that would occur at the full committee. There is some benefit to that. If we have a clear work content —

MS. GREENBERG: But, of course, it took a long time and you would get like one panel per meeting or something; whereas, I think these two hearings, at least, require dedicated time.

MR. HUNGATE: I think so, too. I am just trying to explore because I am not familiar with all the options, I am trying to make sure I understand what is the best way to move agendas.

MS. GREENBERG: On the other hand, you are right. You do want to — you don’t want all the learning and thought to go on in the workgroup because then when you bring it to the full committee, they are not receptive.

MR. HUNGATE: We had a hard time with that this time.

[Multiple discussions.]

MS. GREENBERG: — that doesn’t exist anymore.

MR. HUNGATE: I am a little bit of the fire, fire, fire mentality and so that if we do something we want to say we did it in a way that it doesn’t just stay within the room because I don’t think we have done the right thing if that is what we are doing. That is why I at least a little bit want to talk about the process of it.

MS. GREENBERG: We probably will want something written up after —

MR. HUNGATE: I think so.

MS. HANDRICH: Let’s go back to the format that we were talking about. One option we talked about was presenters. Another option we talked about was more of a seminar style discussion. If we are going to do the seminar style discussion, then we have to get back to if we are going to have a facilitator. If we are going to have a seminar type discussion, what would a product be? If we were going to have presenters, it could be a summary of what was presented.

MR. HUNGATE: The criticism of hearings that I have personally felt so far is that there is no discussion after the hearings of what the content was.

MS. GREENBERG: And we really are always supposed to include that either during the meeting or afterwards on a conference call, but often there is short shrift to that.

MR. HUNGATE: It doesn’t happen in my experience.

MS. GREENBERG: I agree with you.

MS. HANDRICH: And you kind of run out of gas, too.

MR. HUNGATE: But I think if we are going to be constructive, we need to allow for that and if it means that we schedule such that we have got a half day following the hearing to do something. I don’t know what the mechanics will be. Once you get away from it, it is hard to — you lose it, you know, and it is awkward.

I guess if we are talking about a day and a half, maybe I want to save the last two hours is our discussion, where we let people stay if they want, but it is a discussion of the content.

MS. GREENBERG: Well, it could be a day and two-thirds. You could have like a working lunch and go to 2 o’clock or something. If you do like the idea of the facilitator, then that is something we need to be looking into as well.

MR. HUNGATE: In addition to questions, let’s say what do we want — what does each of you want to have as a result of the meeting be.

MS. HANDRICH: I personally would love to hear a group of presentations with an opportunity to react to them after they are all done. That is my personal —

MR. HUNGATE: What kind of a conclusion would you like to come to at the end of it?

MS. HANDRICH: A summary of answers to the questions we posed.

MS. GREENBERG: Do you want them to engage each other or —

MS. HANDRICH: That would be fine, but first there would be — in other words there would be an opportunity for presentations with information followed by exchange, as opposed to something that is more open. Is that what you had in mind?

MS. GREENBERG: I think so, yes. Not just a free-for-all.

MS. HANDRICH: Or less structured because this is a very wide open area. If the summary then were a summary of the key points of the presentations and kind of answering the questions and then reactions to that, I think that would be a super outcome.

MS. GREENBERG: For that type of format, maybe we wouldn’t need a facilitator.

MS. HANDRICH: Maybe not, right.

MS. HOLMES: I think if that is the way — I mean, to me, that seems —

MS. GREENBERG: It is probably good for starters and then, you know, maybe something more interactive —

MS. HANDRICH: You are kind of furthest along in thinking about — you have an idea in mind on this.

MR. HUNGATE: I do, yes.

MS. HANDRICH: I want to be sure we get there.

MR. HUNGATE: I have learned that my ideas don’t always mesh with what works.

MS. GREENBERG: Let’s see what the questions look like. That will drive it, too.

MS. HANDRICH: Then the staff work, I think, would be — that someone would need to know they have the task of summarizing the presentations, the answer to the questions and the dialogue.

MS. GREENBERG: We could possibly engage like Susan Canaan to do that. I mean, there will be a transcript, not to mention the fact that her son is a resident, a medical resident, I think, in Boston.

MR. HUNGATE: I would like very much to have a hard summary. Maybe it is not a letter of recommendation but a hard summary of what the content was and what we concluded, so that there is a record —

MS. GREENBERG: And I agree that let’s make sure that whatever the agenda is we leave about two hours at the end for workgroup discussion.

MS. JACKSON: If not recommendations, then the summary would serve the purpose for what now, as a bridge or backup for the next step or —

MR. HUNGATE: Certainly a report to the rest of NCVHS. This is a subcommittee that is doing things — a workgroup, not a subcommittee — and we need to have communication of that to the full committee. The report is a useful way to do that. It is only a summary of the hearing.

Why go beyond that?

MS. GREENBERG: After this, we feel like we really need to hear from others, these types of people.

MR. HUNGATE: I can visualize saying that there needs to be a follow on on consolidated health informatics that relates to common quality measures to be used by VA, DOD and — I can see that evolving someplace. There needs to be a structure for that.

MS. GREENBERG: Measures —

MR. HUNGATE: Outcome measures.

MS. GREENBERG: But you would be recommending a process. That is a possibility.

MR. HUNGATE: If federal leadership is a good thing and I think it is, then this might be a place where we can focus the content of that part of the federal leadership maybe. You look skeptical.

MS. HANDRICH: Are we talking about just broad level, a question something like what are the data and health system information needs that we have in order to assure that quality measures are appropriately risk adjusted? Is that — that is probably the most professionally stated version of it, but that would be where we were trying to go and then we take that back to — and then think about what next steps there might be.

MR. HUNGATE: The only addition I would make to it is that my sense is that we need to articulate that the quality measures have to be ones that work the same way for all the audiences if they are going to be self-reinforcing.

MS. HANDRICH: That is a strategy as opposed —

MR. HUNGATE: Yes, it is.

MS. GREENBERG: I think you can try to validate that strategy —

[Multiple discussions.]

— assumptions that you have, put them into question form.

MR. HUNGATE: I will do that.

Justine, any final comments before we wrap up?

DR. CARR: I know I am going to be thinking about this tonight, I am sure. We have got a chance to chat tomorrow.

MS. HANDRICH: I am looking forward to meeting you and I would say that if you ever give up your medical career, you have a future in radio. You have such a lovely speaking voice.


MR. HUNGATE: Okay. Thank you all.

[Whereupon, at 5:30 p.m., the workgroup meeting was recessed.]