[This Transcript is Unedited]
National Committee on Vital and Health Statistics
Workgroup on Quality
November 5, 2004
Hubert H. Humphrey Building
200 Independence Avenue, S.W.
Washington , D.C. 20201
CASET Associates, Ltd.
10201 Lee Highway, suite 160
Fairfax , Virginia 22030
P R O C E E D I N G S [8:15 a.m.]
MR. HUNGATE: I think we better get going, Anna will be late, Don Steinwachs will be late, Vickie is I think joining us in a little while, Julia is not expected, I haven’t heard from Gail, so I think we’re what we are in and are presented and accounted for. So I’m Bob Hungate, chair of the Quality Workgroup, we’ll go around and sign in. John?
DR. LUMPKIN: Are we going on the internet? John Lumpkin.
MR. HUNGATE: Do we have any conference call —
PARTICIPANT: No, I just had the phone set up in case.
MR. HUNGATE: So we don’t need to do it then, I assumed with the apparatus here that we were. Okay, let’s forget that. Everybody knows everybody else?
DR. STEINDEL: We should introduce for the record.
DR. LUMPKIN: John Lumpkin.
MR. LOCALIO: Russell Localio, member of the committee.
DR. STEINDEL: Steve Steindel, CDC, liaison.
MS. GREENBERG: Marjorie Greenberg, NCHS, CDC, and executive secretary to the committee.
DR. CARR: Justine Carr, Beth Israel Deaconess Medical Center, member of the committee.
MS. WILLIAMSON: Michelle Williamson, NCHS, CDC.
MR. RODY: Dan Rody, American Health Information Management Association.
MR. HUNGATE: Okay, the first item of business is to work on the letter and get it to a form that will facilitate its message. You have a three standing page which is passed around which is a copy of Marjorie’s notes from yesterday and we’ll work from that one in the letter itself.
MS. GREENBERG: There was so much discussion on the second paragraph that I didn’t really do much except put in parentheses troubled areas so I didn’t try to capture all that.
MR. HUNGATE: And so in the first sentence we need to say what the candidate recommendations are for and I think it’s —
MS. GREENBERG: I have the whole report here so let’s see.
DR. CARR: I think it came down to a question of in what way do we want to highlight medical errors and complications.
MS. GREENBERG: No, no, I think we’re just talking about the very first sentence.
MR. HUNGATE: For its reducing gaps in data I believe because that’s what our recommendations were titled as being for. In other words the candidate recommendations were to address missing information in the system. So we could say candidate recommendations for improving quality measurement —
DR. LUMPKIN: Probably the best way to make this clear is that in May 2004 the National Committee on Vital and Health Statistics issues a report titled Measuring Health Care Quality Obstacles and Opportunities. The committee identified 23 opportunities, 23 changes in the data collection system that would enhance quality measurement reporting and improvement but because of lack of clarity something these were identified as candidate recommendations, or the need for further study these were identified as candidate recommendations.
MS. GREENBERG: I certainly didn’t get all that. You want to completely rewrite this here.
DR. LUMPKIN: Because making it a run on sentence is not going to help.
MS. GREENBERG: And why were they made candidate recommendations, well, actually I don’t think this report was ever transmitted to the Secretary was it? Wasn’t it, because —
DR. LUMPKIN: But it was posted, it’s on our website.
MS. GREENBERG: Oh, it’s definitely posted on our website, yes.
MR. HUNGATE: 23 opportunities for improvement labeled candidate recommendations.
MS. GREENBERG: Yeah, I’d rather do something like that then actually say because of lack of clarity, I mean it undercuts it right from the get go. So you were saying in May 2004 the national committee —
DR. LUMPKIN: In May 2004 the National Committee on Vital and Health Statistics issued a report —
MR. HUNGATE: — identified 23 opportunities?
DR. LUMPKIN: In the report Measuring Health Care Quality Obstacles it identified 23 opportunities that became the agenda for the future work of the Quality, it became the agenda for the committee.
MS. GREENBERG: I like that.
DR. CARR: For the committee or the Quality Subcommittee?
DR. LUMPKIN: Well, for the committee.
MS. GREENBERG: Future work of the committee on —
MR. HUNGATE: Of the committee right?
MS. GREENBERG: Well, but obviously only on this subject, future work of the committee —
DR. LUMPKIN: Related to quality.
MS. GREENBERG: Future work of the committee related to quality around identifying information needs for quality, I don’t know, it says that this committee or this workgroup leads the committee’s work on health data issues affecting quality measurement and improvement, we could use that language.
DR. LUMPKIN: Right, and then we can go into since that set the agenda, we held the hearings on the first eight —
MS. GREENBERG: No, I like that, do you like that —
MR. HUNGATE: What’s the specific wording? Do we have a specific —
DR. CARR: If you want me to type it I’ll type it.
MS. GREENBERG: I’m willing to type it if somebody gives, so do we still want to say in May 2004 the National Committee on Vital and Health Statistics approved, they did approve it —
MR. HUNGATE: Identified.
MS. GREENBERG: You want to say identified 23 opportunities for improving —
DR. LUMPKIN: Well actually in May 2004 the NCVHS, National Committee on Vital and Health Statistics in its report titled —
MS. GREENBERG: You wanted to make it a compound sentence again.
DR. LUMPKIN: Right, in its report titled —
MS. GREENBERG: In its report titled Measuring Health Care Quality Obstacles and Opportunities identified —
DR. LUMPKIN: — 23 opportunities for —
MS. GREENBERG: For improving —
DR. LUMPKIN: Obstacles and opportunities, identified 23 opportunities for improving health care quality.
MS. GREENBERG: Well, not that, we’ve got to tie it in with information, for improving information to measure health care quality and improvement —
DR. LUMPKIN: 23 information related opportunities, information policy related opportunities?
MS. GREENBERG: That’s too wordy.
MR. HUNGATE: We’re getting a lot more words.
MS. GREENBERG: Let’s go back to the two sentences.
DR. LUMPKIN: Okay, two sentences.
MS. GREENBERG: In May 2004 the National Committee on Vital and Health Statistics —
MR. HUNGATE: Issued a report —
MS. GREENBERG: Issued a report titled Measuring Health Care Quality Obstacles and Opportunities, period. This report identified 23 opportunities for improving information on quality, to address quality measurement, no, no, we’ve got quality measurement and improvement, or 23 opportunities —
MR. HUNGATE: 23 opportunities may be our problem.
MS. GREENBERG: Health data issues —
MR. HUNGATE: Identified 23 actions to be considered for improving —
DR. LUMPKIN: 23 areas where actions can be taken to improve —
MR. HUNGATE: Something like that.
MS. GREENBERG: Because we already said opportunities here.
MR. HUNGATE: Opportunities gets too —
MS. GREENBERG: Well can’t we just say this report identified 23 health data issues affecting quality measurement and improvement?
DR. STEINDEL: The report identified four areas of health care and in each one of those areas certain recommendations were made concerning quality measurements to determine what’s going on in each one of those areas. And I think one thing we’re doing is we’re lumping everything into 23 items that just appear to be 23 items.
DR. LUMPKIN: Okay, simplicity, how about this? In May 2004 report titled Measuring Health Care Quality Obstacles and opportunities, well, in May 2004 the NCVHS issues the following report, period. The Quality Workgroup together with the Standards and Security Subcommittee on NCVHS has conducted hearings on issues raised by this report. As a result of those hearings —
MS. GREENBERG: So you don’t even want to say they identified the 23?
DR. LUMPKIN: No, because it’s confusing and it doesn’t add anything. And the fact that we held hearings on eight doesn’t help, all we’re going to say is we held hearings and this issue came out as one that needed, based upon those hearings we’ve identified on issue that we would like to recommend —
MS. GREENBERG: I would say in the first sentence then in May 2004 the National Committee on Vital and Health Statistics issued a report measuring health care quality obstacles and opportunities that provided, well, then you don’t want to say then about the agenda?
DR. LUMPKIN: No, I don’t think we need to say —
MS. GREENBERG: Then we’ll forget about that, about the agenda. Okay, fine.
DR. CARR: So the Quality Subcommittee and Subcommittee on Standards and Security held hearings resulting in the identification or one recommendation or —
DR. LUMPKIN: The Quality Workgroup together with the Standards and Security Subcommittee of NCVHS has conducted hearings —
MR. HUNGATE: And then say the candidate recommendation facilitate, drop the number of three —
MS. GREENBERG: Apparently we did send this report forward.
DR. LUMPKIN: As a result the Quality Workgroup together with the Subcommittee on NCVHS has conducted hearings on issues raised by this report.
MS. GREENBERG: I think it’s problematic not to indicate that this report had a number of candidate recommendations which were pursued in hearings because that also ties in with the last paragraph which says several, I mean that they received support of an informative testimony on several other ones and we’re going to summarize the findings from those, etc., I mean I just think you have to, you can’t just ignore them —
DR. CARR: Conducted hearings on the subset of the first eight candidate recommendations, or just on the first eight.
MS. GREENBERG: I think you need to say that they identified these 23 opportunities and have held hearings on a subset of those, so number of opportunities, maybe you don’t have to use the number 23.
DR. LUMPKIN: Well, we could —
MR. HUNGATE: The fewer changes we make the less controversy we raise —
DR. LUMPKIN: And I’m thinking of shrinking it down because the more we try to describe this the more likely somebody is not going to be comfortable with describing it.
DR. CARR: And I think if there’s so much introduction it’s hard to get to the punch line.
MS. GREENBERG: How about just saying in May 2004 the National Committee on Vital and Health Statistics issued a report, Measuring Health Care Quality Obstacles and Opportunities, which identified 23 candidate recommendations that became the agenda for the future work of the committee. Too many which’s and that’s maybe, I don’t know. I like that idea that, well, I think you’ve got to mention that this report identified 23 candidate, I don’t think we have to say opportunities described as candidate recommendations, or we can make it two sentences then. In May da, da, da the National Committee on Vital and Health Statistics issued this report which identified 23 candidate recommendations. These recommendations became the agenda of the committee, for the future work of the committee to address health data issues affecting quality measurement and improvement.
MR. HUNGATE: That doesn’t, well, it may —
DR. CARR: How about putting that in the last paragraph, how about having the first paragraph just punch out, we had the hearings with these two groups, this thing went to the top and we want to bring it to your attention. And then in the last paragraph we say the remaining candidate recommendations are the work of the committee and this is what we’ll be doing.
MS. GREENBERG: Oh, about the agenda, okay, we could put that —
DR. STEINDEL: I would prefer to do it that way then —
MR. HUNGATE: That sounds goods.
DR. CARR: So what I have, in May 2004 the NCVHS issued a report entitled Measuring Health Care Obstacles and Opportunities. The Quality Workgroup together with the Subcommittee on Standards and Security conducted hearings on a subset of the first eight candidate recommendations —
DR. LUMPKIN: How about conducted hearings based on this report?
MR. HUNGATE: Hearings based on the report is I think the better term because in fact people did comment on the overall structure of the report and the value that they felt it had.
DR. CARR: Okay, and the third sentence, recommendation number three was universally saw —
MS. GREENBERG: I don’t think we have to give a number, I think we can say based on these hearings the NCVHS recommends, I think we could just go right to it, that the next version of the da, da, da, da, da, da, da, da, and then say this candidate or this —
MR. HUNGATE: Could we just say one subject as opposed to candidate recommendation three?
DR. STEINDEL: Yes.
DR. LUMPKIN: One subject, facilitate —
MS. GREENBERG: I’m just thinking we don’t have to repeat this twice —
MR. HUNGATE: But I think it’s useful to have the universally sought —
MS. GREENBERG: No, no, we would say that after we make the recommendation, we could say —
DR. LUMPKIN: One subject was universally sought by purchasers of care, endorsed by providers of care, and is poised for implementation by the Designated Standards Maintenance Organizations. Therefore the NCVHS recommends that the next version —
MS. GREENBERG: Well, I have a different suggestion, that we say based on these hearings the NCVHS recommends that the next version and give this whole thing and then say this data improvement or however you want to call it was universally sought by the purchasers of care, endorsed by the providers of care, and is poised for implementation by the Designated Standards Maintenance Organizations, just put that after, that way you don’t have to repeat what it is twice in the first paragraph.
DR. LUMPKIN: But actually the way I was suggestion which would change it, we conducted hearings, then one issue, it’s just sort of pulling the issue, it’s saying one issue came up, sort of floated to the top, therefore we recommend this issue —
MS. GREENBERG: Not say what the issue is.
DR. LUMPKIN: Not say what the issue is.
MS. GREENBERG: I don’t think we need to mention it twice.
DR. LUMPKIN: Oh, I agree.
DR. STEINDEL: I like ending the paragraph with the recommendation.
DR. LUMPKIN: One issue, so after conducted hearings —
MS. GREENBERG: Is it issue or one opportunity for data improvement? Do you just want to call it the issue?
DR. LUMPKIN: One opportunity —
MR. HUNGATE: One opportunity for data improvement sounds good.
DR. LUMPKIN: One opportunity for data improvement, so that replaces candidate measure, facilitate, strike all that stuff, and then says one opportunity was universally sought, one opportunity for data improvement was universally sought and then the rest of the language of that sentence.
MS. GREENBERG: You sure you don’t want me to be typing this up? Okay.
MR. HUNGATE: Within the recommendation itself the ANSI is struck based on Steve’s recommendation, right?
MS. GREENBERG: I think what it is, no, that was Jeff, but I think what it is is ANSI ASC-X12N, Simon and I were talking. Then when it’s referred to later it should be referred to ASC-X12N, not ANSI X12N, but the full name of it is, it’s an ANSI accredited standards committee, it’s not just some accredited standards committee.
DR. STEINDEL: No, actually it’s ASC, American Standards Committee, ANSI is just a body that recognizes —
MS. GREENBERG: ASC standards for accredited standards committee, and it’s accredited by ANSI —
PARTICIPANT: You don’t say ANSI HL7 —
MS. GREENBERG: Alright, Simon and I both think the full name is the ANSI accredited standards committee X12N but if you just want to call it, I mean we’d have to go back and, I’m almost positive that when we adopted all these transaction standards and everything we adopted them as ANSI accredited standards —
DR. STEINDEL: I have no problem with saying ANSI ASC-X12N —
MS. GREENBERG: We should be consistent —
DR. LUMPKIN: But we’re kind of at the point where —
MS. GREENBERG: I do know that where it says ANSI X12N elsewhere in the letter it should say ASC —
DR. STEINDEL: That’s correct, and I have no problem with saying ANSI ASC-X12N at this point.
DR. CARR: One opportunity for data improvement was universally sought by the purchasers of care, endorsed by the providers of care, and was poised for implementation by the Designated Standards Maintenance Organizations.
MS. GREENBERG: And then therefore the National —
DR. LUMPKIN: Or you can just say the current language —
DR. CARR: The NCVHS recommends?
MR. HUNGATE: So ANSI stays in or goes out?
MS. GREENBERG: I think it can stay there and then fix it in the second to last paragraph.
MR. HUNGATE: There is also a correction on the on secondary to in secondary —
MS. GREENBERG: On admission in secondary diagnosis fields for all inpatient claim transactions.
MR. HUNGATE: Are we done there?
MS. GREENBERG: And this was the easy paragraph, the first one.
MR. LOCALIO: Bob, on the second paragraph, I did a little bit of redrafting because I shared Justine’s concern. Can I read you a couple of sentences?
MR. HUNGATE: You bet.
MR. LOCALIO: The first line is the same so I’ll read that. The secondary diagnosis indicator which flags a condition present on admission can help and here’s where it changes, can help to distinguish between preexisting conditions and those that developed or were first recognized during the hospitalization. Next sentence, the ability to make this distinction can enable both case mix/severity of illness adjustment at admission and quality improvement opportunities in care processes. So it doesn’t say explicitly medical errors or ineffective which I think Justine says may be —
MS. GREENBERG: What you read sounded pretty good to me, do you want to read it again?
MR. LOCALIO: Sure. The secondary diagnosis indicator which flags a condition present on admission can help to distinguish between preexisting conditions and those that developed or were first recognized during the hospitalization. The ability to make this distinction can enable both case mix/severity of illness adjustment at admission and quality improvement opportunities in care processes.
DR. CARR: Just one correction, it wouldn’t change your case mix, it would only change your severity adjustment. The only thing that changes your case mix is your DRG and your DRG is dictated by your principle diagnosis which isn’t going to change here.
MS. GREENBERG: And co-morbidities or complications, so it doesn’t matter which they are —
MR. LOCALIO: It depends on which case mix you’re using because DRG is not the only case mix that people use.
DR. CARR: You’re talking about AP DRGs?
MR. LOCALIO: And people do make distinction between stuff that’s clearly preexisting stuff, it may not be, because they feel the DRG over corrects.
MS. GREENBERG: What I’m not sure about if a person comes in and you don’t realize they have diabetes but then you pick it up —
MR. LOCALIO: That’s a quality issue in terms of, that’s why I think it’s okay —
MS. GREENBERG: Whether you then say that that was present on admission because you just assumed —
MR. LOCALIO: It wasn’t recognized on admission then it’s a problem with either the work-up, which could be an issue, or it’s a problem that it wasn’t recognized by somebody that led to the hospitalization. If somebody has undiagnosed diabetes, they show up in the hospital because of a problem, you identify on day two that the person has diabetes, that’s the first time it’s discovered, it may not show as a preexisting condition, I don’t know, diabetes may not be the best example.
DR. LUMPKIN: If somebody shows up in a diabetic acidosis they’ve had no symptoms, they see their doctor once every three or four years, and they haven’t gone in for a check-up and they show up and experience —
MS. GREENBERG: But they had that when they came in.
MR. LOCALIO: But it’s an indicator of a quality problem because it shows up not as a preexisting because it shows up as something that was recognized during the hospitalization.
PARTICIPANT: It may be a quality problem for the overall system but in that entity it shouldn’t show as a negative.
MR. LOCALIO: I understand but it only shows as a negative if you do it wrong and I don’t think we should be dictating here in this recommendation how people ought to do it right or wrong, I think the only thing we should be doing is saying look, we want to put in this flag, this single binary indicator, this flag that says preexisting or not —
MS. GREENBERG: It says present on admission, not present on admission, or not known.
MR. LOCALIO: It’s for other people to make the distinction as to what they do with it, that’s why I think Justine at least from what I heard you could maybe, we may be making assumptions that we cannot make that this indicates a medical error, give people the data, say A or B, it’s usual for recognizing, it enabled both case mix/severity of illness adjustment at admission and quality, that’s it.
MS. GREENBERG: The main purpose is to differentiate between co-morbidities and complications but —
MR. LOCALIO: And you can’t do it today, if anybody has tried you can’t do it today and this has been batted around for a long time.
MS. GREENBERG: But this kind of —
MR. LOCALIO: The way to do it, how it’s done is not going to be dictated by the fact that we have the three level indicator, yes, no, or —
MS. GREENBERG: Well how the data are used won’t be dictated by that but there do need to be, everyone needs to use it the same way.
MR. LOCALIO: They may not do that.
MS. GREENBERG: Well, there need to be rules at least, they don’t follow —
MR. LOCALIO: As long as people have the information they can begin to devise more effective methods to do this, that’s at leas the way I understood, is that Justine?
DR. CARR: Definitely.
MR. LOCALIO: I mean the whole case mix issue is not something we can conquer in one page but at least we can say if you get this data element you may be able to do better.
MS. GREENBERG: You may be able to distinguish things that were there on admission but developed —
MR. LOCALIO: You don’t want to talk about putting in dates or anything. There are procedures —
MR. HUNGATE: No, what we can do is fairly limited here.
MR. LOCALIO: There are dates in UB whatever it is, 92 has procedure dates —
DR. CARR: For procedures because for exactly your point —
MR. LOCALIO: My handwriting is terrible, I’m sorry.
MS. GREENBERG: Can help distinguish between preexisting conditions and those that may have developed, that developed or were identified, you said something like that didn’t you?
MR. HUNGATE: May have developed or were first recognized.
DR. CARR: Developed, I don’t know what these two words are —
MS. GREENBERG: Or were first recognized in the hospitalization, and the ability to make this distinction —
MR. LOCALIO: The ability to make this distinction can enable, then it’s the same as before.
MS. GREENBERG: But you didn’t want case mix —
MR. LOCALIO: I think case mix, as long as we do not define case mix too narrowly, did you do that? Define case mix?
DR. LUMPKIN: We can put a note they didn’t —
MS. GREENBERG: So the rest of the paragraph can stand.
DR. CARR: The ability to make this distinction can enable —
MR. LOCALIO: Just as it is on the current version.
DR. CARR: It says the ability to distinguish between present on admission, oh, can enable —
MS. GREENBERG: Just starting with can enable then it stays the same.
MR. LOCALIO: Are you happy with that Bob? Otherwise I think you may have, AMA may be, want to put your head on a pike or something.
MR. HUNGATE: No, I think that’s good. Okay, now is that okay for that paragraph?
In the following paragraph the only change I know of is to change ANSI to ASC and it was suggested, Mark Rothstein suggested that assure should change to ensure —
MS. GREENBERG: Where’s this?
MR. HUNGATE: Next to the last line, last sentence, education and evaluation will be needed to ensure as opposed to assure. Is that acceptable? The last sentence, education and evaluation will be needed to assure or ensure.
MR. LOCALIO: Can I make one more suggestion? Did anybody say anything about the preclude on the fourth line down?
MS. GREENBERG: Can reduce the benefit I would say.
MR. LOCALIO: Reduce or erode because it may not completely block it but it may —
MR. HUNGATE: Can reduce the benefit? So replace preclude with reduce? Any votes on assure versus ensure? Or does it make a difference? Let’s leave it alone. And on the back page information needed for quality assessment, quality measurement in the last —
DR. LUMPKIN: Then I think we would change it to opportunities.
MS. GREENBERG: Which word?
DR. LUMPKIN: Well, we don’t mention candidate recommendations anywhere else in this letter now —
MS. GREENBERG: So we just change this to —
DR. LUMPKIN: To opportunities for whatever we put in that first one, opportunities to improve quality data —
MR. HUNGATE: So opportunities to improve quality data —
MS. GREENBERG: Or just other opportunities identified in the report, information opportunities, data opportunities identified in the report —
DR. LUMPKIN: There’s a phrase we used in the first part when we —
MS. GREENBERG: Opportunities for, I can’t remember what we said, something about —
MR. HUNGATE: For data —
DR. CARR: One opportunity for data improvement was universally sought —
MS. GREENBERG: Opportunities for data improvement.
MR. HUNGATE: Okay, are we done?
DR. CARR: I’ll need your written copy, you don’t have to read it to me, if you just give it to me I can just put it in here and make them both the same.
MR. HUNGATE: Marjorie’s is probably more reliable then mine —
DR. CARR: Whatever the last few changes were —
DR. LUMPKIN: Do we need that first sentence in the last paragraph at all?
MS. GREENBERG: Yeah, I think so, I mean it says, I mean there are people who know, who looked at the report or who know, this is in a context I think.
MR. HUNGATE: That there are still definitional problems to be resolved is what that sentence gets at, right?
MS. GREENBERG: Well, it’s not really definitional, there was no consensus on adoption I think —
DR. LUMPKIN: I think what we were really saying is the committee will continue to work.
MS. GREENBERG: Well there were people who wanted to say even more here —
DR. LUMPKIN: That’s part of the committee work. Because I don’t think this letter is the minutes of the hearing, it’s just a recommendation.
DR. CARR: Right, and I think the more it gets distracted with other things the less powerful it is.
DR. LUMPKIN: So we’re just opening, we’re going to continue to work and probably get other stuff.
MS. GREENBERG: Do you just want to delete the first sentence?
MR. HUNGATE: Well, if you do that you got to delete the ones that follow it because they depend on it.
DR. LUMPKIN: We talk about the hearing in the first on and then we just end up saying that we plan to report, plans to develop a report summarizing the findings from the hearings.
MS. GREENBERG: I might say at least to summarize the findings from the hearing, the findings from the hearings on other opportunities for data improvement? I mean otherwise you might just think the findings were just about this one thing.
DR. LUMPKIN: Hearing was on the report.
PARTICIPANT: The thing about the letter and looking at one portion of the candidate recommendations may be very different I think from other things the committee has to do so the context is important, this is one —
MR. HUNGATE: I think I would argue for retention of that statement, because of the range of the comments that were made I think someplace we should say that.
DR. STEINDEL: I actually think we’re saying it in the last part of the second sentence, we’ll continue to liaise with key organizations in the public and private sector that are addressing the information needed for quality measurement. And then you can add something on that and we are anticipating future recommendations arising from these discussions.
MS. GREENBERG: Well, that may be going further then the workgroup agreed on, it’s not clear whether there will be additional recommendations.
MR. HUNGATE: It’s not clear what the next steps are, it is not at all clear.
DR. STEINDEL: Then I think you just sort of leave it at that sentence because that just says you’re going to work on it and you’re going to report on it and that report could consist of a report that recommends nothing or future recommendations.
MS. GREENBERG: But there was a lot of discussion on these things and there was no consensus and there was a lot of pros and cons and there was no consensus on adoption, so you don’t even want to reflect that.
MR. HUNGATE: The first statement is actually more accurate in terms of how far we’ve gotten then the second, I don’t think we have planned to develop a report summarizing the findings.
MS. GREENBERG: I thought we agreed to do that, I mean at the last, at the second hearing we talked about how that would be useful because we got a lot of useful information and yet we couldn’t reach consensus but we thought it would be good to synthesize all of that.
DR. CARR: Didn’t we just get that report?
MR. HUNGATE: We left the minutes —
MS. GREENBERG: But that’s just minutes. That’s what I recall, do you recall that?
PARTICIPANT: Yeah, we were thinking about how — [off microphone] —
MR. HUNGATE: Well, we can decide that for sure now if it was uncertain, I don’t specifically recall that but perhaps we did in the context —
MS. GREENBERG: If you don’t do that the only thing that really comes out of this whole thing is this one recommendation.
MR. HUNGATE: I think that may be where we are —
DR. LUMPKIN: So you could just have as that last one, I just don’t think going into the committee’s functions, the fact that we heard stuff, that’s assumed that any committee is going to look at things and unless there’s a consensus they’re not going to report out. But what’s important in this last paragraph is that we’re going to liaise with key organizations in the public and private sector that are addressing the information needed for quality measurement.
MR. HUNGATE: That’s fine —
DR. LUMPKIN: And we’re not committing with ourselves to a plan, to a report that we may or may not —
MS. GREENBERG: We have good minutes from both of the hearings, maybe that’s adequate.
MR. HUNGATE: Right, I think so. The workgroup will continue to liaise and leave it at that.
DR. CARR: The workgroup will continue to liaise —
MR. HUNGATE: Let’s make this as least committal as it can be at this stage, let’s then set this letter aside, let’s do the rest of our meeting and see what we’re going to do and then come back and review this and see if we need to make changes based on the discussion in the context.
MS. GREENBERG: Maybe once Justine finishes this then maybe we can print it out and have it to come back to after the rest of the discussion.
MR. HUNGATE: That would be perfect.
DR. CARR: Just we changed the word preclude to something, I didn’t get that.
MS. GREENBERG: Reduce, can reduce the benefit.
MR. HUNGATE: The thing we should next move to is the, we’ve got Vickie here —
DR. MAYS: How would it occur, where it would occur, things that I thought we had some insights on from the 14th. Your suggestion was that we bring people in to explain the forms, the format, so I don’t think we’re at the stage where it’s a hearing on just the recommendations but we were backed up a little bit in terms of a hearing that also explains the whole environment of how the data is collected, what the forms are, kind of who it is in agencies that do it, difference between some of the public and private entities doing this.
MS. GREENBERG: But it is a hearing related to these two candidate recommendations —
MR. HUNGATE: Yes.
MS. GREENBERG: How you address that here, I mean whether at the end of that hearing you feel you have enough information to turn them into anything beyond what they are is —
DR. MAYS: Right, I didn’t have the sense that this hearing was one where when we would finish we would be ready to turn it into something, it was almost like this hearing is kind of education and initial fact finding.
MS. GREENBERG: But among the fact finding is the feasibility, the problems, all of that, which you may at the end of that hearing you could decide you needed another hearing or you could say we’re ready to say we’re not going to recommend this, there’s a lot of different options.
MR. HUNGATE: There is this, and I share the uncertainty around where does the UB-04 fit and where does the 837 fit, all those mechanics of what are the forms, so it’s one of the subjects of discussion yesterday.
MS. GREENBERG: Well, these recommendations actually did not even refer to the UB, they were specifically having to do with the transaction standards.
DR. STEINDEL: Vickie, I think there needs to be a differentiation in the hearing on whether it’s an educational session on the data collection environment, the tools, the people, etc., versus anything that will step over into the feasibility. And I think what you’re saying is you probably want to understand more the environment before you address the question of feasibility.
PARTICIPANT: I’m not sure I don’t see that as an artificial distinction —
MS. GREENBERG: I’d say you do both.
DR. MAYS: Let me be clear again about Populations, Populations does not know and do the form, I mean those were things that we kept saying to you all yesterday and why we said we wanted a bit of a tutorial before we jumped into the hearing. Well, it was said that it’s not unusual for that to be a part of the hearing. So all we’re trying to say from the side of Populations is that we can be most helpful once we’re a little more educated about this.
MS. GREENBERG: But I can’t see having a hearing just for that purpose because instead we can gather that information and provide it to you. If you only want to know what these forms are and how they’re completed —
DR. STEINDEL: I think it’s also one step further, who completes the forms, where is it done in the institutional environment, if you’re talking about possibly collecting this data on enrollment, where does it occur in the enrollment process, that’s why I didn’t just focus on the forms I focused on the whole data collection environment. Now when we introduce the question of feasibility then you introduce the question of controversy and Vickie wants to be educated first on what —
DR. MAYS: It’s not just me, but that’s what people in there were saying —
DR. STEINDEL: The Populations Subcommittee —
DR. MAYS: NUCC and NBU, I mean you all are just zipping through that,
MS. GREENBERG: We have tried to describe these things so many times but be that as it may —
DR. STEINDEL: Marjorie, we’ve been living this from day one, the Populations Subcommittee has never seen it.
DR. LUMPKIN: But it’s not the same Populations Subcommittee that we had when we went through all of that four years ago.
DR. MAYS: I know and I tried to say I have done some of this but I’m telling you what the other people say about aspects of this.
MR. HUNGATE: We have to do that, what’s the mechanism by which we can accomplish it?
DR. LUMPKIN: But the important, and I think what Steve raised, is that we need to understand the data flow, particularly at the institutions where it goes in and that’s probably less important then NUBC and NUCC, and that is that are the people who are measuring this different then the people who would be constructing this form and therefore where is the transmission piece. When you look at some of these and part of the problem is is that we’re looking at a form based issue, we could just skip over the form based issue and just talk about the transaction standard because then that becomes a totally different environment and we may want to say that we don’t even want to discuss the UB form as opposed to the transaction standard —
MS. GREENBERG: We never did have the UB on here.
MICHELLE: I know in participating in the 837 workgroup at X12 they are very much against from a claims perspective including this information and that’s one of the reasons we were able to include it within the reporting guide, they felt okay, that’s reporting, but when we brought it to them before they said if it’s not necessary for the adjudication of a claim we don’t want to hear it. So I really think that’s a key part of this discussion.
DR. STEINDEL: I think that is a key part of the discussion, I think it’s the second part of the discussion after the Population Subcommittee is educated on what the process is because then they can make some more informed statements about that.
MS. GREENBERG: I question though how many times you can bring these people in. They already came on the 14th and started to discuss some of this, I have to say it would be my preference to have, maybe have a two day hearing, I don’t know, but have the first part of it be describing all these things that you said, and actually maybe, to me those indicate feasibility, or not feasibility, I mean the shed light on —
DR. LUMPKIN: But to take away from your point I don’t think we necessarily need to bring in the NUBC or any of these folks to describe the process, there can be an initial discussion, we can have one person come in and set the stage with the subcommittee. And then —
MS. GREENBERG: What stage? As to what these transactions are and how they’re completed?
DR. LUMPKIN: One background presentation, okay, let’s set the stage, here’s the environment, here’s what’s happened since HIPAA has been in place, here’s how these things used to work, how they currently work in this environment, how we expect that they’ll work in the future. Here are the alternatives. Now if we make a change it needs to go through the following process, here are the questions that will be raised. And we’ve been through this a number of times so we can summarize it but as we turn over committee members and people who are on the committee who haven’t been involved in those discussions five, six, seven, eight years ago, can now be brought up to speed, everyone is operating under the same context, and then we have our first panel.
DR. MAYS: We were willing to do this, I mean I kind of posed it as a tutorial even, we’re willing to do this on conference call, having things sent to us, then I think we’re at, it’s felt that then we’re at a stage where we can help in formulating questions, that we understand the process better, so I mean it doesn’t even have to be that we wait until the hearing to do it, I assumed that one of the staff really knows this very well and could talk with us.
MS. GREENBERG: I was suggesting that like Bob, we could ask Bob Davis to write this up as to what these different transactions, I mean this refers to basically the enrollment and the encounter transaction, so what their current functionality is, who completes them, who doesn’t complete them, whether they do or don’t collect race ethnicity, where the information comes from, and then about the reporting guide, etc. —
DR. MAYS: They learned a lot just yesterday so I’m just saying —
MS. GREENBERG: We could ask him to write that up and distribute it. And then if there’s still questions that you feel you need input from other people just to get that baseline we can either get that or we can then get it through a hearing. I mean however you want to do it but it might be that just for a baseline we should at least have, give everybody a description of what these transactions are and what their current functionality is in relationship to collecting race ethnicity data.
DR. STEINDEL: I think it would be better coming from something like AIMA or some other group because what we want to hear about is the process with the actual data and the forms.
MS. GREENBERG: Well, I’m saying that process I think would be better in a hearing.
MR. HUNGATE: Yes, I think so too.
MS. GREENBERG: Where then you could have people from AHIMA, people from —
DR. STEINWACHS: You’re going to want to look at somebody from a place where they are collecting the data and how they transmit it and then —
MS. GREENBERG: States that feel they get pretty good data for hospital discharge records, those who feel that they don’t get very good data and why, I mean I think that needs to be in a hearing but I was just saying as for the kind of baseline description of what we’re even talking about in relationship to these transactions and who needs to, whom they are mandated on. I think that we could just provide —
DR. STEINWACHS: I’d go back to Steve’s comment though, I think you’re better off doing your base first and determining how the data is collected and that process, attack your format transmission later because you’ve got a whole set of options in front of you that you might be able to deal with but until you know how the data is being actually dealt with I think it just confuses the issue just to talk format and that piece of the transmission first.
MICHELLE: But I think they are both essential, they need to understand that —
MS. GREENBERG: Unless this isn’t the takeoff point, they have some recommendations here referring to some mechanisms that people on the Populations Committee don’t understand what the mechanisms are, so I do think they need that information.
DR. CARR: Could I step back for a minute because I feel like I’ve gotten a terrific tutorial, especially from the things that Vickie has brought forward, but it sounds to me like there are, we want to begin with what’s the question that we’re trying to answer and what’s the gap, and then match the tools to bring us forward closer to the answer. And I think I’ve heard two different kinds of things, there’s some huge populations data where very kind of first pass slices, maybe the old way of simple classification takes us from this point to that point and helps us know one thing. And at the opposite end there is the very granular refined drill down of information that tells us another story. And which tools go with which question I think are something that we need to think about and then as you talked about yesterday when you have a tool you need to know how complete it has to be, how perfect it has to be, and what did we say, how precise, I mean is it perfectly collected, is it perfectly stated. And I think that we want to keep in mind the question that we’re answering because we know that the front line people at the front desk are never, no matter, you could never fund the educational initiative to get every administrative receptionist to do that, it will never happen, it is a given that some data is going to be front line people that are going to be able to be, are you A, B, or C, and is that data useful at all, does it have a place, will it build the story. And then for the more complete, for a different set it will be collected in a different setting. And I just, I’m just struggling with which question are we answering and we’re worrying about the nuances of a particular field when we haven’t sort of traced it back to what’s going to get better at the end of this exercise.
DR. MAYS: Let me just comment on that because part of what I think we’re reacting to is your question, your candidate recommendation. Your candidate recommendations are very specific around these forms and what have you so that’s why from the Populations point of view in order to, we’re trying to meet not what we might just start off recommendation but to meet very specifically your candidate recommendations. And in your recommendations you have specific places you want considered for this to be done, you have a focus of what you want looked at, so that’s part of what we’re trying to fit into to answer it and that’s why I was saying we need more information to do it that way. If we did it differently, I mean if it was coming from —
MS. GREENBERG: Maybe we need to start over and just say the basis of these recommendations was to consider opportunities for collecting race ethnicity of the patient in administrative data, that was the purpose of these particular recommendations. So there was some suggestions of how that might be done and it was quite broad, it said it could be this data set, or it could be that. But the bottom line question was is it possible to collect, or are there ways to improve, because are already doing it frankly for better or for worse, are there ways to improve the collection of race and ethnicity in administrative data. That was I think —
DR. MAYS: See I think that’s a totally different kind of hearing and approach because then what we do before we even reach the level of a hearing is that we start thinking about what are the places and ways in which such data is collected and what is the outcome that you’re looking at because then you would decide based upon what you’re trying to achieve how much precision you really need. And I think that’s really, Populations can help you with that and Populations can even lead in that but when it’s this way that’s what we kept trying to say, we kept saying to ourselves as we’ll consult with you and help you but we can’t do this and then you all wanted us to lead and we’re like well then you have to teach us then.
MS. GREENBERG: I think we should do what you said Populations could lead on, I mean that’s my sense.
DR. CARR: We need a bit of a gap analysis because even if we enacted this would it be of a caliber and quality and completeness that repeated something that we already have, I mean I think we have to say to get from here to there where are the gaps and then how do we back fill the gaps. And I don’t know if this would give us the same quality and completeness as another dataset or whether this would because it’s collected in a different place or by a different caliber of person whether it would improve.
DR. MAYS: See and it would be I think helpful if what Quality did first was really went through what was your initial recommendations to really determine what’s in here that is almost, it has to be, what’s in here that is critical you think to achieving the goal, so that as we consider things there’s some things we just don’t take off the table and that we know that in those hearings to try and work with it as opposed to just as I said yesterday going with mom and apple pie kind of let’s collect the best, whatever, but if you say that from a collection standpoint in administrative data there are certain things that should or must occur within certain environments, just help us to also know that and then what that allows us to do is to have a sense of how broad are we in looking at this universe of the collection in administrative data. See, again what should the scope that you want us to focus on, administrative data is kind of broad too so just tell us if you’re talking about, now are we down to health plans —
MS. GREENBERG: I think we’re down to whatever kind of data is collected in enrollment and whatever kind of data is collected at an encounter.
DR. MAYS: See that’s important, you all are saying that that’s the universe you want to operate in in terms of giving us some specifics. And then if you’re at the specifics of encounter and enrollment are there any particular things that have to occur.
MS. GREENBERG: There already was a recommendation on health plans collecting this data right?
MR. HUNGATE: Can we get a white paper that is four to six page magnitude that describes the creation process for administrative data as we loosely refer to it in terms of the pieces, the mechanics that go through that? That’s doable isn’t it?
DR. STEINWACHS: I apologize for not being in your meeting yesterday and some of your other side meetings but from the discussion we’ve had in general meetings I’m almost reminded of the identifier questions that we have right now, do we collect five pieces of data and come up with an identity of the patient, or do we collect one number. I think you almost need to say what information, what elements of information do I need to collect to give you the answer you’re looking for when I collect this population data. If you can tell me that then I look at these transactions and say where can I collect these five pieces of data, what’s the best place, is it the health plan, is it the provider, or is it both.
The next question then goes if right now I’ve only got one field sitting in an 837 do I want to go back to ANSI and say on the 834 and the 837 I want to expand the data field to collect these five elements, rather then just say oh, we only have one element and whatever we’re going to collect has to be in there. And I don’t know if you’ve reached a consensus yet on what it is you want to collect and would it give you an answer of the race and ethnicity but I think that has to come before you look at where can you collect it and then how do you transmit it.
And we can certainly, I can even provide Marjorie some information on the 834 and the 837 and Bob can and I mean there’s a variety of people that can do that, but until you can decide what it is you want to transmit and until you can decide where’s the best place to collect it and transmit it, I think the format and the process are secondary questions and to that extent the recommendations are premature. The recommendations are dealing with data we collect today but I’m not sure that’s the data you want.
DR. MAYS: I think we just have to make sure that given that we’re asking somebody to do this that we either know what we hope to achieve or we have some way to prove that doing this achieves something, so either we know or else we show that it makes a difference. And so I’m just trying to get a sense of the universe in which you want this to make a difference.
DR. CARR: I would suggest since I’m a very grid oriented person that we make the grid that says what’s the data, what’s the definition, what is the site of collection, what is the population covered, what is the sophistication of the data collector, how many elements and what level of detail, and then we say okay, we have payer information, and the frequency of collecting, it’s collected once on enrollment and it will give us information about covered lives, 15 years after they’ve enrolled. Or we’re going to do it at every encounter at the hospital and we have a grade three clerk and so it will be A, B, or C and it will be 50/50. We have to make the puzzle, we have to say what are the data elements because we could put a lot of time into doing one thing that is no better then something that’s being done somewhere else and adds no additional information. So I think we have to make the grid and say have we covered all the populations, are we collecting it at the theoretical before we get to the specific, are we getting at this at a level of sophistication that adds value from what we already have.
MR. HUNGATE: Marjorie, did you have a comment you wanted to make there?
MS. GREENBERG: Well I think Justine’s grid sounds like a good idea but I was thinking that rather then kind of going back through what Dan said, rather then worrying about these various forms, etc., bringing in some people who are, who do feel they’re doing a reasonably good job collecting race ethnicity in something other then a population based survey and in something either related to covered lives or related to encounters. So that would be maybe like Aetna that’s trying to do this now and some state, the states that feel they have good data in their hospital discharge data, and finding out how they do it and what they’re using it for.
MR. HUNGATE: John?
DR. LUMPKIN: I wasn’t here for the beginning of the discussion but there’s currently a collaborative between nine or ten large major health plans funded by AHRQ and our foundation that’s addressing this issue currently, and they’re taking a number of different approaches and they’re collecting it primarily and others are using GEO coding or other methodology and I’m just wondering —
MS. GREENBERG: Maybe we could just hear from them.
DR. MAYS: There’s also I thought a report that recently came out I thought, I may be confused, from the Commonwealth Fund on some of these issues also, so part of I think, I mean there’s just some preparatory things I think would even help to, I mean we’re shooting in the dark and if people who have been working on this have been already I think there are people at AHRQ who we can bring in who’ve been doing that. I was trying yesterday for the meeting to get, for our meeting during that quality time to have Harvey Swortza(?), to have Catora(?) Felix-Arons(?), and I can’t remember, there’s one other person I think somebody had recommended. So it’s not as if the information isn’t, I mean I think, again, I think hearing from some people who have actually been doing this would help us I think even formulate what we’re doing —
MS. GREENBERG: I think it would be very good to hear, let’s hear from them.
DR. LUMPKIN: Well, Kay would be the one, the key, she’s kind of playing the lead role at AHRQ pulling the pieces together —
DR. MAYS: She just moved over though to HRSA so she was actually, but she’s in charge of quality at HRSA so that’s very good. So I think having one of them also just have a discussion with us, like I said I was hoping but I couldn’t get, Harvey says he can’t, his plate is very full, he sent me an email with names of people if we were having a hearing who to bring in and Kay I think, Gracie did you ever get her?
MS. GREENBERG: Should we just wait and see what they find out?
DR. LUMPKIN: There’s another piece which is that there’s a second collaborative which is just in the process of starting up, just have identified the health plans, it’s a Medicaid basic collaborative being operated by the Center for Health Change, Steve Summers and his group, and they’re just now starting, so there’s some real health plan based initiatives with the goal of improving quality, reducing disparities, and one of the methodologies is collecting race and ethnicity data —
MS. GREENBERG: It seems to me those are going to be much more protective then trying to pursue these two candidate recommendations, I mean frankly this is why we developed this reporting guide because we were hitting our heads against the wall trying to get, we couldn’t get any consensus on these transactions. But I mean the states that collect this now didn’t want to go backwards and stop collecting it, as inadequate as the data is they do feel it’s better then nothing. So let them continue to do that and now it sounds like there’s some resources going into trying to find better ways to address this. And I’m not sure at this point there’s anything that the committee should be doing other then maybe hearing about this and having the opportunity to comment on it.
DR. MAYS: John, let me ask you a question because I at least what I heard kind of in the back is that the committee can be very helpful in the speed by which things can move along in the sense of shedding more light and people understanding that this is something very significant, so that’s at least —
DR. LUMPKIN: You mean other then what we’ve already done?
DR. MAYS: Well, what was said to me about this issue because I was again trying to decide from our side what we needed to do and who the players we needed in Populations to help us to be able to do this was that if the committee had like a hearing or brought people in that they thought that what that did at the level of the department is gave a message to the agencies about prioritizing this. AHRQ clearly is already doing it but I think the thought was that for example at HRSA as well as maybe some of the other agencies might take a look at kind of the issue of quality data and race and ethnicity relative to quality data, that it may even put it from a research standard on NIH’s radar. So that was what —
MS. GREENBERG: It could give visibility to it.
DR. MAYS: That was what was said, it wasn’t like we need you go to do it and finish it because there’s some activity but who you have sitting at the table helps them to think well if this is going to come to the department maybe we should start lining up and be ready to do this. So that was kind of what was said to me so I don’t know if it’s a good use of resources to try and make that happen or if things are going on their way so swimmingly that we just need to stay out of it.
MR. HUNGATE: None of that’s an issue where the time of our work is best spent.
MS. GREENBERG: I think it would be interested to hear more about what these various collaboratives are doing. And it could give visibility to it because it’s a public hearing —
DR. LUMPKIN: The complication isn’t, I don’t know that the AHRQ collaborative has been announced. It’s bouncing around on who’s going to announce it, when and how, it may have been because we’ve been sort of bouncing around the press release but the collaboratives start working in the spring and so it’s kind of hard —
MS. GREENBERG: If you can see, a lot of us aren’t that familiar with it —
DR. LUMPKIN: Well, it’s kind of hard to hold a hearing on a collaborative that hasn’t been announced —
MS. GREENBERG: This is not the collaborative of RWJ —
DR. LUMPKIN: Yeah.
MS. GREENBERG: Oh, it is a collaborative with RWJ, but it hasn’t been announced.
DR. EDINGER: So how can you disclose this in this new world of secrecy?
DR. MAYS: He’s not AHRQ, he’s RWJ.
DR. LUMPKIN: My only point on that is that it may be difficult for AHRQ to come to a hearing and talk about a collaborative that hasn’t been announced —
DR. MAYS: Now do you understand the person was probably talking about this visibility issue?
MS. POKER: But I can find that out, I don’t know if it’s been announced or not, internally we’re aware of that, and there’s also the task order that Marjorie you were talking about that’s going on simultaneously to look at administrative data as a source to capture quality also.
DR. LUMPKIN: Yeah, because it kind of started out it was going to be like a press event and then it sort of boiled down to being maybe a press release which is why I think it may have been coming out, so we just need, and the collaborative, the Medicaid collaborative is just coming together so it’s a little —
MS. GREENBERG: You’re working with them too? That’s an RWJ thing as well?
DR. LUMPKIN: That’s something we’re funding.
MS. GREENBERG: Are you funding this first one with AHRQ also?
DR. LUMPKIN: We’re co-funding that one.
MS. GREENBERG: So have you made the awards? I mean when you make awards isn’t that public?
DR. LUMPKIN: Only when we want it to be, we’re in the private sector —
DR. MAYS: They could give money and you wouldn’t know, you could see a product. The Board has to know.
MS. GREENBERG: We don’t know.
MS. POKER: Are you co-funding it with AHRQ? Because if you are it has to be, if there’s a public award and AHRQ is making it it should be —
DR. LUMPKIN: It’s to doing the technical assistance of the collaborative, it’s not funding the individual collaborators, and so AHRQ’s funding may go to RAND and it’s been a long standing contract with RAND —
DR. HOLMES: But John it sounds like the only hurdle which you’re describing is the fact of whether or not its been announced and it also sounds as though the announcement either has happened or is imminent —
DR. LUMPKIN: Or it could provoke the announcement.
MS. GREENBERG: Would you please announce this so we can have a hearing on it?
DR. MAY: As I said there’s a reason to try and make these things work, to have some impact on others, I do think there are other things that are brewing within some of the other agencies but I think it would help to kind of have this out there.
MS. GREENBERG: It would be great to hear from these people.
DR. MAYS: It can’t be Kay because she’s moved, and HRSA is going to do something but I think Kay is over there —
MS. GREENBERG: It sounds like there needs to be a little research done here as to whether anything is —
MS. POKER: Would you like me to do that? Because I think I’m positioned that I could do it, would you like me to do that, Bob?
MR. HUNGATE: I think so, the operating premise really is a collection within health plans of race and ethnicity and economic data if that’s part of it as well, is a help to them in eliminating disparities within the group that they manage, that’s the operating premise isn’t? That’s the reason we’re talking about it?
MS. GREENBERG: Probably they don’t know that yet because they haven’t even collected it.
MR. HUNGATE: They haven’t collected it, they don’t know whether they have disparities that they need to address.
MS. GREENBERG: The assumption that if they had this information they could target —
MR. HUNGATE: And that’s the reason we’re interested in administrative data this facilitates those organizations dealing with the disparities that are revealed, right? That’s our logic, that’s our value added to the system.
MS. GREEN: Yeah, we’re not just nosy.
MR. HUNGATE: No.
DR. MAYS: Anna, you may want to also go to Harvey because the email, I have it upstairs, Harvey Schwartz, the email he sent me is similar to something John is saying now that I remember, he had an acronym and he said this is something AHRQ, and I remember him saying I’m not sure whether it’s complete or funded or out there or something but he also gave me an email, I just remember this in terms —
MS. POKER: Is this Harvey Schwartz at AHRQ?
DR. MAYS: Yes, and when we go upstairs I’ll give you the email but there was something that he said and he wanted the guy, I think it was, it was a VP at either Aetna or someplace, there was some other activity that has been let within your agency on this topic which is why Harvey was suggesting the players that he suggested in the email so I do think there’s a couple of things that may be going on.
MS. POKER: Stan, are you aware of any of this?
MR. HUNGATE: Russell, did you have a comment that you still wanted to interject here?
MR. LOCALIO: Two questions, one, John you mentioned that the previously constituted Population Subcommittee had done hearings, do we have transcripts of those that are available?
MS. GREENBERG: Which hearings?
MR. LOCALIO: Eight years ago.
DR. LUMPKIN: No, no, the full committee did hearings on some of the —
MR. LOCALIO: Would it help to see those, do we have, does somebody have —
MS. GREENBERG: I say we should move on.
MR. LOCALIO: The world has changed enough so should we —
MS. GREENBERG: No, frankly the world is about the same as it was then —
MR. LOCALIO: I don’t think people want to hear that.
DR. LUMPKIN: I think that’s true and the point I was making is is that we tend to forget this is not the same committee that was here six years ago when we went through all this stuff.
MR. LOCALIO: I mean it would help me if I knew that this was already well traveled ground eight years ago by different people and that would help. But if it’s not going to help then we can just go on but I do have, I’ve heard some important information, there’s an initiative going on with health plans, that’s RWJ/AHRQ to be announced initiative. There’s also —
DR. MAYS: RAND is also involved —
MR. LOCALIO: Maybe RAND. There’s also a Medicaid collaboration going, and I would say both of those are good especially the Medicaid because the underserved population are the ones who might have the biggest health disparities maybe in that group. But what about the say roughly 45 million people who have no insurance, what are we going to do there, what about the CHIP program that might have a lot of people, young people who fall into this category, what are the options for getting the people who on the state CHIP programs involved, to get, to figure out how we can get information from them. And are there any other groups that we might think by their insurance status or lack thereof are especially vulnerable that we would want to say how are we going to get race ethnicity, socioeconomic position in some transaction.
DR. HOLMES: I though we had acknowledged when we started down this road that in terms of that naughty problem of the uninsured that because we were looking at administrative data that we had set that issue aside and acknowledged that whatever recommendations we came up with would not address that because a bill is not generated. And it would speak then to HRSA and whatever they’re doing since they’re the safety net provider for that. I thought, correct me if I’m wrong but I thought we had sort of set that aside —
MS. GREENBERG: We observed that this obviously only —
MR. LOCALIO: That’s a gap that we would have to recognize. What about the CHIP program, is that something that we want to look at? And again I’m putting on one hat that says okay, if I’m on this Subcommittee on Populations and we’re interested in getting information other then from surveys on health disparities and we want to get it from transaction I would say go to the CHIP program because at least for one —
MS. GREENBERG: I think we’ve made recommendations on that in the past, I think they do collect —
DR. MAYS: I think we made a recommendation on the language and I think they do collect race and ethnicity and we made an additional recommendation about the language.
MR. LOCALIO: So we think we covered CHIP but we still haven’t done the uninsured and we have no, that would be left then to surveys. Is that correct?
MS. GREENBERG: Well the uninsured appear for care sometimes.
MR. LOCALIO: That’s true but we haven’t talked, we’ve talked about the initiative with the managed care, the initiative with Medicaid, a recommendation on CHIP but then what are we going to do with the people who are going in the emergency room? Which I would guess is the place that most of these people have their first encounter.
DR. LUMPKIN: But if a bill was generated —
MR. LOCALIO: I understand, but what have we done in terms of —
MS. GREENBERG: Is it collected on the bill or not? Right now it is not collected on the standard transaction which is generated.
DR. LUMPKIN: Which we already recommended that it should be.
MS. GREENBERG: Well, no, we have a candidate recommendation that nobody is prepared to take forward it sounds like to me.
MR. LOCALIO: These people are not enrolled, we’ve been talking about in the enrollment form, the encounter, these people are not enrolled in anything so they’re enrollment is they go to the counter at the emergency room and they say I’m sick —
MS. GREENBERG: Then you would have to collect it on the encounter and that is one of the recommendations here but as a candidate but nobody is comfortable enough with it to go ahead and have a hearing, that’s what I’m hearing.
MR. LOCALIO: Well, I’m wondering, by the way Marjorie thank you for walking into my trap, because I wonder whether maybe we want to hear from the emergency rooms, what type of, what you do when somebody walks into the emergency room and is that a place where we have a lot of initial encounters on a group of people about which we don’t have good information —
MS. GREENBERG: If you are in a state that collects, that requires you to collect race ethnicity on hospital discharges, not for the claim but to report to the state hospital discharge system, and if that state includes emergency departments which some do and some don’t, then somebody looks at that person probably and decides they’re black, white or —
DR. MAYS: That’s what they used to do, black, white, or other, you almost said it.
MS. GREENBERG: Black, white, or Asian, something like that —
MR. LOCALIO: We have no idea —
MS. GREENBERG: They may ask their, depending upon the circumstances, it differs probably from hospital to hospital, if it’s a hospital that really takes this seriously they may actually have trained their intake people to try to get the information either from the patient or from the family member, that’s what happens —
MR. LOCALIO: This is like a hodge podge, we have no idea as to whether it’s done, when it’s done —
DR. CARR: But I think you’re right, we got the pie chart, we know Medicare has some stuff, Medicaid has some stuff, commercial has some stuff, uninsured, what’s the point of contact, maybe the emergency room, but I mean that’s the kind of thing I think we have to do is what do we have —
MS. GREENBERG: John, I’m really confused by your confusion —
MR. LOCALIO: So John if that’s the case that’s part of the pie, health plans is only a piece of the problem and given that you need a health plan you have to have certain requirements, it does not cover the —
MS. GREENBERG: But it would be better then nothing.
MR. HUNGATE: Is there a definitive place someplace that says how much race and ethnicity data is collected within health plans? Is there someone who could express a percentage?
DR. LUMPKIN: Well, no —
MR. HUNGATE: Fill in the grid that would —
DR. LUMPKIN: There was a survey that was done by AHIP, America’s Health Insurance Plans, a merger of American —
MS. GREENBERG: Old HIAA/AAHP —
DR. LUMPKIN: Right, they completed a survey over the summer that looked at the practices of collecting race and ethnicity data by health plans —
MS. GREENBERG: Is that publicly available?
DR. LUMPKIN: Sure.
MS. GREENBERG: Is it on their website?
DR. LUMPKIN: Should be, it’s on ours, we funded it.
MS. GREENBERG: Well basically John you know more then any of us about this so could you provide us with a tutorial?
MR. HUNGATE: Well, what I want to try to do is take the grid model that Justine has advanced and make an assignment to Anna to help, because I think that’s where it has to go, to begin to document that grid and say what do we know from existing sources and what do we not know because it’s the not knows that might be the substance of a hearing that would be productive. Now is that a fair summary of what might be useful or am I on the wrong track?
MR. LOCALIO: Can I give a little more substance to what I believe? I probably see it once a week, if you’re making a contrast between groups and say it’s based on race ethnicity socioeconomic position, it makes a difference whether you say if you look within a health plan and you look at the disparities what are they, as opposed to whether you say that the disparities that occur are not within the health plans but they are across the population. In other words if you have all the people who are not doing well or going to the emergency rooms and all the people who are doing well are in health plans you’re going to miss a lot if you just look at health plans and look for disparities. One is a within conditional analysis and the other is what we call a marginal or population averaging analysis. So in Subcommittee on Populations if we’re looking at like race ethnicity disparities we’ve got to look at both and it doesn’t help to look within Medicaid, it doesn’t help to look within health plans, you have to look across everybody.
MS. GREENBERG: Well, that’s where the argument has been, surveys, or that’s where the argument has been made to collect it on the encounter but you can see this is very controversial.
DR. LUMPKIN: But that’s the crux of the business case in that with the focus of the collaboratives that I talked about which is to reduce health care disparities, disparities within the health care system, and the fact that there is some increasing interest on the part of health plans to do that, the business case is is they can’t make these quality improvements without knowing what the data is. The broader issue of health disparities, health disparities in the nation which is the population base can only piggyback upon that data collection if there’s a business case to do it but it will not, the change won’t be driven by the fact that it’s important for us as a nation to understand these health disparities.
MS. GREENBERG: Well there could be health care disparities for people who aren’t in health plans because they are getting health care.
DR. LUMPKIN: But there’s no business case for those health care disparities —
MS. GREENBERG: Well hospitals, the hospital would have to make that business case.
DR. MAYS: No business case for the health plans but there’s a business case for health, there’s a business case for HHS to be concerned about these things and to want to better capture, because the cost of care is both at the state and federal level in terms of those uninsured. So there is a business case to be made by the feds in order to help the states.
DR. LUMPKIN: And then that all ties back in to the extent that which you make the business case to piggyback this on a business transaction.
DR. MAYS: See it’s interesting, but for the health plans yes, for the federal government no, they have different values. I don’t see why I would have to make the business case on a business transaction for HHS, I could see why —
MS. GREENBERG: What do you mean for HHS?
DR. MAYS: For the better —
MS. GREENBERG: For care funded by HHS?
DR. CARR: CMS.
DR. LUMPKIN: CMS, but CMS doesn’t run enrollment.
MS. GREENBERG: Well, sort of.
DR. LUMPKIN: Sort of yeah but —
DR. MAYS: See but I think with CMS, the value and knowing that there is a disparity they’re more required to do something about it as opposed to in the health plans there has to be an economic or value added.
DR. CARR: We talked about that yesterday, like how would a health plan get their folks to collect it and collect it right unless there were some alignment of incentives that it would give them market share or something like that.
DR. LUMPKIN: See I think we’re using business case in a lot of different ways. If you’re the committee that’s looking at the business transaction you want to see that there’s a business purpose for that. Now a health plan that wants to improve, wants to reduce disparities so they’re improving quality of care, and they’re looking at potential payment options, pay for performance is another example of that, then you can’t adjudicate that bill or pay that provider unless you understand what’s going on with the patients that they’re seeing. So there now becomes a business case for putting that data on the business transaction. That’s different then the broader case of what the impact is on the nation of the actual cost. So we’re trying to say that this transaction, adding another field, which is an incredible cost, is worth it because it serves the customers who are the people who are paying the bills.
MICHELLE: And that’s the business case that’s essential that has to be made before any change can be made, I mean we can make the decision, HHS can make the recommendation, but when it comes to X12 when you have that committee they need to understand that business case to drive them to want to make that change within the transaction for the collection.
DR. LUMPKIN: And that’s the link because once you make the business case for health plans then everybody else comes along, the uninsured, other payers.
MR. LOCALIO: If you can get the health plans to buy in and therefore you’re saying that that becomes the standard and that the standard then just oozes out to the rest of the health care sector, is that you’re saying?
MS. GREENBERG: Health plans have the ability to collect information about their enrollees and so that’s a different business case then collecting it on every encounter. Health plans should have a way to collect it once and then link it with their encounter data.
DR. LUMPKIN: And that’s a very touchy issue because if you collect it on the enrollment then health plans feel that they’re opening themselves up to charges that they’re making enrollment decisions based upon race and ethnicity.
MS. GREENBERG: But I assume these health plans their preference is not to collect it every time the person is seen.
DR. EDINGER: Well the health plan doesn’t pay for that, the provider —
MS. GREENBERG: I don’t know what these health plans are doing and I thought some of them like after people were already enrolled they were then sending them some kind of survey or something for all new patients —
DR. LUMPKIN: Well the health plans that are involved with the collaborative are now beginning to lobby AHIP as their representative on this issue —
MR. HUNGATE: John, let me ask you, interrupt and ask a question. Is it worth this committee and Populations Committee’s time to work on this issue in a public hearing way in view of the other things that are taking place? In your judgment —
DR. LUMPKIN: My judgment would be it probably would be of value to do hearings in about a year because I think these other things will have gelled enough for us to give visibility to put some pressure on change. But right now it’s probably a touch premature.
MR. HUNGATE: Well, that’s very helpful because that can help us manage our workflow.
MR. LOCALIO: John, could I just ask you for a clarification? Does that mean you want to plan for a hearing in November 2005 or do we want to revisit the issue and plan a hearing for the middle of 2006?
DR. LUMPKIN: I think that revisiting this issue in six months to answer that question would be worthwhile.
MR. HUNGATE: And I would like to revisit it with some kind of a recap of the white paper of this discussion and the grid work, to do some of that documenting of where we are today to help inform that discussion so we don’t have to repeat the process that’s brought us to this point.
MR. LOCALIO: So can we talk about this in June and then John you can give us an assessment as to whether November would be okay or whether we want to put it off for another six months?
DR. LUMPKIN: I think hopefully by then the subcommittee can —
MR. LOCALIO: Will AHRQ have announced its —
DR. LUMPKIN: Oh, yeah.
MR. HUNGATE: Now, everyone has a draft that has the recap thanks to Justine of getting the language into the letter again. I don’t think we want to take the time now to read clear through it but if each of you would read it and give me your feedback sometime if there are things that you see that need further correction then I’d like to have that before I start to read it for the committee again.
MS. GREENBERG: This is going to be presented after lunch.
DR. LUMPKIN: Maybe.
MR. HUNGATE: Unless the agenda changes so much and it is presented before lunch in which case it will occur whenever it occurs.
MS. GREENBERG: I would suggest, I think everyone should just look at it right now, we don’t want everyone giving you edits do we?
MR. HUNGATE: I wanted to spend a minute too talking about how we decide what we’re going to work on because I don’t think we got that clearly set. We didn’t get to it today, we had other things that came in front of it but we still need to do it. I think that we’ll probably need a conference call if that meshes with everybody’s thinking. Anna and I will try to prepare some background for what perceive as options with input for that so that we start from a base and then discuss and then see where we go. Does that meet with everybody’s agreement?
MR. HUNGATE: You’re just glad not to have to talk about it. Thank you.
MS. GREENBERG: We need an s at the end of the first paragraph for all inpatient claims transactions, plural.
MS. POKER: Weren’t we supposed to drop the ANSI?
MR. HUNGATE: Well, I think we agreed to leave it in up there and drop it below so that’s okay, we had further discussion this morning.
MS. GREENBERG: This should say there is experience collecting this information, forget the hyphen, there is experience collecting this information in New York and California —
DR. CARR: While testimony received on this recommendation has in effect made a business case, or hasn’t made the business case?
MS. GREENBERG: Well the previous version said has in effect —
DR. CARR: But I mean what does that mean?
MS. GREENBERG: Maybe just has made a business case —
MR. HUNGATE: Okay, take out in effect.
MS. GREENBERG: Take out in effect, not necessary.
MR. HUNGATE: Going once, going twice, okay, business as usual.
[Whereupon at 9:58 a.m. the meeting was adjourned.]