[This Transcript is Unedited]
Hubert H. Humphrey Building
330 Independence Avenue, N.W.
Room 705A
Washington, D.C.
MS. COLTIN: Welcome to the Workgroup on
Quality. I suppose that for the purposes of the transcript, we should go around and -- you'll figure out who we are? Great.
There are two things I would like to try to accomplish in the next hour. It may be too ambitious to accomplish both of them, but --
DR. GREENBERG: Where is Susan?
MS. COLTIN: She was here a moment ago. I don't know what happened. But I can't wait.
One thing that I want to really discuss today is the report on the work that this work group has been conducting over what now to my amazement is over two years.
DR. GREENBERG: Oh, longer than that, I think. There is Susan.
MS. COLTIN: We really got started in mid-1998, but the impetus for a lot of what we did began in 1997.
DR. GREENBERG: It goes back to when Don Dettmer was there.
MS. COLTIN: Who actually launched this work group in '97. It goes back actually to a session that was held in March, I think it was a full committee meeting in March of '97.
DR. GREENBERG: The one on quality?
MS. COLTIN: On data quality.
DR. GREENBERG: On data quality.
MS. COLTIN: Where I actually was a presenter.
DR. GREENBERG: Right, and I wanted to publish your presentation, and here it is, five years later.
MS. COLTIN: We had Arnie Millstein from Pacific Business Group on Health, and Eileen Peterson from United Health Group, and a number of us talking about issues of data quality. That became the launch pad for some of what we did.
But the other event that propelled this activity forward was the release of the President's Advisory Commission report.
DR. GREENBERG: Right.
MS. COLTIN: They made a number of recommendations around measuring quality, and did not get into the how, simply the what. It begged the question of, do we have the data to actually implement those recommendations. That is what really led to the formal beginning of a series of hearings that we held with people who are out there doing quality measurement or trying to do it in the field, around what were the obstacles and gaps in our present systems with regard to measuring quality.
So that is really the focus of this report. It is not to make recommendations on what should be measured. There are lots of organizations out there that are playing that role. Particularly the National Quality Forum now has become the focal point for trying to make recommendations around what should be measured.
Our focus is on data. That has been the role of this committee, and it is on the adequacy of the data systems that are available to support the measurement of quality and creating the measures that are being recommended by other groups. So our hearings have focused on that narrow topic, up to now.
What we need to do is something as basic as have a title for this project and for this report, to frame what it is that we are about. We need to agree on the scope of the report. I would like to propose that it be limited to the measurement of quality, and not get into those reporting of quality.
I think that may be the next topic area that the quality work group might get into, but it I don't think should be the topic area for this report, even though some of the testimony that we heard certainly touched on issues around reporting. I think there is a lot of work going on in that area now as well, and I think that that will come up in the advice that we are going to be asked to provide to AHRQ around the national quality report and some of the issues that they will be addressing on how to report on this kind of information. That is what led me to think that that might be the next area, in that it will come up in the context of providing that kind of advice.
But for this report, I would like to propose that the scope simply be data limitations and data quality issues around measuring quality. Does anybody have any concerns about that, or problems with limiting the scope to that?
DR. STARFIELD: It is quality of measures and not quality of measurement?
MS. COLTIN: It is the adequacy of the data systems for supporting quality measurement. So it is really focusing on the data systems that are available. It is broad. It is administrative data, it is survey data, it is whatever data are available for measuring quality.
MR. AUGUSTINE: Anyone who has ever done HEDIS measurements knows the difference between poor data and good data as far as your outcome measurements are concerned.
MS. COLTIN: Right. When we are talking about data quality, we are talking about availability as well as accuracy of the data, because there are clearly some aspects of quality that groups would like to measure, but can't, because the data aren't collected, or aren't collected in a manner that will support measurement.
DR. STARFIELD: Is adequacy one of your aims?
MS. COLTIN: I think that those are the main issues, but I think that when I use the term availability, to me that encompasses adequacy. It is not available in the form you need it.
DR. LUMPKIN: Does it include burden?
MS. COLTIN: I think that will come up as an issue in commenting on what could be done and what needs to be done as a rationale. That came up a lot in the testimony, in terms of the rationale for recommendations, that the burden of measuring using chart review could be greatly reduced if administrative systems captured certain kinds of data.
DR. LUMPKIN: And the other piece about collecting the data in a standardized way from plan to plan. The lack of standardization places an additional burden on providers.
MS. COLTIN: Right. So I think we have got some agreement -- at least, I didn't hear any disagreement -- on scope, so that was one of the issues that I wanted to point out.
The next one was a potential organizing framework. On the left side of your book, behind the lined paper, you will see a packet of ideas that I jotted down. What I have been talking about so far is, I started with needing a title. I don't want to take time today to do that, but I would love to have people email me their ideas, or maybe I will put something out there and you can react to it. But I just wanted to lay that out as a need.
The second thing is a potential organizing framework for the findings, common themes that came up in the hearings. One is, we started out with the President's Advisory Commission topic areas, because that is what formed the impetus. But since that time, the Institute of Medicine has published its Crossing the Quality Chasm report and proposed a framework for quality measurement. It might actually make sense to think about -- and that is the framework that is being adopted for the national quality report. So it might make sense to address the data gaps and issues in the context of that framework, rather than the President's Advisory Commission topic areas.
So I wanted to throw that out, and also see if anyone had any other ideas about potential organizing frameworks for the findings. First of all, what you thought about the two options of the Advisory Commission topic areas versus the Institute of Medicine's framework, or if you didn't like either one of them, did you think there was another framework.
DR. EDINGER: Just for political purposes, it might be better to address the IOM's, rather than the previous Administration's.
MS. COLTIN: My preference would be to do that, even though that wasn't the way we started out, only because it would be more relevant in today's context.
I had a conversation -- Tom Reilly called me last week, in reference to the request that we had about getting advice from the committee. There were two areas in which they were going to be looking for advice. One is on the actual topics for which measures would be reported. So they have a list of topics that they would like us to hold hearings and get reaction from various stakeholder groups to the proposed list of topics for measurement.
But the other was the adequacy of the data systems. I said, well, coincidentally we have been holding hearings on this over the past two years, and are planning to write a report on exactly that topic.
So given that that is something that they want, that also suggested that it would make more sense to organize our findings according to that framework. So are people comfortable with making that shift from the Advisory Commission's --
DR. GREENBERG: Isn't there some logical connection between the two?
MS. COLTIN: Well, there is somewhat, but it is not that clear. They did have recommendations around medical errors and patient safety, and that is an area within the framework. They had recommendations around vulnerable populations. That is a cross-axis in the framework, although it is not -- it is a cross-cutting issue. So there is some overlap, but it is not exactly the same.
But I think just about everything that was raised in the Advisory Commission report is covered in the IOM framework. I think the IOM framework actually goes a little further.
DR. GREENBERG: There may be a paragraph that makes that transition, and then use that as your framework.
MS. COLTIN: Yes. So if people are comfortable, I would suggest doing that.
MS. KANAAN: This question didn't occur to me when we were talking the other day, but I raise it now because it seems relevant. In some of the other reports that the committee has done, some of what we have done by way of background is to talk about other authoritative reports that we have done.
DR. GREENBERG: That is what I was thinking, maybe that segue.
MS. KANAAN: I don't see that on your outline. I wondered if we should add that on the outline.
MS. COLTIN: We haven't even started talking about the outline yet, so right now can we hold that question and get to that when we get into the outline?
MS. KANAAN: Sure.
MS. COLTIN: But I think it is a good point, and we do need to make sure that we address it someplace as well. But I mainly wanted to get through these broader issues, because I think the outline is very detailed.
MS. KANAAN: Sure.
MS. COLTIN: Then my next question was, should the recommendations be organized according to the same framework, or some alternative framework. So it makes sense to organize the findings according to the IOM framework. It may make more sense to organize the recommendations according to whom we are addressing them. They might be recommendations that are made to the private sector versus the public sector or recommendations that are made to particular agencies within the private sector or the public sector. So I wanted some reaction to that.
DR. LUMPKIN: I think after my experience with the NHII, I think you have to look at the recommendations and decide. We started out and we finished up with to whom it is focused. Then as we went further down our list of involved parties, the number of recommendations started petering off, and that is kind of strange. The first one had a whole bunch, and then fewer and fewer. There might be a potential for that to occur.
So I think we probably ought to look at it, see how it fills out. Maybe try it by each category, but if that seems to peter out, to maybe look at a different structure, but not lend ourselves to one or the other right now.
MS. COLTIN: Is everybody else comfortable with that? All right, that's fine.
The next item that I had listed here were gaps in the work group hearings and panels. We have a full committee meeting coming up in June, and if there are some major gap areas in the hearings that we held so far with regard to using the IOM framework, then we need to see about plugging those gaps by organizing a panel, perhaps one in June, perhaps one in September.
I took the liberty of listing some of the areas where I thought we really hadn't heard from the field. I thought we could go through these and see whether we would like to hear from these groups.
The AMA and a lot of the medical specialty societies have developed their own measures that they are implementing. We did not hear from them formally. So there is a whole initiative at the AMA and a whole committee that has been putting out measures that can be used for quality improvement in particular. A number of the specialty societies have put out measures, some of which are publicly available on websites, but most of which are not and are used internally.
They obviously run into data gaps and issues as well, in constructing measures. I thought that given the movement toward trying to bring measurement down to the level of individual practitioners, that hearing particularly from the specialty societies and the AMA would be important. So I wanted to suggest that as perhaps a topic area that we had missed and should address, and might be able to organize for June.
DR. JANES: Did you solicit input from them and were refused, or you didn't approach them?
MS. COLTIN: No. Each panel we chose a topic area for the panel, and then went out and found people. We did not have a panel on individual level measurement. So that is more what I was thinking. That is more the topic area, the individual practitioner measurement.
There is a lot that is going on in that area. There is a paper that has either recently been published in JAMA, or is about to be published by Jennifer Dailey that she did for the American Board of Medical Specialties around issues and measuring at the individual provider level. There is a lot of experience that is beginning to be accumulated by some of the specialty societies on what some of the issues are as well. So I thought that would be a timely topic to include, and something we could potentially organize for June.
DR. JANES: Obviously we all have our own perspective, but at least at CDC that is an issue I hear about constantly. So my vision is that it is a hot issue, and we should address it.
MS. COLTIN: So if we are agreed, I think we should try to put a panel together for the June meeting on that topic area. If you have ideas for particular people that you think should be invited, I know a lot of people who are doing work in that area, and I can float my ideas, and then maybe you can piggyback on and add anybody that I have missed that you think would be good to approach.
DR. GREENBERG: And you would like that for the full committee?
MS. COLTIN: For the full committee. That is how we have done it in the past, is hold these panels on the full committee.
The other possibility is to think about having a separate hearing. If we have got enough of these that we think we need to cover, we may need to. But we may decide that some of these are not areas that we do want to get into. But let's go through them and see.
Another issue was safety net providers and the uninsured, and how do you get information about quality of care for the uninsured. A lot of people are treated in state-based block grant programs or whatever, where it is not clear what the data collection mechanisms are or whether there is any standardized data available about the services that are being provided to that population.
DR. GREENBERG: The community health centers, HRSA.
DR. JANES: All I know is that about three years ago when Earl Fox was either coming in the door or -- that was certainly a significant topic. What we were hearing was that they had been collecting all these data for years and years and years, but had never done anything with it. They were in the midst of an initiative to try and develop some standards and to use that for quality assessment.
It was one of those things where you hear some things about it, and then it drops off the map. I don't know what is going on.
DR. STARFIELD: There is a big unit in the Bureau of Primary Health Care that is on quality.
DR. JANES: It should be easy to tap into those folks and at least ask the question of what is going on.
MS. COLTIN: I know they are doing some stuff, but we didn't hear about it. So that was an issue, should we particularly address that topic, because that is a major gap that came up. If you are using administrative data, which is data submitted for claims payment, there is no data submitted for claims payment for the uninsured. So it is a big gap in the data systems.
I know in Massachusetts, and I don't know about other states, we do get from the hospital districts abstracts.
DR. GREENBERG: I was going to say, the state systems collect for everybody.
MS. COLTIN: Right. So there is some data, but there are some big gaps with respect to that population.
Another topic was non-traditional service providers. Susan had clued me into this, I hadn't been thinking about it, but school based clinics is a big area that the RWJ has been involved with.
If you are interested, this is a recent publication from RWJ about the school based health services. They have a whole bunch of quality measures that they are collecting on for school based health programs.
DR. JANES: The local school board, is that who pays for it?
DR. LUMPKIN: I think in our state they are funded through state grants, those kind of things. School boards, they like to have their hands clean about what goes on in these clinics.
MS. COLTIN: But you see these grids that show what it is they are measuring. It was interesting to me that they had these measures. A lot of them seemed to be chart review type measures, but I didn't know what kinds of charts they kept, or whether there were any electronic systems or whatever. So it seems to me that if we are doing measurement about care provided to children and adolescents, might we be missing a big chunk of what is going on if we are not getting information about care that is being delivered in school based clinics.
Some of the surveys would pick up some of that type of information, the population-based surveys. But clearly the administrative data could be lacking. One of the issues is, have any of these schools formed relationships with payors in their area, that they provide services that are reimbursed by the payors in their areas, in which case the data would be in the payor's system, any administrative data. But it is not clear that there is any uniformity around those kinds of practices.
MR. AUGUSTINE: It makes sense from the payor's perspective. They want to squeeze every little ounce out of their HEDIS scores.
MS. COLTIN: They certainly want to get the data.
MR. AUGUSTINE: It is hard to get any better. When HEDIS and NCQA first came out, the first opportunity for improvement was in data measurement and data quality. Then after that, then you had to start doing interventions and improve patient care. There is not a lot more left to do with regard to immunizations. The best place to do it is to try to find these little places where you can get data that you don't already have.
DR. LUMPKIN: I think when I look down this list, the question is what is going to be the scope of this report. I just wonder if, by adding these things, we start -- the first one obviously is a clear gap. But I think the other areas we may want to identify as future work for the work group, and look at specific reports focusing on those areas, rather than trying to put together something that is trying to do too much.
DR. GREENBERG: I do think if you want to try to do these, it is going to definitely delay the report, because you can't get this in one panel in June, so you probably would need a one or two day hearing.
DR. JANES: And I think you will find these are -- when you start working with these non-traditional health care providers outside of the traditional, it is going to get murky and muddy.
MR. AUGUSTINE: There is no one group that represents these.
DR. JANES: No, it is fascinating, but it is going --
MS. COLTIN: That is a relief. I am glad to hear people say that. I think it would be perfectly appropriate to raise these issues in the report and say that they represent potential gaps in data, because it is not systematized.
DR. GREENBERG: The one I am a little uncomfortable about ignoring is the safety net providers and the uninsured. If you are talking about disparities in quality of care, the uninsured, people without a regular source of care, et cetera, have got several strikes against them, if higher quality of care is continuity of care and all that.
DR. STARFIELD: I think it would be relatively easy to add that.
DR. GREENBERG: I think it would be worth it to hear from -- because we know where they are. Not that they are the only ones that deal with the uninsured, because that is a major --
MS. COLTIN: Part of this will depend on how much time you can give me on the June meeting.
DR. GREENBERG: You are stepping up to the plate early here.
MS. COLTIN: I think the AMA and the medical specialty societies, that could easily be an hour to 90 minutes just to do that. In fact, I would say 90 minutes. Hearing from the Bureau of Primary Care, if we are just talking about bringing one person in to talk, then that is fine. We could do that in half an hour.
DR. GREENBERG: But you probably want to hear from a few community health centers.
MS. COLTIN: Or somebody from a league of community health centers or something.
DR. LUMPKIN: I don't think you want to go there. I think that we have looked at Medicaid, which is a major provider for where there are areas of disparity. But when you start getting into these community health centers and the other ones, they have a totally different reimbursement structure, they consider themselves to be different than other agencies. There are just going to be a ton of issues that we won't be able to get into.
So I'm just concerned that that is going to really muddy our focus. If they come and get involved in a hearing and they don't see what they talked about in a report, they are going to feel like they have been slighted.
MR. AUGUSTINE: You've got migrant health, and you have some sort of review mechanism where they go out and look at community health centers on quality.
MS. COLTIN: Some of that is addressed in the Medicaid managed care report. In fact, we had made a conscious decision that we were going to try to integrate and fold our activities in. So what we wanted to do is go back to the Medicaid managed care report and pull out the quality issues, go back to the functional status report and pull out the quality issues, go back to the insular areas report and pull out the quality issues. So we weren't going to try to recreate the wheel in that regard.
So each of the efforts that had been done by the Subcommittee on Populations, we were going to try to pull out the quality issues from that work and not hold separate hearings. So I would even argue that some of what we are currently doing on the race ethnicity in the hearings that we just had could also be brought into this report, in terms of what is relevant for quality measurement. Clearly that is right on target with the disparities issue.
So I guess we can address the issues of the safety net providers and the uninsured by pulling out what we already learned about that from the Medicaid managed care reports. There was something in there.
If you look at D, mental health and substance abuse, we did have one panel where we had one representative. We had Eric Doppleward from SAMHSA come in and talk a little bit. But we really didn't cover that area much at all.
So I wondered whether we should have a panel. There is a lot going on. The American College --
MR. AUGUSTINE: Their data systems are weak compared to primary care.
MS. COLTIN: They are weak, but they also have all the privacy issues. It seemed to me that it was important to bring them in because of some of the other unique issues.
DR. GREENBERG: If you look at the priority topics, it seems depression is always right up there. This cuts across all the populations.
MR. AUGUSTINE: AHRQ or somebody came out with a study a few years ago that said that if someone was depressed, they were 30 percent more likely to utilize a physician's office services. I thought that was really interesting. That was one of the things that incentivized NCQA to start putting such a focus on the mental health aspect of care.
MS. COLTIN: There was a study at Group Health Coop that looked at the costs of care for people who are depressed, costs of care for asthma, costs of care for diabetes, for all these other things. If you looked at the group that had depression, it was much greater.
DR. LUMPKIN: So the question is, are we talking about mental health and substance abuse services in primary care and clinical service delivery, or are we talking about quality in those service providers who are focused on mental health and substance abuse?
MS. COLTIN: I think both. I think we are looking at the quality of care for mental health and substance abuse problems, whether that care is delivered in the context of a primary care practice or a specialty practice.
A lot of the measures -- I know at least the HEDIS measures are blind to where the service is provided. They simply say, if you were prescribed an antidepressant regardless of whether it was a primary care physician or a psychiatrist, did you stay on the medication at least long enough to give it an adequate trial, and did you stay on it long enough to potentially have a remission.
DR. LUMPKIN: I ask that question, because I think if we are looking at the measurement of mental health and substance abuse services, we talk to NCQA and all these other groups who are in the process of measuring it, I'm not sure it is as big a gap, not having mental health and substance abuse providers. They tend to operate in their own little silos, in the kinds of facilities that tend to be specific to those. Those are the providers groups that we would invite and would come in, would be those who run primarily mental health or substance abuse facilities.
MS. COLTIN: You're right. I think we have heard about some of the mental health measures in the context of broader general practice, but I don't think --
MR. AUGUSTINE: They are a gap from the data quality perspective, but not a gap necessarily from the quality measurement perspective.
DR. LUMPKIN: But we could say in the report that we are talking about mental health and substance abuse services as delivered. We have not looked at those specific specialty facilities, and try to keep the report to the general quality issues, saying that there are specialty care facilities.
DR. GREENBERG: If you were going to look at those, that would be a whole other investigation.
MS. COLTIN: I'm not even talking about facilities. I'm just talking about community-based mental health services.
DR. LUMPKIN: But again, the whole mental health system is a totally different system and operates separate from the general mental health care delivery system.
So there are ways to -- if as NCQA and HEDIS talks about, which is that the site isn't specific, then we may have adequate testimony. But if we are looking at the whole mental health delivery system and substance abuse delivery system, which in many ways is outside of the primary care, then I think that that is a different ball of wax, and maybe we ought to do that in a more focused look, set the agenda for a more focused look at the non-traditional providers.
MS. COLTIN: You mean, not within the context of this report, but in a separate initiative?
DR. LUMPKIN: Right, the context of those systems and measuring quality in them, versus the delivery of those services within the health care system I think we need to talk about, but the actual measurement of quality and the separate substance abuse and mental health delivery system really bears a separate and closer analysis.
MS. COLTIN: Well, actually I disagree. I think we do too much separation of mental health and physical health. There really is a need to think about whole person health care, and the fact that that is an important component of health care. To have a report on the adequacy of systems for measuring quality of care and not address quality of care in what is an important part of the health care system, to me is a major gap.
I could actually see a panel with just four people on it that I think would cover the ground pretty well. There is a group called the Washington Circle Group that has been working with SAMHSA to develop quality measures for substance abuse services. I would look to bring in a representative from that group.
The American College of Mental Health Administrators has been holding a series of summits and has developed a list of quality measures. They struggled a lot with data issues and what they could feasibly measure and not measure. So I think it would make sense to bring them in.
There is a new survey that is being proposed by NCQA as part of the accreditation program for managed behavioral health care organizations, which is a survey of patient experiences with mental health and substance abuse services, the ECHO survey. So I think the developers of that survey could come in and talk about that and what some of the issues and challenges were.
Privacy was a big issue in developing it and the methodology that they came up with to try to address that is interesting. Then I think somebody from SAMHSA who could provide a broader umbrella view of where they are headed.
So my sense is that that probably could be done again in a single panel, if perhaps not at the June meeting, maybe at the September meeting
DR. GREENBERG: You have convinced me, though. I think you are right. I think we abandoned mental health when we abandoned the mental health statistics subcommittee, just because we could only do so many things.
But I think maybe you are not disagreeing totally. I think John has in mind some more specialized drug abuse clinics and that type of thing, which might be a little out of scope.
DR. LUMPKIN: I think that we may not -- where you are at and where I am at is not that far away. I think having this hearing -- I still think that we ought to as part of the report identify that there are certain systems or sub-systems in health care that may need to be evaluated, to the extent that there are additional services to other components which would not be measured by the kind of measurements that you are talking about.
Behavior, mass casualty gets a ways there, but there are still other systems, the state funded systems, which I think a lot of them aren't being looked at very closely as to the quality.
MS. COLTIN: And hopefully we would hear about that kind of issue from the SAMHSA representatives, saying can you address some of those gaps.
DR. LUMPKIN: A fascinating statistic I picked up when we were doing the performance measurement with the Institute of Medicine, about five percent of the cost of mental health services at the community and state level are federally funded. So SAMHSA's involvement in mental health services at the community level is fairly minimal. It is primarily a state and private funded system.
DR. GREENBERG: Which is being cut back.
MR. AUGUSTINE: Are you going to have a private representative there? They are the ones who are going to be able to tell you how the data quality -- I forgot the names of the major health care providers, but maybe someone who would be able to testify on the data quality --
MS. COLTIN: They are very involved with both the -- particularly with ECHO; they have been very involved with that, because it is going to be used to evaluate them. So they have been a part of that work group.
I think in terms of the American College of Mental Health Administrators, probably less so. I think it probably would be good to hear from the field. They have a set of measures -- AMBA is the association, American Managed Behavior and Health Care Association, and they have a set of measures that they proposed. They did an interesting study about the feasibility and the problems in collecting data. Their system is called PERMS. I forget what it stands for. So we could potentially invite somebody from AMBA as well.
DR. JANES: What is the relationship between AMBA and the American College of Mental Health Administrators? Is one the providers and the other the organizations?
MS. COLTIN: The Mental Health Administrators might be the administrators in a mental health center or clinic.
DR. JANES: So they may be providers and they may be administrators.
MS. COLTIN: They may be people within health plans who are responsible for the mental health services in that health plan.
DR. GREENBERG: Do they administer the benefits, maybe?
MS. COLTIN: A lot of them aren't clinicians, but they are also administrators.
DR. GREENBERG: I would suggest -- I think that is a good idea, and I think it is an area that has been under addressed by the committee in general. So having a panel at the --
MS. COLTIN: I just thought it would be a major criticism of the report.
DR. GREENBERG: Yes, I think you are right. I think what we should do is, I think you should start thinking about who you would want on these panels. The executive subcommittee is having a conference in early April. That is a ways off. Why don't we plan on one of these for sure, and start working on it for the June meeting, and then when we have that executive subcommittee conference call, we will have a better idea of what else is going to be on the agenda in June? Then get a sense of whether we should try to do two panels at the June meeting or do one of them in September.
MS. COLTIN: Okay. The other possibility is that -- again when I was talking with Tom Reilly about what they need in terms of advice on the national quality report, their timing is that they would like us to hold a hearing at the end of July.
So part of my thinking was that we have an executive committee meeting scheduled for the last week in July in Chicago. Perhaps Thursday in Chicago might be a good place, since most of us that are on the quality work group at least are going to be there. So it might be possible to holds hearing that day particularly on the topic that Tom is most interested in, which is reaction to the topics. But we might also be able to squeeze in a panel toward the end of the day too, because I'm not sure it will take all day to get reaction to the topics.
DR. GREENBERG: It depends on where you think the people are going to be coming from. If they are not necessarily coming from Washington anyway, then it is fine to have it in Chicago.
MS. COLTIN: He was talking a lot about the professional societies and all. Some are in Washington, but a lot are in Chicago.
DR. GREENBERG: Oh, definitely.
MS. COLTIN: So I think it would be a reasonable timing.
MR. AUGUSTINE: Speaking of medical specialty groups, you might as well have the medical specialty groups that you want to have at the hearing at the same time, because in some cases it might be the same people.
MS. COLTIN: Yes, maybe we should do the mental health in June and do the medical specialty -- actually, Tom wanted information on both topics, the listed topics and the data issues. So if we brought in the medical specialty societies, we could get them to address both.
DR. GREENBERG: That would make sense.
MS. COLTIN: Good idea.
DR. GREENBERG: Yes, that would make a lot of sense. So maybe looking at doing the mental health panel --
MS. COLTIN: At the June meeting.
DR. GREENBERG: -- at the June meeting, and July with the specialty groups.
MS. COLTIN: That would make it more convenient for them too, because we will be in Chicago, rather than bringing them in in June to do the hearing in Washington.
DR. JANES: When is that meeting in July, do you remember?
DR. LUMPKIN: The 26th.
MS. COLTIN: So we would be talking about the 25th, which is the Thursday.
DR. LUMPKIN: Depending on the arrangements, we can probably find a spot at the State of Illinois Center.
MS. COLTIN: That would be great.
DR. GREENBERG: You mean, for the --
DR. LUMPKIN: For the hearing.
DR. GREENBERG: I have already requested that we not have our meeting at the airport again.
MS. COLTIN: So that would actually work well because then we could be finished by the end of July.
DR. GREENBERG: Yes, that would be good.
MS. COLTIN: I am making the assumption -- I had dental care on here, not to give them short shrift, but I am not aware of their inclusion -- they have been struggling to come up with a quality measure for dental care, because the Medicaid program and the SCHIP programs have been very interested in trying to develop some. They have come to the Committee on Performance Measurement at NCQA two or three times with proposed measures, and every time there is just such controversy about it, and there is no consensus.
DR. JANES: Is it the ADA?
MS. COLTIN: I think it is the ADA and there is another group, too. They had a panel that had representatives from a number of --
DR. GREENBERG: Would you say there is a cavity in their views?
MS. COLTIN: I would propose leaving it out, but acknowledging that we left it out, so that it is not that it was off the radar screen, it was just out of scope. I don't think we will take as much criticism for that being out of scope as we would for the mental health.
DR. GREENBERG: I agree.
MS. COLTIN: Then I had listed the dissemination channels with a question mark, only because I wanted to make sure that we agreed that reporting was out of scope. So if it is, we don't need to address that.
MR. AUGUSTINE: About the dental piece, we are going to start learning that the dental piece is important, just like the mental health piece, in overall holistic care. They had that study that came out last year about the, gingivitis leads to increased rate of heart disease.
DR. GREENBERG: That is plaque.
MS. COLTIN: Yes, it definitely is a gap, and I think we need to acknowledge it as a gap in the report.
DR. GREENBERG: It is a big issue for children. And quality of life, but nonetheless, --
MR. AUGUSTINE: Can we make comments on the outline?
MS. COLTIN: What I thought I would like you to do is -- this is just off the top of my head, rough draft of the kinds of things I thought we would touch on. I would just like you to take it and react to it and send me e-mailed comments about it, as opposed to -- we don't have time to go through it in depth today. But I did want you to have something to react to.
You will notice, just because it is my bent, that I have a lot of background here. I don't see the pages in the report that are devoted to background being proportionate to the length of the topics here. I think we would very lightly touch on a lot of these things, because the meat of the report is Roman numeral three, which is the findings and all from the hearings and the recommendations.
But if you think I have missed something that needs to be in here in the background, even though it is quite lengthy, please suggest it. If you think there is stuff that doesn't need to be in here, that would be great. I would be happy to cut anything that you don't think needs to be said.
But I would particularly appreciate you also focusing on Roman numeral three, because that is really the meat of it, and suggestions about
DR. JANES: Do we have a time frame that is being imposed by external forces, or do you have a time frame that you have in your mind?
MS. COLTIN: Susan and I talked about this a little bit yesterday. There were a couple of components to putting this report together. One is that Susan has agreed to go back through all of the minutes for all of the panels, the full committee meetings where we had panels, and pull out from the testimony that we took the common themes and findings and suggestions about both what were the gaps, what were the data quality issues, the limitations in the data that are currently available, and then any suggestions that were offered or recommendations that came from those who presented as well, that we can look at and see whether we would endorse them or not.
So that was one piece of work, was to go back through all the panels, as well as, there were two separate hearings that the work group held, one in November of '98, an evening one, and then one on December 12 of this year, which was the patient safety one.
Then the other thing is to go back through the related reports, the Medicaid managed care report, the territories and insular areas report, --
DR. STARFIELD: Actually, you are missing that one.
MS. COLTIN: I don't have the Medicaid managed care one?
DR. STARFIELD: You have the Medicaid one, but you don't have the Asian Pacific --
MS. COLTIN: I should have put that, you're right. If you see any gaps or something I forgot to include, please just jot me an email and we can copy Susan on it, too. So this outline will be a work in progress, and we will try and get something out to you with those initial reactions, and then have you react to that more formally at the June meeting.
MS. KANAAN: So should we just ask people to send their comments to both of us?
MS. COLTIN: Right, to both of us I think would be helpful. Then we will revise this accordingly and get it back out to you for reaction, so that we can then proceed.
MS. KANAAN: We were thinking of maybe trying to have a report for the committee to review at the February meeting, right, Kathy?
MS. COLTIN: Right.
MS. KANAAN: February 2003.
MS. COLTIN: Right. We were hoping that we would for September at least have something preliminary.
MS. KANAAN: I thought it was November. Didn't we change it to November?
MS. COLTIN: We did, you're right, we changed it. November was something preliminary in terms of the actual findings, having pulled all the stuff from the minutes and the common themes and the findings.
DR. GREENBERG: And then something for approval in February.
MS. COLTIN: But in terms of the -- I would like to be able to finalize the outline by the June meeting, and then identify the --
DR. GREENBERG: Pending the June hearing and the July hearing.
MS. COLTIN: I am just talking about the outline. So knowing what we know about what we are going to hear, who we are going to hear from, if you think that there is a broad topic area that is missing here -- most of these are not specific to mental health or whatever; it is very broad, what were the common themes that we heard. So I think that you can react to this without having -- and we can have an outline without having heard from the medical specialties. They are reflected in here, even though we don't know what they are going to say yet.
DR. GREENBERG: I get your point.
MS. COLTIN: So if we can agree on this by June, then that at least leads us to what work needs to get done. So there is a whole piece of background work that needs to get put together. Then there is the work summarizing what testimony we have taken up to now.
MS. KANAAN: And you would be working on your recommendations at your September meeting, right?
MS. COLTIN: Right.
DR. GREENBERG: We do have precedents. We may at some point release you from this committee. I'd be happy if you were on it the rest of your life, but I don't think you probably would be.
MS. COLTIN: So please do, please email me with your comments. I can also send this out electronically.
DR. GREENBERG: Make sure that Susan is on the email, then everybody will have everybody's email and they can respond to it.
MR. AUGUSTINE: I missed the hearings. Were there any discussions about risk and severity adjustments?
MS. COLTIN: There will be a lot of stuff in the testimony about that. Mostly, don't forget, we are not talking about methodology, we are talking about data. So what would come out is that the data weren't granular enough to be able to --
MR. AUGUSTINE: The data requirements for doing that are a lot different than the data requirements for just a regular measure. We are finding that they don't code racial and ethnic data correctly, so we are having a hard time making those types of adjustments. I mentioned to Debby about looking back; '99 on are on the website, but pre-99 are not. So maybe getting some stuff out of the archives for '97 and '98.
MS. COLTIN: Yes, we will need to go back and do that.
DR. GREENBERG: Kathy, you will be working with Stan on the panel for -- probably on both of those, because I think we decided that we were definitely going to do it in those two stages, right?
MR. AUGUSTINE: I will probably have knee surgery at the end of April, so you will probably need somebody to help out for part of the time.
DR. GREENBERG: But we have got a plan.
MS. COLTIN: So I think we are adjourned. I will get this out to you electronically. If you can get your comments back to us by say the 15th of March, that would be really helpful.
(Whereupon, the meeting was adjourned at 5:55 p.m.)