This Transcript is Unedited
Department of Health and Human Services
Hubert H. Humphrey Building
Washington, DC
P R O C E E D I N G S 3:50
MS. COLTIN: We have got about an hour and 15 minutes, and we are going to spend about 10 minutes hearing from Dan regarding the visioning project that has been going on, the activities. You have had three meetings now, and then we will turn to the insular areas and territories report. I have about 15 to 20 minutes to try to address -- there weren't a lot of issues brought up but see if we can adjust for those, and then we will have 30 to 45 minutes to talk about the report.
Okay, if we can try to keep to that we may get through this agenda.
Dan?
MR. FRIEDMAN: I will be quick in that case. As you know there are one, two, three, four components to this 21st century process. The first is the five papers if I am counting correctly which have already been commissioned and we have had a series of conference calls with the authors. I have lost track. I don't know how many it is but it is quite a few, and we are in the process of scheduling additional conference calls with an aim, and Jerry, please correct me if I am wrong of having a first draft somewhere in the August, September range?
PARTICIPANT: September 1.
MR. FRIEDMAN: September 1, and certainly what we have heard and given the time I am not going to go through the speech but what we have heard in the way of preliminary outlines several of them look quite promising and the discussions that we have had really have seemed quite promising. There are, also, at least one other paper that we would like to get done, one and one-half other papers. There is one other paper that we would like to get done having to do with a review of past recommendations relating to system or systems and it is not quite clear yet. We had hoped that CINSTAT(?) was going to do that they don't seem to be inclined in that direction. It is not quite clear what is going to happen with that and NM(?) had a meeting I attended recently where we did a, in reference to a recommendation that SOMNIK(?) volunteers have a paper done on health statistics vision and local areas, health statistics needs in local areas. It is not clear if that is going to happen or not or if that is going to be sort evolved out.
So, that is one set of activities. That is clearly moving along. Secondly there have been a couple of discussion groups broadly speaking on health information needs of the 21st century that were held in, I have forgotten the dates but have been held in the past several months and one working session on basically definition of health statistics, criteria for evaluating health statistics and so forth.
I thought they were very good sessions. Larry Barlett was the facilitator. Barbara was at all of them, and I thought they were very productive. We have first or second drafts of a summary of those that we are sort of circulating internally now among people who were most involved, and hopefully those drafts will be ready within a couple of months.
The third activity is since that workshop which has been scheduled for early November I have here in hand, I was just given by Jane Jirch the latest draft of the agenda which she said I could certainly share with the subcommittee, and what I would suggest is maybe I could leave it with you, Patrice, and tomorrow you could just get copies.
PARTICIPANT: We can get copies in the afternoon.
MR. FRIEDMAN: Oh, if you could that would be great. Unfortunately we don't really have time to discuss that draft, but I would really encourage people to e-mail me or you can e-mail directly to Jane. There are some things that I think we really need to discuss about it. I will be glad to take them. There seem to be some, what shall I say, procedural issues about how since that deals with the committee and NCHS, but having said that overall they eventually seem to have been fairly accommodating in terms of our suggestions. I only glanced at this. I haven't really read it carefully.
A fourth, actually there are five things, a fourth part of the process that really needs a lot of effort and a lot of thought is a more quote, public process on how we solicit broader professional input and broader consumer input and broader advocacy input, and this has been really a very small group of people that has been very much focused in Washington both literally and figuratively.
I think that Barbara and I have discussed it. We have discussed it with NCHS and there seems to be some real agreement that we need to broaden it out greatly, and we are taking as some informal models for that broadening both the NIOSH, National Occupational Research Agenda process which was focused very much on building specific research agendas and this is not necessarily research agendas we are talking about. This is essentially an expert group approach but together with that and preceding that more the kind of an approach that was used in Canada in the national health information needs process which is really trying to go out and solicit some broader opinions. Marjorie isn't here, but we keep talking about going to Fargo. In any case whether it is Fargo or not I think it is really important to get out of Washington, go to a couple of real local areas, not necessarily San Francisco and not necessarily Chicago but certainly not necessarily Boston but really get out and see some discussion and not see it just from the folks whom we talk to all the time and so that is part of it.
Part of it would, also be going to professional meetings and trying to engage in these discussions. We had something that we called a town meeting a couple of weeks ago at the National Association for Public Health Statistics Information Systems, and Gail was there. We set aside an hour and one-half for it, and we were actually quite concerned that we were going to have to end it after around 5 minutes before we started it, and it ended up being a very successful discussion and I think really helped us. Interestingly enough, and these were people who are whatever, health data professionals after around half an hour or 45 minutes we had to cut off discussion on the confidentiality issues because that is what everybody wanted to start with, and these were by no means privacy fundamentalists.
Then the final part of this is really trying to nail down some concept in terms of what we want to do in terms of products, and I think that has been evolving over time. I think when we started there was much more of a focus on the CINSTAT workshop as sort of the epicenter of these activities and we are really moving away from that, and I am very glad of that, and we are talking now about two or three things one of which is some sort of a vision report. Second is some sort of a road map and hopefully with some level of specificity, and third, perhaps some kind of an edited volume making use of the commissioned papers and some other relevant material dealing with health statistics issues in vision, etc. That is the 10 minutes.
MS. COLTIN: You did great.
I was remiss at the start, I didn't do introductions, and I think for the purpose of the minutes on the tape we should just go around and say our names, so that they will know the attendance at this meeting.
I think the committee members can just say our names. For anyone who is not on the committee you probably should say your affiliation.
So, I am Kathy Coltin.
MS. WARD: Elizabeth Ward.
MS. AMARO: Ortensia Amaro.
MS. JAMES: Gail James, CDC and staff to the subcommittee.
MR. SUMMY: Jim Summy with AHCPR.
MR. LUMPKIN: John Lumpkin, Illinois Department of Public Health.
MR. MOR: Vince Mor.
MR. FRIEDMAN: Keenan Friedman.
MS. STARFIELD: Barbara Starfield.
MR. NEWACHECK: Newacheck.
MR. HANDLER: Aaron Handler with Indian Health Service, staff person to the subcommittee.
MR. HENDERSHOT: Jerry Hendershot, National Center for Health Statistics, staff to the committee.
MS. WILL: Margaret Will, Office of Emergency Health Policy.
MR. ENNINGER: Stan Enninger, AHCPR.
MS. QUEEN: Susan Queen, HRSA.
MR. HITCHCOCK: Dale Hitchcock, ASPI(?).
MS. RYAN: Carolyn Ryan, State Fund.
MS. COLTIN: Thanks.
Okay, now, we can move on to the next item which is, Elizabeth if you could sort or recap for us the suggestions that were made at the full committee that we need to consider?
MS. WARD: I came up with one. I think that we had some discussion, but I think there was one recommendation to add another recommendation, and I wrote down my recommendation. Request the data council to identify a single point of accountability and a point of contact related to health statistics, health information system, data needs for the Pacific Island areas, Puerto Rico and the US Marshall Islands. I think that is what you said.
MR. LUMPKIN: I wish I had said that.
MS. COLTIN: Why don't we put that on the table as a motion to add a recommendation with that wording?
Does anyone second?
MS. NEWACHECK: I do.
MS. COLTIN: Okay, discussion?
MR. MOR: I was just reading Recommendation 14, and that doesn't, this doesn't, there is no, because it is a specific recommendation asking HHS to say something to the Department of the Interior about development of health data on systems in the islands. So, I just wonder how these two dovetail.
MS. WARD: I think we could add, I thought about starting off with make sure the Data Council reads the report, but I just assumed that we would be doing that anyway, but we could say, "Look at all the other recommendations that the committee has looked and see how they could" -- I would see that as being assigned to, once they this point of accountability, point of contact, they would say, "Here are the reports and recommendations. How would you do something about these?"
MS. PRIMARO: I think part of the issue because these different entities have different relation to US Government that DHHS isn't always the right, even though it conceptually makes sense that it is the Department of the Interior in some places that needs to relate to them. So, I think both avenues are good, and there needs to be collaboration.
MR. MOR: I am just worried about their being in some sense contradictory, but reading it more carefully 14 wasn't inconsistent.
MS. WARD: That is why I started with sort of a yes, but back to the committee, but I think the point that was worth it is that at least for all the stuff that HHS does that they have a responsibility for they ought to have a single place for all these people to go to.
MR. MOR: I think it is important, and the language you use does not necessarily imply that all of these concerns would go to one entity, one individual in HHS but rather that necessarily that all of them could be identify to having a route of responsibility. So, it could well be as was suggested upstairs that the Virgin Islands, Puerto Rico, etc., would have one group within the HHS orbit to talk to and the Pacific Islanders might have another group to talk to. It is not necessarily as we heard that they have anything in common.
MS. WARD: But there would be one point trying to make sure that there was --
MR. MOR: Right, that there is somebody who is responding to them.
MS. WARD: Coordinating and accountable.
MR. HANDLER: I used to be an employee of the Population Division of the Census Bureau, and they have a special office that handles the censuses for outlying areas including all of these locations and there isn't one office that handles some and one offices that handles others. It is one office that handles all of these. That would be a parallel type structure. There is a precedent.
MS. STARFIELD: Doesn't it make sense to put the new recommendation as part of 14?
MR. MOR: It could. We might have it as a preface and then say, "Oh, and by the way," but then actually --
MS. STARFIELD: If we are talking about HHS it is going to be the Data Council that does it, I think.
MS. RIMES: Maybe you are saying that one was staff and one was, that there is a place at the table issue, I think.
MS. STARFIELD: HHS should work with other departments. The Data Council of HHS should follow the plan to work with the --
MR. NEWACHECK: It seems like there are separate issues. One is attribution of responsibility and accountability and this is working with other agencies.
MS. STARFIELD: We cannot recommend that, I don't think. I mean we can recommend that HHS do it. We cannot recommend that other agencies do it.
MR. MOR: Right. That is what this says. Fourteen says that HHS should work with other agencies.
MS. STARFIELD: Should but how is it going to do that? It is going to do that through the Data Council or that is what we are recommending anyway.
MR. MOR: Now, we are recommending that HHS and the Data Council identify specific groups, entities with individuals within HHS to do it. That is all.
MS. STARFIELD: It seems to me to be logically part of 14.
MR. MOR: It would be in the same section.
MS. STARFIELD: Would it be No. 15?
MR. MOR: Yes, that way you don't need any more editing.
MS. WARD: And I will make sure that Dale and the first author, Joan, get recognized tomorrow. I forgot to do that. I will make sure of that because this is an enormous amount of work, Dale. I want to say that to all the people around the table.
And Aaron found one edit that he can point out to you.
MR. HANDLER: The draft I was handed out today on Page 24, Recommendation 14 says, "Now, HHS should, also, support DOI's efforts to export IHS's patient care information system to the Pacific Insular areas." Actually the IHS is Indian Health Service where I work. The patient care information system was revised within IHS and now it is called the Resource and Patient Management System. However, when there were some representatives from the outlying areas that came to IHS, saw what we were doing and wanted the same thing done in their locations, then it was called the patient care information systems, and now the correct name for that data system is the Resource and Patient Management System, RPMS, and it is part of our own Department of Health and Human Services. It is not DOI.
MR. HITCHCOCK: But DOI is working with HHS and these islands to encourage the adoption of the system.
MR. HANDLER: Yes, but it is the system that is being run by the Indian Health Service that they are talking about.
MR. HITCHCOCK: I don't see the problem with the sentence.
MR. HANDLER: They are not identified as being part of Health and Human Services. DOI is the system we are running. I don't know if they are paying our people to go there.
MR. HITCHCOCK: No, they are paying for infrastructure, for training and for travel of their own folks.
MR. HANDLER: Maybe we should make it clear that what is called now the RPMS system is part of the Department of Health and Human Services. It almost reads as if it is part of DOI.
MR. HITCHCOCK: All right. I see your point.
MS. STARFIELD: So, it is the HHS Resource and Patient Management System?
MR. HANDLER: Right, well, from Indian Health Service. It is a subgroup of the Health and Human Services.
MR.. NEWACHECK: One minor point, if we are going to add Recommendation 15, the subheading in front of that Beyond HHS doesn't really make sense anymore. We will have to change that.
MS. AMARO: Kathy, I just wanted to make a comment. I think that part of the effort of this report and the recommendations was to get us, HHS and other agencies to really be both inclusive in terms of thinking of mechanisms by which people and needs in these other places can be considered as we develop agendas that we can think of ways to have them be both more physically present as well as the resources going to those areas, and I think when we make those recommendations it is always good to start at home with the behavior you are suggesting, and so, I would really encourage the committee because I am not going to be here next time to really think itself on how it can begin doing that itself in the different meetings that are going to be held, that when we are thinking of vision just as you presented that, not to think on this, but if we are thinking of a vision of anything in the future that we need to make sure that we are including the vision as it would be seen by these other places, so that we begin by doing it ourselves and encouraging other committee members to do that.
MS. WARD: An invitation or something like that for participation and make sure those participants are reviewing materials?
MS. AMARO: Right and to do it in a way that the input, because we heard from people that to get an invitation when the travel was so expensive and the resources are so limited isn't going to make participation real, so, trying to come to something that would really result.
MS. WARD: I meant reviewing material not asking them to come to a meeting but to really make sure that we have some sort of contact. I see that as we need a point of contact and need to go to someone and say, "Put stuff out, and get something back."
MS. COLTIN: Anything else? Any other discussion?
So, your provide the wording to Dale, and we will incorporate it.
So, we had a motion on the table to adopt this, but we never took a vote on the motion. The discussion all seemed to be positive, but is anyone opposed?
MR. HITCHCOCK: Maybe just before, about this review process I agree we should send it out to everyone who participated in the meeting. Does the subcommittee have any feel for the amount of time we should allow for this review to take place?
MS. STARFIELD: If it is going to get accepted before the review, it doesn't really matter, does it?
MR. HITCHCOCK: It just matters to me in terms of doing the staff work.
MS. STARFIELD: What are we going to do with the comments when we get them?
MS. WARD: If they have suggestions, additions, changes --
MS. STARFIELD: But we have already approved the report.
MS. WARD: No, what I said was if there were enough substantial changes after our participants look at it then we will change the report and come back and ask them to recommend a new one.
MS. STARFIELD: What we said was we are not expecting that there will be so many significant changes because what we really want to do, what we are asking the full committee to do is to approve the recommendations. The reviewers may add material about their problems, may add material about who they are. If they change the recommendations then --
MS. WARD: We will come back.
MS. STARFIELD: So, we cannot send it on to the Secretary.
MS. WARD: No.
MR. NEWACHECK: So, should we leave enough time to get their comments and if necessary have say a conference call to make provisions for the recommendations before the next committee meeting?
MS. WARD: Yes, and I think the people who get it need to know that we have a -- I mean they won't think we are very serious about it if we don't say, "Please try to get them back to us."
MR. HITCHCOCK: I want to operate on your schedule. So, I am just asking you.
MS. COLTIN: It seems like if our next meeting is late September then we certainly would want to get those comments by very early in September so that we could potentially have a conference call before then.
MR. HITCHCOCK: Wouldn't a month be adequate?
MS. WARD: I don't know if they take vacations, but we do. Sometimes the summer is difficult.
MR. HITCHCOCK: We are talking federal participants as well as people from the various islands. So, I think probably about a month's working time would probably be all right.
MS. WARD: I think the real problem we are going to have in some of those areas is that people reading it have been replaced. It may turn out that the one person we heard is no longer there. I think we should say something about anyone else who is -- please try to review it.
MR. AMARO: Yes, I think what I was planning on doing is talking to Lloyd Winawata who seems to know all those folks and Lynnette to a certain extent to find out who the current players are as well as where the previous ones may have disappeared to that we can contact.
MS. WARD: And they may be able to personally follow up. I think personal phone calls or contact would be really important. They will have to prioritize responding to that.
MR. NEWACHECK: So, how do we decide whether there are substantial changes that require going back to the full committee? Do we have a criterion?
MS. COLTIN: My guess is if any of the recommendations change we would probably need to go back. If they are just going to change some of the descriptive material it may not be substantive enough to take it back but if the changes they recommend to the material change our conclusions and therefore our recommendations, then I think even one recommendation would require it to go back.
MR. NEWACHECK: It seems likely that that would happen. It is going to go out to a lot of people, and somebody is going to make a suggestion to change one or more of the recommendations. So, should we plan, like build in a conference call or something like that ahead of time, so that we can make sure it is ready to go?
MS. COLTIN: My sense is we are not going to be able to get a conference call together until September anyway because of everyone's vacation schedules.
MS. WARD: So, rather than bring it on the September agenda we would do a separate conference call?
MS. COLTIN: We could do the conference call before the full committee so that we could resolve whatever the suggestions or changes are, and then if necessary bring a revised report to the September meeting.
So, Patrice, can you poll people about availability for a telephone conference call in early September about the insular areas and Puerto Rico and Virgin Islands report?
MR. HITCHCOCK: And we need to send out some sort of letter to almost all of the participants probably asking them what our time table is and asking for real comments and who should the letter come from?
MS. STARFIELD: You mean that the comments will be circulated ahead of time. The letter should come from Lisa but I think the comments should come to you.
MR. HITCHCOCK: That is fine. I was talking about who should sign. Okay, Lisa, good.
MS. COLTIN: So, can you draft a cover letter for that? Okay.
Anything else on the report that anybody wants to bring up?
Then we should move on to the Medicaid request. All right. There were lots of comments as you all heard about the Medicaid report. Carolyn has shared with us a copy of a revised set of specifications, contract specifications and of course, none of us have had an opportunity to review these, obviously. There is too much here for us to do it now.
Can you, Carolyn, sort of tell us what some of the key changes have been?
MS. RIMES: It was generally prepared by attorneys and the key changes that they have made are summarized nicely in bold. A lot of the footnotes that were strictly legal have changed as has the tenor of the sample purchasing specifications. They are more written as guidelines which I think is useful and helpful, and the question about them is you have got some that -- I xeroxed it after I started reading it. So, I apologize for having hen scratched on some of them, but I think it is more of a helpful sort of document as compared to an assertive mandate document and the question that arises, there are two questions that arise around this. One is how you would recommend that we have this document reviewed, and second, because the draft report on the Medicaid report from this subcommittee is based on the specs that you have in front of you or will be based on this, the final specs, how do you want to proceed with the document?
Kathy and I talked a little this morning. It basically will change some of the tenor of the document, but we are assuming that we will be enclosing these final specs in the document as a tab, because if we get this any longer no one will read it, a la the Sorting(?) no one really read anything but the recommendations, and I think that unfortunately a lot of the interest in the report was missed by that.
So, I don't believe we are going to have final specs any sooner than September.
MR. NEWACHECK: Do these take into account the three pages of comments?
MS. RIME: The discuss in more detail the privacy. You will not find it consistent with everything that he desired, but Bob Gilman's comments were included in the final revision as were everyone else's.
MS. COLTIN: They weren't included. They were taken into account.
MS. RIMES: Taken into account and --
MS. COLTIN: But the Privacy and Confidentiality Committee specifically is considering --
MS. RIMES: Unfortunately what they are considering is the copy that Marjorie sent out that was not the revised copy which we have in front of us.
MS. STARFIELD: Can't we get them?
MS. RIMES: Certainly. I mean it can be xeroxed and that may be something Patrice may want. I xeroxed it and brought it down for you guys because I was asking who did you want to review it and whatever.
MR. NEWACHECK: I think that is still useful because they can see it easily, the bold corrections or changes when they are discussing it.
MS. RIMES: So, do we want to get copies to them for tomorrow, please?
MS. COLTIN: And whoever is going to be there. We need to let them know that the changes are in bold, that they really only need to pay attention to those.
MS. RIMES: Kathy, can you do that, please? I would sure appreciate it because I know that rather than have them go ballistic over the fact that nothing has been changed, that is not the case, but these came through late to me.
MR. HANDLER: Do you want to suggest that they are interested to have a separate section devoted to privacy and confidentiality, a stand-alone section just for that, and then they won't nit-pick the whole report for that one section?
MS. RIMES: Nothing is going to preclude some of the concern about the specifications going on even if we use the term "guidance" as opposed to more of a mandate. I think if they come in, that is certainly an option, but I think the subcommittee needs to define who we want to send it to for comment and how we want to deal with that.
MS. COLTIN: Okay, so we will certainly need to incorporate whatever recommendations come out of the Privacy and Confidentiality Committee in some way once we know what those are, and we will need to have a process for doing that. So, I don't know if that is going to be another conference call or what, but before this could go back to the full committee that will need to be taken into account.
MS. STARFIELD: Where are these draft regulations mentioned in this document? Does anybody know?
MS. RIMES: The draft specifications? It is replete throughout the report. It is in a lot of the footnotes, and it is, also, mentioned in a couple of them.
MS. COLTIN: And they have a copy. The Privacy and Confidentiality Committee has received a copy of Bob's comments. So, even though they may have the wrong version of the specs, they do have his specific comments. So, when they get this they can look at the bold and see whether they think it addresses his comments.
MS. RIMES: And in the past what we did was ask them to review the specifications and then send comments, and I was the person who got the comments.
MS. COLTIN: Okay, so in addition to incorporating whatever comments come from the Privacy and Confidentiality Subcommittee there are other issues that were raised today by myself and others on the full committee. So, we probably should address those as well.
Before we leave this, however, you wanted some advice about the vetting process?
I think clearly the stakeholders who are involved in this need to somehow participate in that process. So, I think health plans or the MCOs that are going to be asked to comply with these specifications need to have an opportunity to comment on them.
I think that we may want to have some people identified maybe by whether it is APWA or whether it is National Association of State Medicaid Directors to look at this and then obviously if we are going to talk about possibly deleting Recommendation 4 which had to do with the notifiable diseases --
MR. MOR: There is stuff in here on Page, whatever, it is 14 and 15 that --
MS. COLTIN: Absolutely.
MR. MOR: Also, in terms of vetting, given the comment, and I keep remembering this, that lots of small NCOs do nothing but managed care business that have paper systems, we may want to have smaller as well as larger more established ones respond to this.
MS. COLTIN: I think both HIAA and AAHP should be approached. I think HIAA doesn't tend to include that many of the smaller --
MR. MOR: No, I know.
MS. COLTIN: But it includes a lot of the managed care organizations that are not direct providers of care and who would share some of the concerns I mentioned whereas I think AAHP tends to include most of the ones that do have a direct provider role as well as others.
MR. MOR: My concerns are just simply data delivery.
MS. COLTIN: Usually the trade associations are pretty good about pulling together some representative plans. They won't send it out to everybody. What they will do is identify a few plans that come from representative parts of the country in different sizes, different model types and they will send it out to them and try to get responses, and they will put something together as a single set of comments.
So, I think we should definitely send it there, and I think Ken Lashala is probably the right contact person at AAHP. You might ask Kathleen whether she is the right person or knows who the right person is at HIAA.
MS. STARFIELD: She could raise that question about are we talking only about electronic or are we not?
MS. RIMES: We are probably talking of both.
MS. COLTIN: It turns into electronic data at some point. I mean he was talking about something that I think is totally different which was did we want to make a recommendation that plans have to accept electronic data that comes in to them as opposed to dropping it to paper and then putting it into their system in some way, but I don't know any plans that are processing paper. They are taking paper and they are inputting it into a claims system as opposed to having a direct interface between an electronic submission vehicle like their system. So, I thought he was saying that he wanted plans to -- everybody had to build that interface.
MR. MOR: There are plans that are just merely aggregating paper into counts in spreadsheets and reporting spreadsheet results.
MS. COLTIN: Really?
MR. MOR: Yes.
MS. COLTIN: That is not what I thought I heard him say.
MR. MOR: That may have been the issue he was talking about, but I am quite certain that is what some plans are doing. They just count up, one, two, three.
MS. COLTIN: They are approving every claim manually and paying it manually?
MR. MOR: Or they have got people on a capitated basis.
MS. COLTIN: There may be some plans like that, and if there are, we should get them to comment. I am not aware of that being an issue because clearly a plan that is doing that would have been heard from in terms of all kinds of complaints about HEDIS reporting requirements and all kinds of other reporting requirements, not just these report requirements, and I haven't heard that. So, it surprises me a little.
MS. STARFIELD: For example, a lot of the community health centers will do that.
MR. MOR: That is not what we are talking about, the neighborhood health plans.
MS. COLTIN: But then you are talking about the providers.
MR. MOR: No, it is the providers then submit the data. The neighborhood health centers submit the data to a plan and each provider is sort of in some sense capitated and then they just have a way of reporting up aggregated statistics.
MS. COLTIN: That is not what they are doing in Boston. I mean the neighborhood health plan gets detailed data from all the community health centers. I don't know if they are the exception rather than the rule. You may be right. That may be an issue, and I think if so they are going to have lots of comments.
MR. MOR: There are some small groups out there that are aggregating.
MS. COLTIN: So, we are sort of going down the chain now and saying that if the managed care organization is going to have to comply with this, they are going to have to turn around and say to their providers, "You have to send it to us this way," and so, you are saying, "Let us get the input from the providers.
MR. MOR: They are already all broke but when Philadelphia went into the managed care world they had nothing but small new providers basically, and there were various carve-outs and things like that.
Most of those were of this aggregated orientation. So, if you are counting welfare whatever it is in some place and you want to do this Medicaid managed care in your area then really what you are talking about is if you can accept these purchasing you can only contract with the big guys. So, that is an implication in certain markets which may well be appropriate because the little guys are going broke very quickly.
MS. COLTON: All right. So, what we are hearing is maybe we should get the Bureau of Health Care to distribute this to some representatives from community health centers and see about having some comments from them about how this might affect the way they currently report to managed care organizations and whether they could do it.
MR. NEWACHECK: I think we, also, need to include some representation from consumer groups in this external review process since the major goal is to improve quality care for the beneficiaries.
MS. STARFIELD: You recommended the American Public Welfare Association.
MR. NEWACHECK: I think like in the kids' area there is a couple of organizations who would be very interested in seeing this, Family Voices which represents disabled children, kids with special health care needs.
MR. MOR: They testified in Boston.
MR. NEWACHECK: Testifying is different from reviewing the --
MR. MOR: No, no, I thought we were going to send it to people who testified.
MR. NEWACHECK: Everyone? Oh, okay.
MS. WARD: Yes, that is a good idea because we heard from them.
MS. COLTIN: I guess that raises a question, are we sending the contract specifications to everybody or the report to everybody? There are two different streams of input that we might be looking for. The contract specifications are very specific and nitty gritty and they are a way of operationalizing some of the recommendations. I am not sure whether the advocacy groups want to comment or need to comment on the specific contractual language so much as they do the recommendations.
MR. NEWACHECK: That was a problem with bringing this up today as Bob pointed out. We are asking people to vote on something without seeing the complete document, and I don't think we can say that we did an external review and we gave people half of the information, even if it is technically -- we could say in the cover letter that this report is in two parts, a narrative and the technical detail. You may prefer to look at one or the other, but we will accept comments.
MR. MOR: This is a hefty chunk. This is a big time investment for someone to sit down and go through this.
MR. NEWACHECK: So, we give them a choice.
MR. MOR: I know, but I think you are right we can give people the choice, but the managed care companies really should look at this.
MS. RIMES: I think it does raise a point to what you are saying. It will be an appended to the report at such time as the report goes out, maybe to all the stakeholders.
MR. NEWACHECK: We, also, refer to contract specifications throughout the document.
MS. RIMES: That is true.
MS. COLTIN: All right. So, maybe we should put the draft contract specifications into the draft report and send the whole thing out and ask for comments, so that it is one package, whatever level of detail they want to comment on.
MR. HANDLER: Then the draft report can refer to pages in the contract by page number, using cross referencing.
MS. COLTIN: All right, so, I will have you do that.
Okay, so we have talked about the vetting. I think we have identified all the groups that we want to get input from. Before the document actually goes through the vetting process though, are there changes that were suggested today that we would like to make before it goes through the process, and now I am talking about the report rather than the specifications?
MR. MOR: The sentence, and I don't know where it came from on Page 48 that you pointed out, that should be dropped. That is sort of like an opinion. This should be a model for every other managed care contract in the world. Give me a break. That is not necessary.
MS. RIMES: I think I would have remembered that. It is only in this draft.
MR. NEWACHECK: When did this draft happen because we shouldn't present to the committee that we haven't reviewed as a subcommittee?
MS. RIMES: We had discussed that several times in a couple of ways.
MS. STARFIELD: I think I know how it got in there because I remember we discussed the fact that there were hardly any recommendations in this report that didn't apply to the larger committee and I think that has to be recognized someplace. We are dealing with very generic issues here. It is anything that is specific to Medicaid managed care.
MR. MOR: I am not sure I agree with that. There is a lot of stuff in here that relates to management of the program responsibility that the state has for its Medicaid program, and that is quite different, for instance, than what an employer's responsibility might be.
MS. STARFIELD: What about Medicare?
MR. MOR: I didn't say about Medicare. It could be that Medicare --
MS. STARFIELD: The issues aren't the same in Medicare because it is a single entity making decisions. The problem here is you have got 50 states, and they are all giving different directions about formats and data.
MR. MOR: And, also, Medicare beneficiaries have a lot more choice in this process than do Medicaid recipients. In some states this is it. Sorry, there is no choice. This is how we are doing Medicaid.
MS. STARFIELD: That is the same thing in the private sector. People have very little choice. Employers choose for them.
MS. WARD: There may be some generalities here, but I think it really makes the report difficult to communicate with that because I think it started off as a Medicaid managed care issue.
MS. COLTIN: And we didn't even take testimony from those other groups. So, I think we can only write a report on what we did.
MR. STARFIELD: Maybe that is true, but if you look at all the things that came up from the testimony, I don't want to make a big issue of it, but it is obviously true to me that there is not much unique about the recommendations that are specific to Medicaid.
MS. WARD: I guess for me it is the privacy confidentiality part because there are very clear rules that govern Medicaid, HCFA and its relationship with Medicaid directors and Medicaid agencies and their relationships that are strictly in statute that have nothing to do with if this went somewhere else, and that is part of the thing to me that makes it difficult to communicate. That is part of why I can talk about some of the issues about expanding things and taking eligibility data because one government is demanding of another government to collect that information and government-to-government sharing of that information, when I say, "Take a race ethnicity code," a public assistance government agency that is guarded by certain kinds of regulations about what they can divulge is giving it to another government agency, and if you start taking that out of a government-to-government relationship and start putting it in the private sector --
MR. MOR: In fact, that is what this is. Basically we are saying all kinds of stuff specifying the nature of the relationship and responsibility that private entities have for doing government data collection on its behalf. So, they are assuming that it is an agent of the government, and that is why you have all this contracting stuff. It is because if the government does it itself it doesn't have to worry about the quality. It just is doing it. On a contracting basis they have to worry because it is a fiduciary responsibility.
MS. STARFIELD: There is nothing wrong with making a case on the basis of an example.
MS. COLTIN: All right, we have a motion on the table to strike the last sentence of the second paragraph on Page 48.
Do I have a second to that motion?
MS. WARD: Second.
MS. COLTIN: Thank you.
We have already had quite a bit of discussion. Any more discussion on this?
Okay, all in favor?
(There was a chorus of ayes.)
MS. COLTIN: Opposed?
(No response.)
MS. COLTIN: Okay, that one is out.
Other recommendations other than Bob's privacy and confidentiality concern? Simon had some concerns regarding Recommendation 1 and the wording at the beginning of the second paragraph and specifically I think what he was questioning is whether we should be just specifying the full 834 and the full 837, and the discussion had to do with diverging opinions about that and the feeling that we were not out there saying, "Get everything." We were saying, "Identify what you need and get what you need," and that may or may not, depending on some of the recommendations that come through the Privacy and Confidentiality Subcommittee include all the identifiers which are part of the 834 and the 837. So, personally I think that what we were recommending was a subset of data elements to be drawn from the 834 and the 837 and to be formatted in a manner that is consistent with the implementation guidance for --
MS. STARFIELD: That is what that says to me.
MS. COLTIN: That is what that says to me, too.
MR. NEWACHECK: But with those numbers in there so it says, "Standardized code sets based on 834 and 837."
MS. COLTIN: Based on data elements contained in the 834 and 837 and provided in a format consistent with the transmission of standards, okay.
So, we have a motion to modify this to say, "To adopt a standardized set of data elements based on those data elements contained in the 834, the NCX 12 and 834, 837 including standardized code sets."
I think we can then take out the words "which should be based on the National Committee on Vital and Health Statistics 1996 recommendations."
MS. STARFIELD: Wait a minute, are we taking out --
MS. COLTIN: Because we are saying that they are being drawn from the 834 and the 837 and that implies that they are based on the National Committee's recommendations. I still --
MS. STARFIELD: So, you are saying that the core set, that the choice of which ones to include should be based on that.
MR. NEWACHECK: Why can't we say, "Consistent with the NCVHS recommendations and standard administrative transactions"?
MS. COLTIN: We are not necessarily mentioning all of them, everything.
MR. LUMPKIN: I am not sure I know the answer to this, but the issue is what about those data elements that are in the core data set but not in the 837 or 834?
MS. STARFIELD: That was my point.
MS. COLTIN: That was Barbara's point.
MS. WARD: We are trying to communicate that is, not trying to --
MR. LUMPKIN: It is either/or. It is either in 837 or 834 or --
MR. COLTIN: The only ones I think that we were recommending specifically, the only place where we got specific about data elements was in the enrollment data. Otherwise we just said, "Draw them from our recommendations," but the one area where we did get specific was in enrollment data where we said, "Race and ethnicity," and we said, "Using the OMB codes," and we said, "Language and reason for eligibility."
Now, I know that language is on 834. I think race and ethnicity are, also, on the 834. The concern has been that we cannot mandate that employers use it, but we could suggest that HCFA mandate Medicaid use it.
MR. LUMPKIN: The question is are there any in the data set that are being recommended that are not in --
MS. COLTIN: The only one that is a question is this reason for eligibility. So, there were only four that we identified. Three of them I know are in the 834. I don't know about the reason for eligibility, whether there is a field in there that would capture that. I just don't know. There might well be, but I just don't know. This is enrollment data. So, it is the 834.
MR. LUMPKIN: I am just raising that because while it may not necessarily need to be in the recommendation, I think that would clarify it. I just don't think it was clear what the data elements were that were in effect.
MS. STARFIELD: And I am not 100 percent sure that we are clear either.
MS. COLTIN: We did not specify. We didn't say that these are the data elements you should choose. We said that they should choose a common set. In fact, in our recommendations we said that there were two sources. We said that there are our recommendations for the core data set, and there is the 834 and the 837, and I guess Simon's point is where they don't overlap what do we do, and I think from what I can see the functional status measure is there. There is a space for it. It is just not defined what it is, but there is a space for it in the 837. There is a placeholder. So, I think everything else that is in the core data elements has a placeholder in either the 834 or the 837 except possibly this reason for eligibility one.
MR. NEWACHECK: So, maybe we could check that out and add a footnote if that were the case.
MS. COLTIN: I think that would help.
Can we consult with Bob Mayes and find that out?
That would help me because I think I have raised this question with him before.
MS. STARFIELD: I think maybe adding a footnote alone would clarify it. We don't have to make changes.
MS. RIMES: Let us see what it is, and even I can probably make that decision.
MS. COLTIN: Okay, so, just to recap this is in the first sentence on the second paragraph where it says, "Which should be based on," we will insert data elements in the NXC 12 and 834 or 837 and then jump to "and consistent with" and then put in the National Committee on Vital and Health Statistics, 1996 recommendations and standard administrative transactions and transmissions. So, this is a very long sentence, but that is how we reorganized it as I understand it. Okay?
All right, I will write that out. So, any further discussion on that change?
All in favor?
(There was a chorus of ayes.)
MS. COLTIN: Opposed?
(No response.)
MS. COLTIN: All right, so that was Simon's comment.
John suggested that in Recommendation No. 6 which has to do with the training to increase staff analytic capacity, that one area that we did not consider in our recommendations had to do with sharing across state agencies of trained personnel and resources to support analyses, and that we may want to consider adding that to our recommendation.
MR. MOR: A recommendation to HCFA or a recommendation to the state agencies?
MS. COLTIN: It is a recommendation, well, some of our recommendations are to HCFA and some of our recommendations actually are to states. All we can do is recommend. We have no authority.
MS. STARFIELD: Page 44 clearly says, "Despite these perceived problems, most believe there is little need for technical assistance from the Federal Government." I mean it says that real clear.
MS. WARD: I imagine saying this to state Medicaid directors. If you don't have the analytic capacity at your agency, go to look at some of your sister agencies. They may be able to collaborate with you and get it done. In some states they already are.
PARTICIPANT: Yes, they are, I mean an assessment initiative but Dan Friedman is working on sponsoring that kind of an arrangement in Oregon, and I don't think we have to address it to anyone because it is a collaboration. So, you don't mandate Medicaid to go get an epidemiologist from public health or mandate public health to get the data.
MR. LUMPKIN: I thought the structure said that the first paragraph is discussion and the second one is the recommendation. Can you add it into the discussion section in the first paragraph?
MS. WARD: Other states are starting to do that collaborative --
MR. LUMPKIN: Right. Resources may be available, something like that and then you can leave the recommendation being the same.
MS. STARFIELD: Well, but there is an inconsistency. The recommendation says that the Federal Government should do something and Page 44 says that they shouldn't.
MR. NEWACHECK: Page 44 says that there really isn't a need for it.
MS. AMARO: I see it as a contradiction in what we observed. On one hand we observed that people talked about having problems, but didn't want to say that they needed help. So, I don't see that --
MS. COLTIN: I think there is a difference between technical assistance and trained personnel.
MS. AMARO: When you look at the technical assistance that is often provided I can understand why they say that they don't need more.
MR. NEWACHECK: Very specifically the states, I mean I remember Boston and others saying, "We don't want the Federal Government coming and telling us how to do this. We would like more trained personnel."
MS. AMARO: They talked about the assistance that did come from local. Maybe the problem is despite these perceived problems, I think maybe the transition -- it needs to be clear, the distinction between technical assistance and trained personnel.
MS. STARFIELD: The recommendation says, "Technical assistance," too.
MR. NEWACHECK: It seems that what we need to do is change 44 to add to it that although there was not a clear request for technical assistance there was a clear indication that inadequate staffing existed to analyze the data fully or whatever.
MS. COLTIN: And they said that it was difficult to recruit people who had the skills.
MR. NEWACHECK: And then we need to change Recommendation 6 to reflect that it is really a personnel issue, a staffing issue rather than necessarily a --
MS. COLTIN: And they talked about things that they cannot compete salary-wise for the people who have the training, and so they have to develop the training themselves or recruit people who have the capacity to learn and then try to train them themselves.
MS. WARD: What they wanted from HCFA was more money to go buy technical assistance from their local areas. Boston said, "We had our own money to go contract with these universities to give us the help, and we wish HCFA would give other states." If they get that they have to find a way of buying it.
MS. AMARO: I think it was the issue of technical assistance. I think there were states that said that they could use it, but it needed to be local, and it couldn't be imposed.
MS. STARFIELD: In any case both have to be changed to make it consistent. They don't want that Medicaid auditor coming out.
MS. AMARO: Right.
MS. COLTIN: All right. So we need to resolve those two, and add the sentence in the back of the discussion about cooperation among state agencies.
MR. NEWACHECK: Tell Ann that we read it and found that 44 and 53 were inconsistent and please fix it.
MR. LUMPKIN: Just before we leave this, I am just wondering on the issue of audits, to what extent are we looking at a HCFA only issue or problem because it may be that if there were technical assistance available to Medicaid agencies from NCHS or from CDC they might be more willing to accept that but they just don't even see those agencies in their sights.
MS. WARD: That is true. Yes, the Medicaid directors get put in little boxes.
MR. LUMPKIN: That is right, and so they see the Federal Government as being HCFA and they might be more willing to look at some other --
MS. COLTIN: So, it is really the last sentence that is particularly inconsistent in Recommendation No. 6 where it says, "We recommend that HCFA commit to providing the states technical assistance." Why don't we take out that last sentence? The rest of it gets at what they really did want.
MR. MOR: Yes, funding of PHS scholarships and you know, through some mechanisms, etc.
MS. RIMES: Then they will add the sharing of staff in the collaborative.
MS. COLTIN: And I think we should, also, think about the kind of model that you were describing in Boston which is the partnerships with the academic community, if that really isn't highlighted as another -- it comes up in the data sharing when we talk about approved research but sometimes approved research is a way to get some analysis done that you want to get done internally by working with a doctoral student or someone else to do that sort of thing.
MS. STARFIELD: That relates to Page 5 while we are on that topic on Page 52. This is responsive to some observation about researchers, but it doesn't mention anything about academic researchers, only the state agencies, sharing of data among state agencies.
MS. COLTIN: The second sentence says, "Approved research projects by academic centers."
MS. STARFIELD: Oh, sorry.
MS. COLTIN: Okay, let us get back to six. On six we have a motion to take the last sentence out, to add to the first paragraph a statement about encouraging cooperation among state agencies and sharing trained staff and in the second paragraph adding partnership with academic institutions as another in the list of possibilities.
MS. STARFIELD: We have to do five.
MS. COLTIN: Can we do six first and then go back to five?
MS. STARFIELD: Sure.
MS. COLTIN: Do I have a second to that motion on six?
MR. NEWACHECK: Yes, but we need to add something on Page 44, too.
MS. COLTIN: Yes, I got it and to correct Page 44 when we get to that.
All in favor?
(There was a chorus of ayes.)
MS. COLTIN: Opposed?
(No response.)
MS. COLTIN: Okay.
MS. STARFIELD: We have to change the title.
MS. COLTIN: So, can we just add that at the end and sharing of data among state agencies and academics?
MR. MOR: I think that this particular one is one where Bob's comments are specifically germane and relevant, and I think there has got to be at least something in there about confidentiality protection and on the intergovernmental agency exchange processes.
MS. RIMES: On personally identifiable information.
MR. MOR: Yes, on personally identifiable information. That could be the policy, state agencies, all kinds of things, truancy organizations or whatever it is.
MS. COLTIN: Can we change the heading to say, "Data dissemination, availability of data for research"?
MR. MOR: I don't think it is dissemination.
MS. COLTIN: All right, data availability for research and analysis?
MR. HANDLER: I have a suggestion. I used to be the privacy act officer for Indian Health Service, and we have something in the Federal Register that comes out every other year or so, the privacy act system of notice, and it includes routine uses, what kind of disclosures can be made from the medical data system and maybe what you are looking for is those types of routine use disclosures.
One of them is to the police if they want to check blood alcohol levels of someone whom they are arresting, and there is a whole series of things that are routine uses that maybe you should consider as something if you want to get into that, but we have about 15 different routine usages in our agency, and there are other agencies.
You don't have to invent the wheel, but if you list only two or three and there are 15 you could choose from, someone is going to say, "What about all these others?" and it is all sitting there in the Federal Register.
MR. MOR: This is actually very messy. It sort of has in it here the more you use it, the more people like it, and more want it, and so the better the data will be and that is a sort of programmatic utility function.
Then there is a research availability function. Then there is a reporting function, and they are all mushed together here, and they have each of them very different compromises on confidentiality purposes, goals and I am not sure that as currently outlined it is going to be --
MR. HANDLER: Maybe there should be a preamble about the different levels of confidentiality and protection needed for different uses.
MR. NEWACHECK: I think it needs a little bit more than that, too. First of all why do you need to generate reports and studies? You do that to enhance the quality and efficiency of the care delivery system.
So, you start out by saying that in order to enhance efficiency and so on of the care delivery system reports and studies need to be generated by the following entities. Access to data should be available through the following mechanisms, memorandum of understanding and so forth that adequately protects privacy, only give access to identifiable data when necessary in order to complete the study, and then have the same sort of statement, preliminary statement about academic research in order to enhance the quality of health care services, you know research is important; they should be given access to data and only in cases where it is absolutely necessary, and I just think we can structure it in a way that would say the same, you know, would imply the same thing without --
MR. MOR: One of the things that Nancy was saying, she started off with this conflict between basically confidentiality and privacy and need to know and clinical standards and there are lots of reasons for that conflict, but one of the key issues is that Health Care Financing Administration and virtually all state governments don't have the capacity traditionally to do all of the data matching, merging, etc., in order to keep that in a sacrosanct iron room and then hand out to everybody else encoded, crypted and other kinds of data for other purposes, and we could have a discussion about the applicability and appropriateness of states building that capacity because I know HCFA is trying to build the capacity to do that and make it available so that those matching functions are at least embedded internally keeping that kind of protection on privacy and confidentiality.
MS. STARFIELD: I have a procedural question. The latest version of the agenda says that we will adjourn at five, and I made plans on that basis.
MS. COLTIN: All right, well we are not going to come to any consensus on No. 5 tonight anyway. I have a list of things that we are saying we need to consider in rewriting this, but I don't think we are going to come to any agreement on it right now, and we are still going to have to discuss this again after we get the recommendations from the Privacy and Confidentiality Subcommittee.
I would suspect that they will pay particular attention to this kind of use. So, why don't we revisit this particular recommendation after we see their recommendations, and I believe that was actually the last.
MS. STARFIELD: No, I have one, too.
PARTICIPANT: That was the notifiable review.
MS. STARFIELD: And the striking of the specific mention, and I don't like it, and in fact, I feel strongly about it I am prepared to write a minority report on it. It says, "CAPS or other instruments if they become standards that are widely," and I think we should just say, "Instruments that become standards."
MS. RIMES: Can we just maybe say as an example?
MS. COLTIN: Instead of putting it at the beginning of the sentence say, "Recommend that standardized instruments such as CAPS."
MS. STARFIELD: I will write a --
MS. COLTIN: What is it that --
MS. STARFIELD: CAPS has a specific purpose. It is to help people choose and that is all. It is not a quality instrument or a satisfaction instrument at all. It has huge limitations, all of which are recognized by AHCPR. I think it is a way station in developing something good, but I don't think it is there yet, and I don't think we should it up as a standard.
MS. WARD: It is not a standard, but it is standardized.
MS. STARFIELD: Yes, that is right.
MR. RIMES: Dan had a comment.
MR. FRIEDMAN: I did have a comment. I just wanted to mention it so that you can note it down which is that I think that getting back to five for one second, I think if we say anything that would imply public use data set I think it is practically suicidal. I think we have to be really careful.
MS. COLTIN: What we are talking about right now is the report on Medicaid and managed care, and right now for Medicaid and managed care the only standardized instrument out there is CAPS around the patient experiences. Managed care is a health plan. So, we are talking about an instrument to evaluation patient experiences with a health plan.
MS. STARFIELD: But this doesn't says, "Experiences." It says, "Satisfaction." If you just replace the satisfaction --
MS. COLTIN: You are right. Down in that paragraph we should take out the word. It should be member experiences.
MS. RIMES: And quality of care and recommend that HCFA encourage states to rely more on standardized satisfaction surveys.
MS. COLTIN: Take out satisfaction, yes. Actually it is much better because I like it better than satisfaction. It is broader and more to the point.
MS. STARFIELD: And standardized population base, take out satisfaction.
MS. COLTIN: Do a word search on satisfaction and every time you see it replace it with experience because it is in the last sentence of the first paragraph, too, and I keep finding it.
All right, there is a motion to change satisfaction to experience in No. 2. Is everyone okay with that?
Great. And dropping No. 4 there is a motion on the table for dropping No. 4 completely.
MS. RIMES: And we want to when we drop No. 4, also, to be somewhat consistent in dropping No. 4 when we talk about the specs?
MR. MOR: The specs. It is on Page 13 or 14.
MS. COLTIN: I have to tell you that in drafting those specs the CDC was on the conference call and very strongly advocating for these kinds of provisions, and so, when this gets vetted we will get those kinds of comments. So, we need to make sure that they see this.
MS. RIMES: They will be seeing this. They have to vet it, too or will be vetting it.
MS. STARFIELD: I would like another opportunity to think about CAPS.
MS. RIMES: This isn't a final for quite a while.
MS. COLTIN: So, we have a motion on the table to delete No. 4.
MR. MOR: I don't think managed care is the solution to doctors' under reporting infectious diseases.
MS. WARD: No, I think CDC is grasping for straws. There is nothing in the research we have done that says that would make any difference at all, and you cannot delegate enforcement to a non-enforcement agency.
MR. LUMPKIN: Especially when they don't have enough teeth to enforce them themselves.
MS. WARD: Right, but the providers say that if you make the system more rational, you are more effective and you make it efficient.
MS. COLTIN: There are two points that were brought up that I do have sympathy for. One is that when the MCO is a provider that they would conform to applicable laws governing providers and then the second, but the MCO would be accountable for -- it is like the medical director or administrator of a medical group being accountable for all acquisitions.
They are saying that the MCO would have some accountability when it is a direct provider, the individual doctor --
MR. MOR: That is going to be a function of doctors' employees and the doctors' contracts and the foundations.
MS. COLTIN: We are saying --
MR. MOR: There are lots of HMOs where the doctors are foundations.
MS. COLTIN: Then they are not an HMO. They are an ICH.
MR. LUMPKIN: Let me give a similar example? What about reporting child abuse? Most states tie in those kind of reporting responsibilities with the licensure, and if you are going to tie in, I mean I think it is well and good to say that the person over there should be responsible, but if you take the responsibility away from the individual practitioner, then that is where you are going to have trouble because they are the ones who are seeing the patients and as much as I would like to have that --
MS. COLTIN: I am not suggesting you take it away from the individual. I am saying that you add on another responsibility which is the MCO is making sure that all of his physicians are complying and meeting their individual responsibilities.
MS. AMARO: I think I agree with that perspective. I think as an individual provider in the case that you gave the provider would be liable if he failed to report, but the organization would have some level of responsibility, also, for example, in that case.
MR. MOR: The organization has responsibility insofar as if one of their doctors loses a license it is a black eye for the organization. I think that is the actual incentive.
It is to not have your doctors get in trouble with the local licensing organization as opposed to necessarily saying that the organization has got to, telling the organization how to police its own doctors.
MR. FRIEDMAN: I have a couple of points one of which is if we do go this route, I don't quite understand why it should be limited to notifiable diseases and specifically infectious diseases, and second to the extent that it is not, there are certainly other mandated reports for which there is not just provider responsibility but also, institutional responsibility.
PARTICIPANT: It depends what they are reporting.
MR. FRIEDMAN: It does. It depends on the reporting, but I don't think that, personally I think that requiring MCOs as providers to bear the same responsibility that for example, hospitals do and in some cases labs do is perfectly reasonable, and I think it is, also, a good example of the kind of whatever, collaboration that we should assume between state agencies.
MR. LUMPKIN: I wonder if maybe Recommendation 4, something like this, instead of being looked at as adding commissions into the contract should just discuss that these may be in a better position or circumstances to enhance reporting through giving brownie points and reimbursement and those kinds of things and then just kind of make it as an observation more than a recommendation.
MS. COLTIN: And that they should be encouraged to --
MR. LUMPKIN: They should be encouraged to do so.
MR. FRIEDMAN: I think that is a good idea.
MS. COLTIN: The other point that I was going to make, and that was the one, when they are a direct provider, and the other point that Sara Rosenbaum brought up is that sometimes the managed care organization can be the tool which creates a barrier to reporting by for instance contracting with an out-of-state laboratory.
So, if they are saying that you have to send all your tests to this lab, and the lab is out of state, then that lab isn't governed by the state laws in the state that the managed care organization is in.
So, that was creating a problem in that because the tests were getting done out of state they weren't getting reported to the state, and so, there was a suggestion that the managed care organizations should put a provision in their contracts that said that their contracted providers, their labs and so forth would have to comply with state regulations for where the test was obtained as opposed to where it was analyzed.
That was her concern. She said that a big part of the data that they were losing seemed to be from organizations that were creating contracting arrangements that sent a lot of data out of state and then it never got reported because the tests were being done out of state.
I guess the point was if the MCO is the instrument by which reporting, they are creating the barrier, they ought to be responsible for doing something to try to remove it.
MR. FRIEDMAN: I am going to have to go back to our staff and check because I know for instance HIV reports we get reports from out of state labs because in order for them to do business in the State of Illinois they have to, you know, if they are going to do a lab test in Illinois, they have to follow Illinois laws.
MS. WARD: We have the same thing in Washington. We have all kinds of lab tests going out of state but if they are testing Washington people they still have to advise Washington, and they still have to comply with Washington law.
MR. EDINGER: Some states, New York and some others who have state licensure laws do, but I guess the case comes up what about the ones who don't have their own state licensure laws that require it.
MS. WARD: To me it is a licensing issue for that state to solve.
MS. COLTIN: I can live with that. So then maybe we will just soften the language in No. 4. We will get rid of all the stuff that has to do with the contract and just deal with direct providers recognizing they have the capability to influence behavior and they should be encouraged to do so, but not making it a contract requirement.
MR. LUMPKIN: And I would even soften it that it is not that they have the ability, that they may have the ability.
MS. COLTIN: They may have the ability, all right, good point.
Okay, I think that is it.
Thank you.
(Thereupon, at 5:17 p.m., the meeting was adjourned.)