[This Transcript is Unedited]
Hubert Humphrey Building
Room 305-A
200 Independence Avenue, S.W.
Washington, D.C. 20201
JULIA: Hello, this is Julia.
MR. HUNGATE: Welcome Julia, Peggy Handrich has joined our committee, everyone else you know is here, Don Steinwachs, Peggy, Debbie Jackson, Gail Janes, Vickie, Susan, and we’re missing at the moment Marjorie, who’s gone upstairs, and unbeknownst to him I’m now going to ask Don Steinwachs to summarize the prior discussions at the full committee just for your edification because --
DR. STEINWACHS: This may take an hour, but Bob says it’s going to be a lot shorter then that.
JULIA: There’s not a sweet short answer?
DR. STEINWACHS: Well, I think there were sort of two parts to it. We presented the draft report, which I thought was a great job that reflected Cathy’s input, Susan’s been working on it, and Bob and others, I’ve just been reading it and enjoying it. But I think what the committee as a whole found that it was not even bite size, it was a huge proposition, in great part because the recommendations as we talked about what are the barriers and what needs to be done in order to make it possible to collect data relevant for quality, whether you’re going to pay for performance or you’re going to monitor and assess quality in other ways is a complex undertaking. So the decision was, which I thought was a good decision, was to try and provide feedback to the Quality Workgroup by having a survey in which all the members would rate each of the recommendations, and I think now there are what, 21, 17 in the report, four additional, in terms of their important, sort of high, medium, low. In terms of I guess it was what, there were two other dimensions, doability --
MR. HUNGATE: Doability, relative importance and timeframe I think.
DR. STEINWACHS: And timeframe, and then also is to comment if they could is are there other committees or workgroups in NCVHS that would need to address that, and so who we have to work with, is Security and Standards.
The expectation is that survey is going to get completed by mid-October I think is the optimistic hope and that will feed into the November meeting agenda and I think it will help us try and figure out what can we move ahead as a report now, because some of the discussion also said well maybe if you don’t make the recommendations so specific and you make them more general, that is we recognize there’s a barrier and something ought to be done about it kind of recommendations.
MR. HUNGATE: I agree, I think probably the first thing we need to recognize is that the term recommendation has a weight that goes beyond what we can probably achieve given the content we’ve got. And so I think we have to change the term recommendation to something else, and I don’t know yet what that is, maybe it’s an ongoing information need, maybe it’s, because recommendation has a very specific --
DR. STEINWACHS: Bob, at the same time I guess it seems to me the committee sort of measures this work by recommendations.
MS. GREENBERG: Right, I think some can be recommendations and some can be objectives or something, an objective is to --
MR. HUNGATE: Let’s think about what those terminologies should be --
MS. GREENBERG: But I would think you should have some recommendations.
MS. KANAAN: Isn’t is also possible to think of it as you can either recommend an action, an outcome like putting a data element on the 837, or you can recommend study? It seemed as though some of the more touchy ones, hot buttons you’re recommending --
DR. MAYS: Well I think there’s going to be some where there’s going to be difficulty getting consensus and I think in that sense you may want to think of them as issues to consider as you try and approach this problem, I think the issue of identifying the barriers and then talking about some of the issues. I think it may be at some point that some of them will be just issues that you’re just not going to get consensus on from the group.
PARTICIPANT: You know one of the things that occurred to me, too, in listening to the discussion was, Susan and I were chatting probably too much back and forth, but it wasn’t clear to me that whether the members of the full committee grasped the fact that these were in fact the distillation of statements, of recommendations if you will, that had been made to the committee by outside groups which we then admittedly have massaged, packaged and put our own spin on, but that we hadn’t made these up out of whole cloth as my grandmother used to say.
MS. COLTON: Some of them were not framed as specifically as ours, they were we need to collect race and ethnicity, and that’s really important because, as opposed to how should we collect race ethnicity data. But they were more specific then just we need it, they were things like there are two different reasons for wanting to collect that data, one is to uncover discriminatory practices in health care delivery and the best way to do that is through having it reported on the claim because it’s the provider’s perception of the patient’s race that is the most important factor in addressing that particular problem. The other problem was being able to identify populations who are at greater risk, health risk, for poor outcomes or for failures in process, and that relies on the patient being able to tell you more accurately what their race and ethnicity is so that you can say ah, this is an African American, this person is at higher risk for diabetes then the average person is. So to be able to identify high risk populations for quality improvement, disease management, other types of purposes. That was the reason we requested it both ways because it was addressing two different needs.
I think where we failed is that, and I apologize for being late but I was talking with Kepa about his suggestion and what the window of opportunity might be here, and really I think the point he made about making the business case for each thing is really critical and what I just said I said to him and he said well that’s it, you’ve just made the business case. So he said that’s what you need to do is you need to, you know we have four separate recommendations under race and ethnicity, we have to take them apart and for each one say why we need to do that, what is the problem we’re intending to address and why is this needed. And so there may be some umbrella business case that cuts across like pay for performance as a reimbursement strategy but then there are some very specific issues that drive each of those individual recommendations.
MS. GREENBERG: This may be self evident or whatever but I think that you all should feel good about the fact that, this is one of the better discussions that the national committee has had around quality, data needed for quality and I think particularly in recent years they’ve been so focused on all the technical aspects of the transactions and the rules and all of that that you’ve really gotten them back to focusing on well what is all this for and what is the information that we need and how are we going, and we do have a role here, we have a role, the committee has a role in trying to assure that the kind of information needed to monitor and improve quality of care is collected in various ways. So I felt good about that and I think you should to.
MR. HUNGATE: I think we finally got their attention and involvement, and that’s been a little harder to achieve then I thought it was going to be.
DR. MAYS: One of the things that really influenced that, which I think argues that we need to keep doing that is that you can now see the difference in John from having been on the IOM Committee, and I think maybe that as a function of his new job, because I do, no, I think it’s also --
MS. GREENBERG: I’ve seen some evolution, yeah.
DR. MAYS: And you see the presentations I think also on populations, I think to some extent the reason we’ve stayed so focused on the more technological aspect is because that’s where their heads have been, but I think as we get to population health issues you can see the quality, I think, of the difference in thinking and the kind of really pushing I think these issues. What I was going to suggest is in making the business case, because the IOM report is coming close to fruition, John probably has at his fingertips the actual studies that you can also use as background to site, I mean you don’t need to go into great detail, but as evidence.
MS. COLTON: I think we’re dealing with a bunch of people who process claims in Kepa’s situation, and they’re not going to look to the literature, they’re going to want to hear how in real life is this going to be used in a payer organization, a provider organization, in state Medicaid agency, that’s their customer and they want to know why it’s needed in the context of paying a claim or processing a claim. So that’s different from the recommendations that we’re making around surveys, or the recommendations that we’re making around electronic health records. But the ones that we’re making around the administrative transactions, that’s the mindset that we have to get into and I think it’s a less is more mindset, it’s a really terse business case, they’re not going to read a lot --
MS. HANDRICH: But I think the business case concept would apply equally to any other strategy or the survey or whatever.
MS. GREENBERG: I thought part of the business case though for the claim was that ideally it would be an enrollment and you’d be able to link enrollment with claims and everything else, but that the enrollment transaction is problematic. I thought that was part of the issue there.
MS. COLTON: There are two, there are multiple issues --
MS. GREENBERG: There are a number of them, I mean I’m a little uncomfortable with wanting to collect the same information two different ways because I think that can lead, I mean I understand what you’re saying, that it is not irrelevant as to what the provider thinks a person’s race and ethnicity is, although I mean in many cases --
PARTICIPANT: The research says its very relevant.
MS. GREENBERG: Although I mean in many cases it’s also what, maybe in the majority of cases it’s what the person thinks it is too, I don’t know, I mean it just depends on how fine grained you’re getting. Your position is a reaction to the response, it’s not going to be very good for quality data because they’re just going to eyeball the person and put down what they think and you’re saying that’s useful too, just to know what they think.
MS. COLTON: That’s exactly what I want and in fact that’s why I really wanted both places because you need to understand the strengths and the weaknesses of each data source and the problem with enrollments is that first of all they, not every employer has --
MS. GREENBERG: Yes, that’s the issues with enrollment.
MS. COLTON: So you’re not going to get it from employers who aren’t covered under HIPAA necessarily unless they voluntarily say yeah I’ll give you the HIPAA transaction for enrollment. Many of them are still saying here’s our paper form. So it’s going to be very limited. Even for those that are progressive and are submitting electronic transactions you generally get them for new enrollees and for changes in coverage, now individual family --
MS. GREENBERG: And you get it for every family member or only the enrollee?
MS. COLTON: Usually when there’s a change in coverage they actually have to list everyone because it effects everyone, so if they’re changing from a point of service plan to an HMO plan or if they’re changing from an individual coverage to family coverage, you’re going to get everybody in the family listed onto the family coverage application form. And if they’re changing the address and they want it to be changed in every record, not just the subscriber’s record, you’re going to have to get it for everyone. But there may be instances where you don’t get it.
MR. HUNGATE: Cathy, where did you and Kepa end up on the X-12 discussion?
MS. COLTON: Well, he was going to first explore whether it was even possible to get 30 minutes on their agenda, which would have to be either Monday afternoon or Tuesday morning.
MR. HUNGATE: How many of our recommendations involve X-12, which ones are they?
MS. COLTON: Well, the first seven do, all the data content ones do, or portions of them do, I mean like on the race ethnicity two out of the four bullets. And then I mentioned to him about whether the coding ones would or not and he said well not all of them but maybe a couple of them would, so it could be eight or nine I’d say maximum that would go before that --
MR. HUNGATE: Has he added the ALFA(?) ones? A couple of those are two are they not?
MS. GREENBERG: Yeah.
MR. HUNGATE: A, B, C, are all X-12, right? D and E, so all five of those are X-12 related.
MS. GREENBERG: Quite a few of them.
MS. COLTON: For some of these it’s not clear, like C, I’m not sure whether that’s a DSMO issue, I mean it’s the CPT coding guidelines.
MR. HUNGATE: Marjorie, what’s the protocol issue of talking about something like this to a committee like X-12?
MS. GREENBERG: Well, if you think about, you can’t present them as committee recommendations, but you can certainly present them as things, issues that the committee is dealing with and recommendations that they’re considering, I mean that’s already been presented in an open meeting.
MR. HUNGATE: We need feedback on feasibility right? And that’s the place to get it, so it would be I think the request of this workgroup for you to address that --
MS. COLTON: Well, I think we can say these are the recommendations of this workgroup --
MR. HUNGATE: They were the recommendations --
MS. COLTON: That we are taking them to the full committee and that we need to understand whether in fact they’re feasible.
MS. GREENBERG: I think what you can say is they are recommendations that the workgroup put forward for consideration by the full committee and for feedback from the full committee, because I don’t even know if you’ve had a voting process within the --
MR. HUNGATE: We haven’t had a vetting process here to say that they’re our recommendations, we’ve had them but we haven’t talked them through, we don’t have a process that’s done that.
DR. MAYS: -- step back even before that because after you hear what you hear you may bring something different to say that this is what’s evolved from your process of your hearings and whatever else you’ve had, and that these are the recommendations you want to get, that have been identified as barriers --
MS. GREENBERG: Or as possible solutions to barriers.
DR. MAYS: I’m sorry, as possible solutions to barriers, that’s what I meant, and to let them know, because otherwise I think what they’ll do is to make the recommendation because it sounds like this is the recommendation but you’re actually being more open --
MS. COLTON: What we’re going to put before them if we go, or if I go, is not the specific language here, it’s the more general concept behind this which says we want to, it’s been proposed to us and the group is planning to put a recommendation before the full committee to collect race and ethnicity data on enrollments. It’s been recommended to us and we’re planning to put a recommendation to the full committee to collect it on claims. And here’s why for each one of them.
PARTICIPANT: And then your request from them would be some feedback on feasibility?
MS. COLTON: How could this be done?
MS. GREENBERG: When he says, when Kepa says, it’s just mind boggling to think of reporting it on every claim except for, the majority of states have hospital discharge systems, if we’re talking about inpatient, that collect this, and it is, it’s reported on every claim.
PARTICIPANT: In every claim.
MS. GREENBERG: It is, it’s reported, I mean the inpatient. I think if you start thinking about every time a person comes in for a shot or something that could be kind of overwhelming but --
MS. COLTON: Actually, what I said to Kepa was in an earlier iteration of this recommendation what we were really trying to get was to have this collected the first time, as the physician sees the patient, so that if in fact you tied the situation description and the implementation guide to say anytime a new patient ENM(?) code is used race and ethnicity must be recorded. But only a new patient, this way you get it the first time a patient sees each physician that they see and you know how each physician or each physical therapist or whatever the character is perceives that patient.
MS. GREENBERG: Did that seem to complicated?
MS. COLTON: No, actually he liked that, he said that’s easy, he said that you could do because then, he said what they’re going to object to is the every claim, millions of claims, but if you’re just saying, and they’re worried that they’re not going to get paid if they don’t put it on the claim, whereas if all you’re talking about is the first claim, put it on the first claim, after that you don’t need to think, you only have to do it once, after that we’re not going to bother you. It was much more palatable.
PARTICIPANT: And aren’t new patient visits actually reimbursed somewhat at a higher rate? Because there are additional pieces of data, things that are done.
DR. STEINWACHS: You hope.
MS. COLTON: Well we ought to be able to guess it’s higher for a new patient then established patients.
MS. GREENBERG: So you’re talking about in the non-institutional environment.
MS. COLTON: In the non-pay for performance world.
JULIA: This is Julia, just as an aside, even on the institutional side for institutional inpatient records race and ethnicity are missing to an alarming extent, that’s true of our surveys at NCHS and it’s also true of the data collected by AHRQ from the state databases.
MS. GREENBERG: In particular ethnicity I know is worse then race.
JULIA: And that will come out when the National Health Care Quality Report and National Health Care Disparities Reports are published because it was a significant problem in terms of reporting on race and ethnicity, that the data are missing.
MS. GREENBERG: I thought race was pretty good in hospital data but --
JULIA: No, it’s not.
MS. GREENBERG: Like under 80 percent?
JULIA: I would say yes, probably under 80 percent.
MS. GREENBERG: I know ethnicity is not good at all.
MS. HANDRICH: And I don’t know, just thinking about Medicaid, I think the policy is that the states may not require that at the time of application, that it is an optional field and it’s mandated as an optional field, that’s just a point of fact that somebody would have to verify but --
MS. COLTON: I think you’re right about that and that when we formulated the recommendation for the 834 we actually didn’t make it, we made it situational for that very reason, that you can’t mandate that the enrollee provide it.
MS. GREENBERG: I think we got some feedback from some Medicaid agencies, too, that they would rather it was collected on the claim then having to collect it in enrollment because of some of those issues. It’s a classic everybody wants the data, nobody wants to collect it.
MS. COLTON: I think one of the issues is just enabling it to happen when consenting parties agree to share it and right now the implementation guide is a barrier to that occurring, so Aetna has agreed, they want to go out and collect race ethnicity data on their enrollees, some of those enrollees, and I have no idea what percent, are going to be willing to provide it. But if the transaction can’t carry it, or the implementation guide doesn’t support it, now you’ve got two willing parties and no mechanism for communicating, so that’s really the issue.
MR. HUNGATE: Marjorie, can Cathy’s time be funded for this if that works out?
MS. GREENBERG: Sure
MR. HUNGATE: So that those things could happen?
MS. GREENBERG: If they can work it out we’ll just have, I mean work through the contractor to do the travel.
MR. HUNGATE: I think the specificity of all those things is such that if we can carry it direct through the X-12 that it’s going to be better to just deal with it there at that level of specificity.
MS. GREENBERG: What happens is, you know maybe they don’t react positively to this, that or the other, but it gets them thinking about these things, I mean that’s what happened when Arnie Millstein came, well first someone else came who didn’t make a very effective case and the then next time Arnie Millstein came to the NUBC and now the NUBC is kind of thinking about well how could they collect that qualifier for secondary diagnoses on the UBO-2, so it evolves --
MR. HUNGATE: It takes time.
MS. GREENBERG: But it starts them thinking about it.
MS. COLTON: And I think part of it is just trying to crack the nut of understanding the process, too, I mean Kepa was trying to explain to me that this is a window of opportunity that if we don’t do this next week it’s like two to three years before --
MS. GREENBERG: Because the next version is being --
MS. COLTON: Yeah, because two things are happening that are going for balloting in December and they’re happening at this meeting, so what happens at this meeting determines what goes on the ballot. And the first thing is the 40/50 implementation guide will be closed after this meting, so if you want any change in the 40/50 implementation guide --
PARTICIPANT: I’m sorry, what’s the 40/50 implementation guide?
MS. GREENBERG: Well, it’s the next version, the 40/10 was what was implemented under HIPAA, and the next version is 40/50, though the next HIPAA mandate may not be the 40/50, it may be something after that.
MS. COLTON: Well the 60/10 was what I was told. The two things that are happening at this meeting that are going for balloting in December are closing the changes to the implementation guide for the 40/50 version of the transaction and agreeing to the data elements that will be on the 60/10 version of the transaction.
MS. GREENBERG: 60/10. See we originally got race ethnicity into the 40/50 but then they, you never win these things, but then they decided that they didn’t want it in the HIPAA implementation guide.
MS. COLTON: Well, yeah, that’s the problem, each of these data elements you sort of need to know where the problem is, is the problem that it’s not on the transaction --
MS. GREENBERG: Not in the standard, and it is in the standard.
MS. COLTON: But it’s not in the claims standard.
MS. GREENBERG: It is in the claims standard.
MS. COLTON: Oh, it is in the claims standard?
MS. GREENBERG: Race and ethnicity is in the claims standard but not in the HIPAA guide --
PARTICIPANT: Which is the 40/10.
MS. GREENBERG: Well it isn’t even in the claims standard that the 40/10 was based on but it’s in the 40/50 claims standard, that’s why we have it in our --
MS. COLTON: So we need to address the 40/50 implementation to say look you got into the standard but it needs to get implemented.
MS. GREENBERG: If this would be a window --
MS. COLTON: -- like test results and vital signs, which aren’t in the 40/50 then you’re addressing, my understanding from Kepa is, the 60/10 content. So our recommendations kind of, we need to decide some of these are 40/50 implementation guide recommendations and some of them are 60/10 transaction standard recommendations. And then when they get to the implementation guide for the 60/10 you’ve got to watch it because it could be in there and the implementation guide could say not used, so it’s like --
MS. GREENBERG: So if you can go, no, if she can go I think that would be great.
MR. HUNGATE: I think so, too, so let’s say that’s going to happen if it can happen.
MS. GREENBERG: You could make the time on your schedule?
MS. COLTON: Yeah, I said if it could be Monday afternoon or Tuesday morning I could do it, 30 minutes in San Francisco, San Diego.
MR. HUNGATE: What time do we have to leave here to get to dinner?
MS. GREENBERG: 6:15.
MR. HUNGATE: That’s seven minutes from now. I’ve got some more things I’ve got to cover. I will do a draft of a communication tool, which I will send to all of you folks and ask you to critique, change, send back. You can even score it if you feel like it. We’ll do a cross classification of the various strata, it will have no statistical validity --
MS. COLTON: Do we want to combine, given that I’m going to have to write a brief business case for each one of the things for Monday do you want to combine that into this? In other words here’s the recommendation, here’s the business case and here are the questions?
MR. HUNGATE: Anything you can send me would be super --
MS. GREENBERG: So these things aren’t kind of floating out there, they’re anchored.
PARTICIPANT: It would just be useful for us to see.
MR. HUNGATE: Send it to everyone, it will be quicker. Then that will need to get out to all the executive subcommittee first and then second to the committee as a whole, and then we need to get it back and then we need to work on it.
MS. GREENBERG: Analyzing it.
MR. HUNGATE: And we need to do that between now and November 5th.
MS. HANDRICH: Is our target, is that the executive committee or is that the full committee --
MS. GREENBERG: No, that’s the full committee.
MR. HUNGATE: That’s the full committee --
DR. MAYS: But they want to have it in the book --
MS. GREENBERG: He was talking about it sort of helping to structure the meeting and I would imagine that we will do an agenda that will kind of like just have some block of time to discuss the quality report and recommendations and everything because we can’t wait until, exactly how you’re going to want to use that block of time gets figured out --
MS. HANDRICH: So theoretically what we would do with that time, at least one thought is we would present to the committee what results and our thoughts if we can formulate them on our next steps.
MR. HUNGATE: Yeah, I think we’ll wind up taking up those results and make some decisions based on it.
MS. GREENBERG: Right, see where’s there consensus, where there’s --
MR. HUNGATE: This is what we think this says --
MS. HANDRICH: And what do we want the committee to do then.
MR. HUNGATE: Here’s what the agenda is for the time at the full committee.
MS. GREENBERG: And you are planning to be at the executive subcommittee meeting?
MR. HUNGATE: Yes.
MS. GREENBERG: You are, okay.
MR. HUNGATE: Now when you say executive subcommittee meeting --
MS. GREENBERG: November 21st in Princeton.
MR. HUNGATE: You’re talking about, that’s afterwards --
MS. GREENBERG: I know it is.
MR. HUNGATE: So yes I will be there.
MS. GREENBERG: I wanted to make sure you’re there because workgroup chairs don’t come but you should be there.
MR. HUNGATE: I will be there, I guarantee it. Some people are more liable to attend these then others.
DR. MAYS: No in terms of being reliable.
MR. HUNGATE: So that will be following the full committee meeting.
MS. HANDRICH: So after the results come in you’re kind of talking through out loud with us about how we get to that point, what would we convene a telephone conference call, is that the plan?
PARTICIPANT: You have one scheduled, but is it, October 12th or 18 or something, because there’s already one on the calendar.
MR. HUNGATE: The 3rd is what mine says.
MS. COLTON: I have 1:00 on the 3rd.
MR. HUNGATE: The 3rd won’t happen is my guess.
MS. COLTON: I could give you an update on what happens in San Diego on the 3rd.
MS. GREENBERG: Well, that would be beneficial.
PARTICIPANT: Will somebody make sure I get that?
MS. GREENBERG: If you’re going to try to get the questionnaire out by the end of next week --
MR. HUNGATE: The end of next week, that’s the 3rd of October --
MS. GREENBERG: That’s already the 3rd of October?
MR. HUNGATE: Well you’ll have feedback, we better go for the 1st of October to get that --
MS. GREENBERG: 1st of October?
MR. HUNGATE: To get something out to here to look at.
MS. GREENBERG: To this group to look at.
MR. HUNGATE: It probably needs quick turnaround.
MS. GREENBERG: It will be something we can email, it would be nice if it were web based.
PARTICIPANT: Could you give us a weekend to take a look at this?
MS. GREENBERG: Actually I think I’m going to -- PARTICIPANT: Leave, run?
[Whereupon at 6:15 p.m. the meeting was adjourned.]