Meeting Minutes, March 27, 2015
National Advisory Council
Minutes from the March 27, 2015, meeting of the Agency for Healthcare Research and Quality's National Advisory Council.
Contents
Summary
Call to Order and Approval of November 7, 2014, Meeting Summary
Director's Update and Strategic Directions
Selected Internal AHRQ Research on Access and Affordability (CDOM)
Surgical Site Infections Following Ambulatory Surgery Procedures
Hospital Inpatient Utilization Related to Opioid Overuse Among Adults, 1993–2012
Young Adults and the Affordable Care Act: The Impact of Dependent Care Coverage Expansion to Age 26
Patient-Centered Outcomes Research Dissemination and Implementation
Selected Internal AHRQ Research on Access and Affordability (CFACT)
Does Public Insurance for Children Improve Single Mothers' Health Care Use?
Many Families May Face Sharply Higher Costs if Public Health Insurance for Their Children Is Rolled Back
The Growing Gap Between Public and Private Payment Rates for Inpatient Hospital Care
Public Comments
Chairman's Wrap-Up and NAC Input
Adjournment
Summary
NAC Members Present
Elizabeth A. McGlynn, Ph.D., Kaiser Permanente (NAC Chair)
David J. Ballard, M.D., Ph.D., M.S.P.H., FACP, STEEEP Global Institute, Baylor Scott & White Health
Francis J. Crosson, M.D., Medicare Payment Advisory Commission
Shari Davidson, National Business Group on Health (by phone)
Mary Fermazin, M.D., M.P.A., Health Services Advisory Group, Inc.
Andrea Gelzer, M.D., M.S., FACP, The AmeriHealth Caritas Family of Companies
Paul B. Ginsburg, Ph.D., University of Southern California
Kevin L. Grumbach, M.D., University of California, San Francisco
Leon L. Haley, Jr., M.D., M.H.S.A., CPC, Medical Care Foundation, Emory University
Ann L. Hendrich, Ph.D., R.N., FAAN, Ascension Health
Carol Matyka, M.A., National Breast Cancer Coalition (by phone)
Victor M. Montori, M.D., M.Sc., Mayo Clinic College of Medicine
Mary D. Naylor, Ph.D., R.N., FAAN, University of Pennsylvania School of Nursing
Jean Rexford, Connecticut Center for Patient Safety
J. Sanford Schwartz, M.D., University of Pennsylvania
Paul E. Sherman, M.D., M.H.A., CPE, FAAP, Group Health Physicians
Patricia J. Skolnik, Citizens for Patient Safety
Jed Weissberg, M.D., Institute for Clinical and Economic Review
Alternates Present
David Atkins, M.D., M.P.H., Veterans Health Administration
Chisara N. Asomugha, M.D., M.S.P.H., FAAP, Centers for Medicare & Medicaid Services
AHRQ Staff Members Present
Richard Kronick, Ph.D., Director
Sharon Arnold, Ph.D., Deputy Director
Jaime Zimmerman, M.P.H., PMP, Designated Management Official
Karen Brooks, CMP, NAC Coordinator
Call to Order and Approval of November 7, 2014, Meeting Summary
Elizabeth A. McGlynn, Ph.D., Chair of the National Advisory Council (NAC), Agency for Healthcare Research and Quality (AHRQ), called the group to order at 8:30 a.m. and welcomed the NAC members, invited speakers, visitors, and viewers of the Webcast. She noted that the meeting would feature a session in which public representatives could make comments.
Dr. McGlynn referred to the draft minutes of the previous NAC meeting and asked for changes and approval. The NAC members unanimously approved the November 7, 2014, meeting minutes without changes.
Director's Update and Strategic Directions
Richard Kronick, Ph.D., AHRQ Director
Transitions
Dr. Richard Kronick welcomed the NAC members, in particular six new members: Dr. McGlynn; Jennifer E. DeVoe, M.D., D. Phil., M. Phil, MCR; Paul B. Ginsburg, Ph.D.; Kevin L. Grumbach, M.D.; Mary D. Naylor, Ph.D., R.N., FAAN; and J. Sanford Schwartz, M.D. He announced that Gregory Baker, R.Ph., who was unable to attend, recently became Vice President, Pharmacy, at Premise Health; and Leon L. Haley, M.D., M.H.S.A., CPE, recently became Executive Associate Dean, Clinical Services-Grady Health System, Chief Medical Officer, Emory Medical Care Foundation, and Professor, Department of Emergency Medicine, Emory University.
Dr. Kronick announced that Irene Fraser, Ph.D., the Director of AHRQ's Center for Delivery, Organization and Markets, will be retiring. Dr. Fraser was instrumental in building AHRQ's Health Care Cost and Utilization Project (HCUP) and many other important projects at AHRQ through the years.
AHRQ Budget
Dr. Kronick stated that the 2015 Federal budget was enacted, with AHRQ receiving funding nearly equal to the previous year. AHRQ recently was given the funding status of "budget authority," which may make future funding more secure. The President's 2016 Federal budget request, released in February, featured an increase for AHRQ. It includes $12 million to support improvements in care of people with multiple chronic conditions, $10 million for the President's National Strategy for Combating Antibiotic-Resistant Bacteria, and $5 million to support the prevention of prescription drug overdose, focusing on medication treatment programs. AHRQ also will be contributing to a project in the U.S. Department of Health and Human Services (HHS) Office of the Secretary to conduct an investigation of effects of insurance design and cost-sharing on the utilization of services and health outcomes.
AHRQ Updates
Dr. Kronick reported on the following initiatives at the Agency:
- AHRQ will offer 3-year grants to promote the adoption of patient-centered outcomes research (PCOR) in small- and medium-sized primary care practices. The projects (eight in all) will feature regional collaboratives and will focus on the Million Hearts® ABCS program (Aspirin use, Blood pressure control, Cholesterol management, and Smoking cessation) to prevent heart attacks and strokes.
- AHRQ is supporting a large project about comparative health system performance in utilizing PCOR, featuring three AHRQ Centers of Excellence.
- A smaller internal project will use commercial and Medicare data to gain a better understanding of health care spending and utilization in large U.S. health systems. It will attribute the activities of patients to health systems and measure performance based on the systems' physicians.
- An AHRQ-supported medical records review published in December reported that concerted efforts by hospitals reduced adverse events to patients by more than 1 million. The most significant improvements occurred in 2012 and 2013. Hospital-acquired conditions (HACs) declined by 17 percent in a 3-year period.
- AHRQ released a funding announcement for patient safety learning laboratories that identify threats to patient safety. The projects will feature multidisciplinary teams and the use of brainstorming and rapid prototyping techniques to stimulate thinking.
- Addressing a requirement of the Affordable Care Act, AHRQ will use funds to advance clinical decision support (CDS). It will partner with the Centers for Medicare & Medicaid Services (CMS) to develop a repository of PCOR findings relevant to CDS. It is offering grants for simulating the uptake and use of CDS artifacts and will facilitate a national learning community featuring stakeholder feedback.
- AHRQ released a brief titled "Health Care Simulation To Advance Safety: Responding to Ebola and Other Threats." It describes the potential of simulation to help prepare for Ebola and other emergent epidemics.
- HHS is conducting a departmental initiative on delivery system reform, with support from AHRQ. The project seeks to improve the ways in which providers are paid; improve care delivery; and share information broadly to providers, consumers, and others to support good decisions.
- In November, the U.S. Preventive Services Task Force (USPSTF) produced a final recommendation on screening for vitamin D in community-dwelling, nonpregnant, asymptomatic adults. It concluded that the current evidence is insufficient to assess the balance of benefits and harms from screening. The Task Force also produced draft recommendations for screening for speech and language delay and disorders in children age 5 years or younger and screening for high blood pressure. Upcoming recommendations will address screening for iron deficiency anemia, counseling for tobacco use in adults and pregnant women, and breast cancer screening.
- AHRQ's evidence-based practice centers (EPCs) have produced a long list of systematic reviews, technical briefs, and methods reports since the last NAC meeting.
- A new arm of the Medical Expenditure Panel Survey (MEPS), the Medical Organization Survey (MOS), will respond to a need for linked information on organizational characteristics of provider practices and patients. Steven Cohen, Ph.D., Director of AHRQ's Center for Financing, Access and Cost Trends, described the new survey, which will permit analyses of the impacts of organizational characteristics (practice size, specialties, etc.), use of health information technologies, and financial arrangements on access to and affordability of health care. The MOS initially will result from a nationally representative sample of office-based physicians providing care to MEPS participants in 2015. A MOS field test is under way.
- AHRQ will resume its annual research conference October 4–6, 2015, at the Crystal Gateway Marriott in Arlington, Virginia. The conference theme will be "Producing Evidence and Engaging Partners To Improve Health Care." The final day of the conference will include the teaming of AHRQ, AcademyHealth, and the Patient-Centered Outcomes Research Institute (PCORI) in joint sessions.
Discussion
Andrea Gelzer, M.D., M.S., FACP, asked whether AHRQ might use some of its funding to focus on issues in performance measurement and value-based payment, for example, to identify gaps in the quality matrix.
Regarding the funding to address multiple chronic conditions, Patricia J. Skolnik stressed the need for two-way conversations between patients and physicians. Regarding the HHS evaluation of effects of cost-sharing on utilization and outcomes, Dr. Ginsburg noted that complexities in the health care system make it difficult to perform such studies.
Regarding efforts to address HACs, David J. Ballard, M.D., Ph.D., M.S.P.H., FACP, noted the benefit from addressing coding issues. Dr. Schwartz cited the need to identify best practices. Ann L. Hendrich, Ph.D., R.N., FAAN, proposed using hospitals with data to study how changes lead to improvements (for example, case-controlled studies).
Jed Weissberg, M.D., wondered about overlap between the learning laboratory project and other patient safety programs, such as those of the Joint Commission. Dr. Kronick responded that there are commonalities, with AHRQ focusing on the acquisition and dissemination of evidence. The approaches are often similar.
Regarding CDS, Victor M. Montori, M.D., M.Sc., encouraged AHRQ to consider supporting decision support that engages the patient as well as the physician.
Paying for Value Project
Dr. Kronick asked the NAC members to comment on AHRQ's Paying for Value Project, which will feature the publication of a series of AHRQ-commissioned papers in Health Services Research in October 2015. He asked the council members to consider questions such as the following: What research should AHRQ be commissioning on how to effectively pay for value? How can external public reporting and pay-for-performance be used to catalyze internal quality improvement efforts? What kinds of financial incentives might be beneficial? Which parts of the health care system are susceptible to measurement?
Dr. Grumbach suggested that targeted incentives might not be the most important tactic. Calling out a harmful practice can be more effective. What do patients want? Dr. Schwartz cited the difficulty of measurement and the need to reduce unnecessary medical applications. Dr. Montori stressed the need to focus on the day-to-day experience of the patient and avoid treatment burden. How much life quality is lost by applying quality improvement efforts?
Francis J. Crosson, M.D., stated that financial incentives are important but small, and we must distinguish between the individual physician level and the collective level. Confounding issues include attribution and ethics. Some incentives (e.g., peer groups, professionalism) are stronger than financial incentives. Dr. Naylor added that high-performing communities and theories of change are important. Jean Rexford added the importance of the patient's health literacy.
Dr. Ginsburg cautioned against going too far in using incentives with individual physicians. There are better strategies. He encouraged AHRQ to investigate whether quality measurement has been performed satisfactorily. Dr. Ballard stated a need to determine the power of incentives and the effects of differential payment by Medicare. Chisara N. Asomugha, M.D., M.S.P.H., FAAP, proposed research on value for families and an emphasis on population health, leading to a theory of change. Dr. Weissberg emphasized the importance of leadership in an organization. Dr. Hendrich suggested that leadership can be the difference between low-performing and high-performing hospitals.
David Atkins, M.D., M.P.H., asked whether we know how to measure value. Where should it be measured—at what level? Can a measure be a biopsy of overall system quality, or can it indicate what needs to change? Paul E. Sherman, M.D., M.H.A., CPE, FAAP, cautioned about unintended consequences from the use of incentives for physicians. Dr. Schwartz cited a need for measuring value throughout the care continuum, not only in hospitals. Dr. Haley suggested considering the safety net.
Dr. Kronick steered the discussion to how change can occur. How does improvement occur? There are a few levels, and a theory of change is needed. Dr. McGlynn suggested examining workflow for ways to create change. We need to understand work-arounds, and we need developmental work on what to measure and how to perform measurement.
Dr. Kronick asked the NAC members to consider learning health-care systems. Dr. Montori stated that another way to stimulate change is through collaborations. Dr. Weissberg noted that the Institute for Healthcare Improvement developed a theory of change and has been using it in collaborative processes for years. Dr. Asomugha suggested that some current programs (e.g., Partnership for Patients) are offering learning on the ground. Dr. Grumbach suggested that a conceptual framework (acting as a tool) and patient engagement at the organizational level would be helpful. Engagement at the family level also should be considered. Dr. Montori wondered how health care systems might collect the patient's and family's ideas about care that works well.
Selected Internal AHRQ Research on Access and Affordability
AHRQ Center for Delivery, Organization and Markets
Dr. Fraser introduced a session featuring reports on three recent internal AHRQ research projects that focused on the use of HCUP data. She began by describing elements of the HCUP program, which is a comprehensive set of publicly available all-payer health care data. It features inpatient and outpatient data based on hospital billing records.
Surgical Site Infections Following Ambulatory Surgery Procedures
Claudia Steiner, M.D., M.P.H., AHRQ
Dr. Steiner reported on a study to determine rates of incidence of clinically significant post-surgical infections. The investigators focused on outpatient surgeries, noting a lack of literature for that area regarding surgical site infections. They employed 2010 HCUP data, selecting low- to moderate-risk surgeries in a number of body systems and in eight geographical areas. They identified a homogeneous population of patients at low risk for infections and other complications.
The study and report produced the following conclusions:
- The rate of clinically significant surgical site infections following ambulatory surgery was low, despite documentation of poor infection control practices and in contrast with inpatient cases, which have higher rates.
- Nevertheless, a large number of ambulatory surgeries result in these complications.
- Quality improvement is warranted.
The NAC members asked about finer aspects, such as the effects of facility attributes. Dr. Steiner stated that the investigators looked at such aspects, but, because of low numbers, did not have the power to draw conclusions.
Hospital Inpatient Utilization Related to Opioid Overuse Among Adults, 1993–2012
Raynard E. Washington, Ph.D., M.P.H., AHRQ
Dr. Washington reported on a study of trends in opioid misuse and abuse, using HCUP data. The investigators sought to determine whether trends in use varied by patient characteristics, expected payer, or geographical region during the 20-year period beginning in 1993. They considered HCUP billing information from community, non-rehabilitation, short-term, acute-care hospitals and identified opioid overuse based on the ICD-9-CM diagnosis codes. The focus was on prescription-based drugs and not illicit drug use. The investigators found that resulting inpatient stays increased by nearly 150 percent during the 20-year period.
The study and report produced the following conclusions:
- Rates of inpatient hospitalizations for opioid overuse have increased significantly since 1993. In particular, inpatient stays for the age group 45 to 64 years have risen strongly.
- In 1993, rates were highest among men and younger adults and in the Northeast region. In the 20-year period, hospitalization rates for opioid misuse broadened geographically, rising in U.S. regions other than the Northeast.
- Continued efforts to address hospitalization and death related to opioid misuse are needed.
The NAC members suggested that the investigators look at prescribing patterns and data on related diagnoses. One limitation is that the HCUP data do not follow people over the course of care. Dr. Washington noted that the study looked at use for any diagnosis; it did not include illicit use. The study did not address use related to dental care.
Young Adults and the Affordable Care Act: The Impact of Dependent Care Coverage Expansion to Age 26
Herbert S. Wong, Ph.D., AHRQ
Dr. Wong reported on a study of the effects of expanded health care insurance coverage for dependents under the Affordable Care Act. In particular, the investigators estimated the impact of expanded coverage on emergency department visits and inpatient discharge rates. They assessed utilization in the 19–25 year age group using HCUP data, and they used the 27–31 year age group as a comparison. Dr. Wong suggested that care utilization might have been affected by one or more of the following: (1) lower out-of-pocket expenditures, (2) a substitution effect (more use of preventive care), and (3) a lower use of resources by the studied age group.
The study and report produced the following conclusions:
- Coverage expansion was associated with an overall decrease in total inpatient discharges. This was driven mainly by large decreases in pregnancy and delivery discharges.
- For inpatient discharges other than pregnancy/delivery, inpatient visits increased.
- There were decreases in use of emergency department and inpatient care for those with no insurance coverage, but increases for those with private insurance coverage.
The NAC members asked about the effects of Medicaid expansion in some States. Dr. Kronick noted that the data mostly were from a period before the recent expansion. Dr. McGlynn noted that there is an opportunity to dig down into details. The data seem to indicate that, in the short term, the price/expenditure effect might play a larger role, whereas, over time, the role of the substitution effect might grow.
Patient-Centered Outcomes Research Dissemination and Implementation
Sharon Arnold, Ph.D., Deputy Director, AHRQ
Dr. Arnold reviewed an AHRQ project to create a new framework for ongoing efforts supporting the dissemination and implementation of PCOR findings. AHRQ receives money from the PCOR Trust Fund to perform this work. It responds to a charge in the Affordable Care Act for AHRQ to broadly disseminate the research findings published by PCORI and other governmental research relevant to comparative clinical effectiveness. AHRQ will seek to ensure that the evidence is understood and used.
Dr. Arnold listed the main activities in the draft framework that has been developed, including the nomination of PCOR findings, the analysis and prioritizing of the findings, the dissemination of the findings, support for implementing the findings, and evaluation of the dissemination and implementation efforts. The nominated findings will be identified through discussions with funders, including PCORI and the National Institutes of Health. Analysis of the findings will address strength of the evidence, potential impact of implementation, and an environmental scan. Many tactics will be used to disseminate the findings, including press releases, social media, and outreach. Support for implementation will be multi-pronged. The evaluation step will feature knowledge development and the identification of promising strategies for implementation.
Discussion
Dr. Arnold asked the NAC members to offer input for the developing framework. She stated that the project will seek nominations of findings from major funders because of the funders' knowledge and perspective on the issues. Ms. Rexford cautioned about the need to be wary of research that has used small population samples. Dr. McGlynn cited the challenge of understanding the incremental contributions within any research field. Knowledge is cumulative. Dr. Montori suggested using, in the nomination process, third-person sources, such as crowdsourcing. Dr. Naylor suggested welcoming nominations broadly and then using a strategy of themes and evidence to cull and organize them. Dr. Schwartz agreed and added the need to allow the process to be driven by stakeholders. Ms. Rexford stressed the use of patients and families. Mary Fermazin, M.D., M.P.A., reminded the group that we already have priorities developed in national initiatives, which could help to guide the nomination process.
Dr. Arnold noted that the process will include attention to research gaps in implementation. Dr. Montori stressed the importance of the point-of-care level rather than the system level. Drs. Crosson and Schwartz suggested that about two-thirds of the funding will be needed for implementation support, with the remaining one-third being used for dissemination. Findings should be disseminated to physicians as well as funders and researchers. Dr. Kronick stated his belief that implementation is part of the charge to AHRQ. He summarized this session's main themes as (1) the need to work with stakeholders, (2) the need to use public media to elicit broad input, and (3) the need to use a majority of funding to support the implementation of meaningful change in practices.
Selected Internal AHRQ Research on Access and Affordability
AHRQ Center for Financing, Access and Cost Trends
Dr. Cohen introduced a second session featuring reports on recent internal AHRQ research projects on care access and affordability. These projects featured the use of data from AHRQ's Medical Expenditure Panel Survey (MEPS).
Does Public Insurance for Children Improve Single Mothers' Health Care Use?
Jessica Vistnes, Ph.D., AHRQ
Dr. Vistnes reported on a study of the effects of expansion of public insurance for children, in particular, switching from employer-sponsored insurance to the Federal Children's Health Insurance Program (CHIP). Benefits of public insurance include improved access to care for low-income children, a reduced spending burden, and improved health outcomes. The researchers stressed another aspect, the effect on a mother's use of health care services. They used MEPS data from 2001 to 2008, featuring low-income single mothers aged 25–54 years. They considered two variables: measurements of out-of-pocket premiums for coverage and whether children were enrolled in public insurance (or not insured). Results showed little effect for single mothers with employer-sponsored insurance. For uninsured single mothers, enrollment of children in public coverage led to strong positive effects on use of preventive services, number of office visits, and more.
The study and report produced the following conclusions:
- Children's public insurance coverage has a positive effect on uninsured single mothers' use of health care.
- That fact has implications for possible rollbacks in public coverage for children.
- Assessments of the impact of Medicaid expansion on single mothers' medical care should take into account whether their children have public coverage.
Many Families May Face Sharply Higher Costs if Public Health Insurance for Their Children Is Rolled Back
Edward Miller, Ph.D., AHRQ
Dr. Miller reported on a study of effects that might occur when public health insurance for children is rolled back, in particular, if children lose CHIP coverage. The researchers used MEPS data to determine employees' additional out-of-pocket premiums for employer-sponsored insurance to cover children no longer eligible for CHIP. They also used the data to determine potential access to insurance plans other than those with high deductibles. The marginal costs in private low-wage establishments were found to be lower than in all establishments; yet they still were often high. Marginal costs were very low and even zero for State and local government employees. About one-third of workers with single coverage will not be able to enroll their children in non-high-deductible plans.
The study and report produced the following conclusions:
- For families not eligible for insurance marketplace subsidies, some have access to dependent coverage at zero marginal cost; others might have to pay high family premiums (relative to CHIP premiums and income); many will have access only to high-deductible plans.
- Rollbacks in public coverage might leave some families with much more costly options for covering children.
The Growing Gap Between Public and Private Payment Rates for Inpatient Hospital Care
Patricia Keenan, AHRQ
Ms. Keenan reported on a study of the increasing gap between public and private payment rates for inpatient hospital care. Evidence suggests that during the past 20 years, the gap between private (more) and Medicare (less) payment rates has widened from 10 to 20 percent. The researchers looked at all-payer MEPS data and standardized for different patient mixes.
The study and report produced the following conclusions:
- The public-private inpatient rate gap has widened considerably. The researchers' methods offer strong reliability.
- Additional analyses might address questions such as the following: Are payment gaps widening in outpatient care, emergency departments, and elsewhere? What factors are driving the widening payment gap? What are the implications of the widening gap for treatment?
In discussion, Ms. Rexford suggested that the data do not account for all costs that the patients pay. Asked whether there are gaps between the public payers (Medicare, Medicaid), Ms. Keenan responded that there are differences, although they are small. The NAC members suggested that the researchers consider studying differences in outpatient costs, capital expenditures of hospitals, and the overall financial health of hospitals (regarding various margins).
Public Comment
Margo Edmunds, Ph.D., of AcademyHealth, stated that her organization values its ongoing relationship with AHRQ. AcademyHealth will be collaborating with the Agency and PCORI in meetings during the fall of 2015. It stands ready to serve in future initiatives.
Chairman's Wrap-Up and NAC Input
Dr. Kronick asked the NAC members to continue to offer suggestions about the focus of AHRQ's work and the focus of NAC meetings. He stated that the Agency will be generating evidence on the health insurance coverage expansion, will be working to understand pricing issues, and will be using MEPS and HCUP data to investigate the role of new technology on health care utilization and spending.
Adjournment
Dr. McGlynn stated that the next NAC meeting will take place on July 24, 2015. She thanked the NAC members and other participants and adjourned the meeting.
Respectfully submitted,
_________________________________________ ____________________
Elizabeth A. McGlynn, Ph.D., Chair Date
National Advisory Council
Agency for Healthcare Research and Quality
