February 21, 2013
TTAG Data Subcommittee Face-to-Face Meeting Action Items
Action Item
Timeline
Identify current CMS data staff members
who could meet with the Data
Subcommittee concerning the data
architecture.
Update the Data Subcommittee
membership list and distribute it to the
members.
Identify a date in late March or early April to
meet with CMS data staff.
Distribute the CRIHB protocol for the CCW
data research project.
Person
Responsible
Status
ASAP
Capt. Lyon
Ongoing
ASAP
Ms. Heintzman
Ongoing
ASAP
Mr. Crouch and
Capt. Lyon
Ms. Heintzman
Ongoing
ASAP
Notes
Ongoing
February 21, 2013
TTAG Data Subcommittee Face-to-Face Meeting Minutes
Agenda Item
Documents
Received
Welcome and Call
to Order
Roll Call
Discussion
Action
None
Mr. James Crouch, Tribal Technical Advisory Group (TTAG) California
Area Representative and Executive Director, California Rural Indian
Health Board, Inc. (CRIHB), stated that the purpose of the meeting
was to review Goal 5 of the Strategic Plan and identify any new
business the Data Subcommittee should undertake.
Ms. Liz Heintzman, Legislative Program Associate, National Indian
Health Board (NIHB), took the roll. Participating in the meeting were:
TTAG:
David Antle
Frances Antone
Pearl Capoeman-Baller
James Crouch
Richard Narcia
Diddy Nelson
Madan Poudel
Alec Thundercloud
Tribes and Tribal Organizations:
Laura Bird
TTAG Data Subcommittee Face-to-Face Meeting – February 21, 2013 – Page 1
Carol Korenbrot
Liz Malerba
Karen Massey
Joan O’Connell
Sherrie Varner
CMS:
Bonnie Hillsberg
John Johns
Jim Lyon
Kitty Marx
Rachel Ryan
NIHB:
Jennifer Cooper
Liz Heintzman
Others:
Sue Clain
Kathryn McGrew
Discussion
Mr. Crouch stated that the work of the Data Subcommittee is driven
by the TTAG Strategic Plan. The overarching data goal identified in
the plan is to develop and improve Centers for Medicare & Medicaid
Services (CMS) data systems to evaluate and expand the capacity of
CMS to serve American Indians and Alaska Natives (AI/ANs). There
are five objectives under this goal.
Goal One
The first goal states that CMS will create a data system that identifies
AI/ANs appropriately to ensure that they receive the benefits and
protections afforded them under law and regulation. This objective
relates to the shaping of the CMS data architecture, including
systems for collecting, organizing, and sharing data.
The first task under this objective is to schedule a meeting between
the Data and Policy Subcommittees and CMS representatives
concerning data architecture. Mr. Crouch indicated that
representatives from the Indian Health Service (IHS) should also
attend in order to facilitate data sharing between the two agencies.
He stressed the importance of discussing the challenges concerning
the limited definition of Indian used in the Patient Protection and
Affordable Care Act (ACA) for the health insurance marketplaces. He
reminded the participants that there are no premiums or copays in
the Medicaid program for AI/ANs (based on a definition published in
the Federal Register). IHS and CMS need to collaborate on sharing
data to ensure that AI/ANs receive these benefits.
Capt. Jim Lyon, Tribal Affairs Group (TAG), Office of Public
Engagement (OPE), CMS, indicated that CMS is willing to work with
the Subcommittee to identify tentative dates for the meeting. There
has been some turnover in the CMS data staff, including Mr. Michael
Forman, Former Deputy Director, Division of Information Analysis
and Technical Assistance, Data Systems Group, Center for Medicaid
and CHIP Services, CMS, and Ms. Goldie Austen, CMS. He promised
to identify their replacements. Capt. Lyon suggested inviting
representatives from the Medicare Chronic Conditions Data
Warehouse (CCW) to the meeting. Mr. Crouch also believed that
Capt. Lyon will identify current
CMS data staff members who
could meet with the Data
Subcommittee concerning the
data architecture.
TTAG Data Subcommittee Face-to-Face Meeting – February 21, 2013 – Page 2
representatives from the Office of the IHS Director should be invited
as should Dr. Richard Church, Director, Office of Public Health
Support, IHS, and Mr. Howard Hays, Chief Information Officer, IHS.
As part of health care reform, Mr. Crouch noted, agencies are being
urged to make the enrollment and application processes as efficient
as possible. Linkage between the IHS data warehouse and CMS
eligibility systems is virtually nonexistent. As a result, the burden is
on the states to identify Indians and ensure they are receiving the
benefits to which they are entitled. In his opinion, this means that
the protections provided by Section 5006 of the American Recovery
and Reinvestment Act are three years behind in terms of
implementation.
Capt. Lyon stated that CMS needs an updated membership list for
the Subcommittee. Ms. Heintzman read off the names of the
Subcommittee members from the most recent membership list. As
many of the members were no longer participating in Subcommittee
activities for a variety of reasons, she agreed to follow up with
several individuals, add others who expressed an interest in working
on data issues, update the membership list, and distribute the
revised list to members.
Ms. Heintzman will update the
Data Subcommittee
membership list and distribute
it to the members.
Dr. Joan O’Connell, Consultant to CRIHB and Assistant Professor,
Department of Community and Behavioral Health, University of
Colorado Denver, recommended that the group invite a
representative from Medicare who is familiar with the current
CMS/IHS matching work to attend the Subcommittee meeting with
CMS.
Ms. Kitty Marx, Director, TAG, OPE, CMS, asked when Mr. Crouch
would like to hold the meeting and if it needs to be coordinated with
other meetings. Ms. Jennifer Cooper, Director, Regulatory Affairs,
NIHB, added that the Strategic Plan requires the TTAG Tribal
Consultation Subcommittee to have an in-person meeting with CMS
staff. Mr. Crouch noted that the Strategic Plan only ties the
Data and Policy Subcommittees together for the purposes of this
meeting. He welcomed the participation of other subcommittees and
indicated he would prefer to schedule the meeting at the earliest
date possible given the ACA implementation timelines. Mr. Crouch
and Capt. Lyon agreed to target a date in late March or early April for
the meeting.
Mr. Crouch and Capt. Lyon will
identify a date in late March or
early April to meet with CMS
data staff.
Objective Two
The second objective calls for the development and improvement of
data for AI/AN populations that can be used to evaluate CMS
program enrollment, health care delivery, outcomes, and payments
across states and IHS areas during the implementation of the major
health care laws and policies.
Objective Three
The planning and execution of a data symposium at which the data
work products can be discussed is the third objective. Dr. Carol
Korenbrot, Consultant, CRIHB, indicated that the symposium will not
take place for another year or two. Ms. Marx added that it would
TTAG Data Subcommittee Face-to-Face Meeting – February 21, 2013 – Page 3
likely be held in conjunction with a TTAG face-to-face meeting. Mr.
Crouch stressed that the symposium provides an excellent
opportunity for those with interests in this data to raise challenges
and brainstorm. Dr. Korenbrot indicated that CRIHB would scour the
country in an effort to identify researchers doing similar or related
work and invite them to participate.
Mr. Richard Narcia, TTAG Secretary and President, Board of
Directors, Gila River Indian Community, stated that it is not the intent
of the Phoenix Area tribes to challenge the data analyses in the
Medicaid report that was presented to the TTAG the previous day.
The report is a fundamentally good report. The tribes simply wanted
to raise concerns about the future use of the data. He indicated that
the tribes might develop a longer set of comments. Mr. Crouch
expressed his appreciation for the comments from the Phoenix Area
tribes. He explained that he used the word “challenge” in the context
of the symposium to refer to the research decisions. Dr. Korenbrot
encouraged the other areas to submit comments on the report as
the feedback helps CRIHB plan future activities.
Objective Four
The fourth objective under the data goal calls for the establishment
of a research agenda. Mr. Crouch explained that the Data
Subcommittee is responsible for shaping the research conducted by
CRIHB. It was the Subcommittee’s efforts to identify other
researchers with experience with and interest in Indian data that led
CRIHB to the Census Bureau’s American Community Survey data. This
data has been very helpful in understanding the number of Indians
with coverage or access to IHS services. Dr. Korenbrot used this data
in a series of reports. He welcomed suggestions for future research
topics.
Ms. Diddy Nelson, TTAG Technical Advisor and Executive Director,
Oklahoma City Inter-Tribal Health Board, stated that the tribal
epidemiology (epi) centers hold monthly conference calls, which
begin with an educational presentation. She suggested that CRIHB
present its work during one of these calls. The epi centers could be
potential sources of funds and new partners for the symposium. Dr.
Korenbrot responded positively to the suggestion. She also pointed
out that epidemiology and health services research are separate
fields that ask different questions. Epidemiologists are not interested
in claims and payments or performance of the system for better
outcomes.
Mr. Crouch noted that any future research should use CMS-based
data or related data. CRIHB has done state and area level analyses,
but has not undertaken service unit level analyses. CRIHB has also
done work on Census Indians and IHS active users. He indicated that
CRIHB has not identified a way to conduct research only on members
of federally-recognized tribes; he anticipated that this would be
possible once CMS opens up access to the marketplace to members
of federally-recognized tribes.
Dr. O’Connell reported that CRIHB recently completed a five-page
protocol, which is the basis on which CRIHB obtains the data that it
Ms. Heintzman will distribute
the CRIHB protocol for the CCW
TTAG Data Subcommittee Face-to-Face Meeting – February 21, 2013 – Page 4
needs to conduct research. The protocol was sent to the individuals
on the old Data Subcommittee list; she promised to distribute it to all
of the members on the revised list.
data research project.
This year’s research will take advantage of the information available
through the CCW. The data will allow CRIHB to analyze health status,
service utilization, and Medicare and Medicaid payments for people
with Medicare coverage. CRIHB will use Medicare information on
AI/ANs who have used IHS services. One of the CCW data sets has
one record per Medicare beneficiary that includes indicators for
chronic conditions (e.g., diabetes, heart disease, hypertension, etc.).
The CCW also includes summary medical service utilization
indicators, including the number of hospital admissions, number of
days in the hospital, number of outpatient visits by type, and
Medicare and Medicaid payment information. CRIHB can combine
this data set with other Medicaid data sets (e.g., a set with one
record per hospital admission) to determine whether an admission
was preventable or not. She looked forward to working with the
Subcommittee to identify more ways to use the data.
Mr. David Antle, TTAG Albuquerque Area Representative and
Director, Health Services, Isleta Pueblo, asked whether the new study
would clarify or utilize the same aggregates that were mentioned in
the earlier study, specifically IHS active users who encounter the IHS
system. Mr. Crouch indicated that CRIHB has learned that IHS
enriches the Medicare data set through a quarterly data transfer. The
Social Security Administration enrolls individuals in Medicare and
then sends the list of new enrollees to IHS. IHS flags the individuals
known to the agency as active users and sends the flagged data set
to Medicare. As a result, Medicare has well-structured data files that
clearly identify Indians. There are approximately 800,000 active
users.
Dr. O’Connell pointed out that the Medicare data indicates whether
an individual has ever used IHS services. She did not know if
Medicare also uses an active user designation. For the Medicaid
report, CRIHB had to use IHS data to identify active users because
Medicaid does not ping against the IHS data system. Mr. Crouch
indicated that although there is a relatively small number of Indians
who are on Medicare based on their age (approximately 400,000
AI/ANs), CRIHB will have access to a very rich data set concerning the
services they received and the cost of those services. Dr. O’Connell
noted that the data would allow CRIHB to look at payments for longterm care for individuals who are dually eligible for Medicare and
Medicaid.
Mr. Crouch indicated that the Subcommittee would welcome
recommendations, suggestions, or requests from other
subcommittees concerning data needs.
Dr. O’Connell stated that some of the things that CRIHB could learn
from the data include health status of Medicare enrollees (both the
over 65 population and those under 65 who are on disability status),
the prevalence of 27 chronic conditions, comorbidities (e.g., the
prevalence of heart disease among those with diabetes), insurance
TTAG Data Subcommittee Face-to-Face Meeting – February 21, 2013 – Page 5
coverage (including Medicare Part D drug coverage), payments, and
utilization.
Mr. Madan Poudel, TTAG Navajo Area Representative (by proxy),
stated that more than 80 percent of available resources are used to
treat chronic conditions. He believed that determining how much is
being spent to treat chronic conditions within Indian Country is very
important. He added that the epi centers are expanding their work to
include information technology research and data. The epi centers
are publically authorized public health entities. All of the public
health data in the possession of CMS can be made available to the
epi centers. He recommended that CRIHB establish data sharing
agreements with each of the 12 epi centers as they are authorized to
have the data components within their reach. Mr. Poudel also
recommended identifying all of the data sources and ongoing
research efforts concerning Indian health care and abstracting any
findings. Abstracts would be very useful to Indian leaders as they
make decisions concerning planning and financing. The Navajo epi
center is ready and willing to assist the Data Subcommittee in its
work.
In additional to the data analysis work, Mr. Crouch reported that
CRIHB has tasked Mr. Ed Fox, Health Services Director, Port Gamble
S’Klallam Tribe, with developing a series of single-page policy briefs.
He will use CRIHB’s work with the Census Bureau’s American
Community Survey data as a basis for the papers.
Mr. Crouch added that Dr. Korenbrot will be transitioning out of the
data project. She has retired from her position with CRIHB and is
currently working on a contract basis. He anticipated that the
analysis work would, over time, shift away from determining who
receives care toward analyses of the cost of care and its
effectiveness.
Schedule Next Call
The Subcommittee scheduled the next meeting/conference call for
March 22 at 2:00 p.m. EDT.
Adjourn
With no other business outstanding, Mr. Antle made a motion to
adjourn the meeting that was seconded by Mr. Poudel. The motion
carried unanimously, and Mr. Crouch adjourned the meeting.
TTAG Data Subcommittee Face-to-Face Meeting – February 21, 2013 – Page 6