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. 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