AFTERNOON SESSION    

    DR. WOOD: We do have one person who has come at noon to ask to be able to make public comment and we do have time built into our schedule for public comment so to be consistent with the rules that were established for the commenters from this morning, I'm pleased to invite Mr. Steve Lacey to the microphone to share his comments and Mr. Lacey, we'll give you five minutes for your comments.

    MR. LACEY: Thank you to the Advisory Committee. I apologize. I wasn't here this morning and I hope I'm not way off the subject but I'm a long-term ombudsman that works in Maricopa County and we receive many calls every day, myself and my staff, from dissatisfied families on the issues of what they see is premature or unsafe discharges from the hospital due to -- hospitals and skilled nursing facilities because the Medicare coverage has stopped.

    And what I pick up doing this for the last six years is people like yourselves and professional people, doctors, lawyers, nurses, are very strong advocates when their parents go in the hospital or skilled nursing facility with Medicare coverage. They're demanding that their family member get the best of care, the quality of care, the proper diagnosis and they don't get discharged before they're ready to leave and they get the rehab services that they need and the follow-up. And quite often they're successful because they themselves know how to speak to the medical establishment to demand the kind of services people need.

    Unfortunately, we get the many 80-year-old wives that their husband may be in the exact same situation, there are no children, the wife doesn't know what to say and quite often they're very fearful and upset because they've been told they have to take their husband home the next day. They haven't been prepared for this and many of these people are quite sick and ill and really aren't ready to leave the acute care center or skilled nursing facility.

    So one of my comments would be there are long-term care advocates in the nursing home field and we do our best there but there's not a comparable type of advocate for people in the hospital settings. A lot of times it's misinformation and communication, not knowing the resource system. Other times it's just people are rushed out too quickly. We see this what we call Friday afternoon discharges. Hospitals like to discharge people on Friday afternoons (indiscernible) to skilled nursing facilities. I'm not criticizing skilled nursing facilities but a lot of times they don't have their services in place over the weekend at the same extent that they would during the week. So it's not uncommon for someone to go in on a Friday afternoon, late on a Friday afternoon, they may not be picked up on as quickly until the next Monday when the system is back in place and it's unfortunate the things that have happened (indiscernible) they're quite often dictated by Medicare decisions with the HMO's or people trying to follow Medicare guidelines.

    The second issue and then I'll stop is the staff in hospitals and nursing homes will come to us as ombudsman, we're advocates, sometimes they can't stand their jobs, they can't take it any more because they are seeing what's happening to people that really need a lot more care that can't get it because of no way to pay for it. And it's very stressful to people that work in these settings. Say a social worker that's a discharge planner having to carry out an order when they know that this is not really that safe for the person. So I'm not sure they are clear to mandate what we can change but if you could look at that issue, I'm sure it's not unique to Maricopa County and here in Phoenix, but I've heard people throughout the country mention the same kind of problem.

    DR. WOOD: We appreciate your comments. Are there any other members of the public who have come and did not sign in and want to talk?

    FEMALE VOICE: Yes, it's Senator Kyl's staff.

    DR. WOOD: Yes, please. And would you please identify yourself.

    MS. GRACE: Sure. I'm Jane Grace from United States Senator Jon Kyl's office here in Phoenix and I am his healthcare expert for the state. I'm a registered nurse, worked 20 years in critical care trauma. I've seen ER and I've also done peer review organization work for aged day care. I've done physician billing and I've been involved with the Senator for seven and a half years.

    The reason that I am asking to speak today is because I won't be able to be here tomorrow. You're going to be touching on Medicare Plus Choice. I'm not certain what your exactly if you could use the information that I'm about to share.

    However, Senator Kyl and I have been actively involved in trying to make sure that there are quality health plans available for all Medicare beneficiaries in Arizona for a number of years. He had met with Nancy Amendropollo (phonetic) twice in the last administration, towards the end of that administration, on the very issue of the inavailability and high cost to rural Medicare beneficiaries in Arizona and probably elsewhere in the country.

    We see that the quality also at times may not be as good for those beneficiaries in the rural area at times and that is not making a critical statement of any providers in the rural area, be it facilities, doctors, ambulances, whatever.

    One idea that we had and I will be submitting this in writing, I just don't have it completed as yet, is that the consideration of considering that plans would contract on a state by state as opposed to county by county basis. Still maintaining the variation from county to county of the per beneficiary allowance per month and I do understand that there is -- there are recommendations for increasing the amount per beneficiary per month from 95 percent to 100 percent in the Medicare Plus Choice arrangements payment policies and also an additional pay increase. I know Congress is looking very closely at increasing funding for Plus Choice plans.

    But at any rate, the ability to be able to take a county in which a plan had possibly a negative balance and balance it out with the county in which they possibly had a very positive balance might be -- might allow them to over a statewide basis look still financially favorable and offer their benefits statewide. Many of these plans have provider networks throughout the state in the private sector. I'm not certain what the legalities or possibilities of allowing to utilize those same providers in the private sector in the Medicare sector would be. I know that the pharmacy benefit would be -- is already in place. They already have pharmacy networks statewide.

    I was thinking that, excuse me, it might be beneficial for Medicare beneficiaries not only to be able to access Medicare Plus Choice plans statewide but also to be able to access the best of quality. Because their benefit would not have to be received just in the county which they reside. Most care that beneficiaries receive is not urgent/emergent so it could be planned or could be appointments could be made so if they didn't live in a county or a city in which there was a provider of their plan, it wouldn't be necessarily a disadvantage.

    One of the reasons that, you know, we're fully aware that money alone is not the issue here, there's so many other demographics in the rural population and the rural situation that play into this. The fact that Mohave County has a per beneficiary monthly allowance which is exactly the same as Maricopa County, yet they haven't had a plan in three years and we have six is, you know, you do the math. It figures out exactly that already we know that money alone is not the answer.

    The rural beneficiaries for the most part seem not to be as willing to sign up for the Medicare Plus Choice plans unless they are very ill. So you see a smaller risk pool in the smaller counties, the rural counties and you see a sicker risk pool. Being able to share that risk from county to county as opposed to over a whole state I believe could be possibly be beneficial from that standpoint as well.

    I believe that the provider network could be used statewide. We also believe that contracting has been an extremely difficult issue. It is possible that contracting on a state by state basis would be easier for plans because those rural providers who have really dug their heels in and that's hospitals as well as ambulances and physicians. Maybe there's one hospital in a county. If they thought that they weren't going to be able to hospitalize any Medicare Plus Choice pensions in their county, in their one facility, I think they might look twice at signing the contract. Maybe it wouldn't be as advantageous a contract as they're able to get signed in Maricopa County. The same would be true of physicians. But -- and ambulances. But they would still be more prone to sign a contract, all of those providers, if they were concerned with the loss of their patient population to a city or an area where still living in the area they live in, where they could access all of their healthcare needs under Medicare Plus Choice. They could see a huge amount of patient population shift and that might incentivize people to sign contracts to provide Medicare Plus Choice coverage to beneficiaries. And I think probably you want me to sit down.

    I respectfully thank you for the opportunity to make these comments and I will submit them in writing. And they'll be more extensive than this. Thank you very much.

    DR. WOOD: Thank you very much. There are several items that I would like to take the time to pursue this afternoon for the members of the Committee. The executive committee has been discussing a topic of how the process for this Committee should work and so I have, you have each of you on a piece of paper a draft process and I'll put it up here on Powerpoint in a minute so you can see it. And we need to think about how it is that we're going to handle that. So let me go to the computer and get that up.

    And then just to -- and Christy has a piece of prose that she has also given you that I don't have in front of me on the computer so these are both for discussion. These are draft. They have been discussed at the executive committee level. After we left Washington, we started in our meeting in Miami and then the question was how would we manage potentially all of the issues that might be identified and where solutions might be present. Remembering that the Secretary has the idea that we will get to him suggestions early in the process so that we don't wait till we're entirely finished. But at the same time, there is an adequate time for review.

    Here is a process that we have considered, and by the way, at the last count yesterday when I went through the issue areas that I had summarized and I think I've gotten all of them by e-mail from the Committee, the Committee chairs and subcommittee chairs and individual members of the Committee. There were 74 separate issue statements and of the 74 separate issue statements, several of them had multiple recommendations and I'm probably the worst offender because after Miami, you all -- all of you who have seen and know that I wrote three of them for the three major issues that they each have about ten recommendations on them or ten items for consideration.

    But what we need to try to come to some agreement about is the process that we want to use in moving these forward. So after the issue areas are identified and any of these issue areas could come from the subcommittees as well as from any individual Committee member and we would send them to Christy and colleagues and the senior staff for technical advice. And what I mean by technical advice is this. Now as we go through these things here, sometimes we will know fairly well what is statutory and what is regulatory. But we're not always able to tell that from our level of expertise. And because what we're really looking for are those things that we can change rather rapidly that are regulatory that is that the Secretary can directly change without having to wait for a piece of legislation, it would be helpful for the steering committee to have the ability to look at our issue areas and then to say yep, That's pure regulatory, let's continue to look at that. In some circumstances, as that's done, and the progress report is sent to the Secretary, the Secretary may make a decision that we have to fix this, we'll fix it now. It'll be done. So the announcement that Liza had this morning about Medicare as a secondary payer is an example of how that might work.

    For the rest of them then, in order for us to fulfill our requirements as a FACA committee and Leslie didn't bring her counsel with her today so I have to be very careful. She's my lawyer today. As a FACA committee, we have to make sure that we follow a specific process that allows us to have careful review, public review, and public agreement about what it is that we're going to do. So in this circumstance then, an issue would come back to me after having sent it up for technical advice and we would bring it back to the Committee for a discussion and review. And I'll show you the three examples of how we're going to do that and the examples being from Miami.

    We then need to review them and reach some agreement and take some sort of a vote. Now that could be and this document by the way is a draft. The important word here on the bottom left hand corner is draft. So we need to think about the process that we would use in that regard. Do we want to have a simple majority or do we want to have a two-thirds majority or a three-quarters majority or some other super majority that could be for all intents and purposes if you believe that consensus means unanimity, I suppose that we could actually consider that definition.

    But we simply need to agree on the process that we want to follow and we'll use that then from here as we go forward.

    My thought was that if we achieve consensus within the Committee, we can then move these to the Secretary as final recommendations even ahead of our final meeting later this summer. Now there may be quite frankly something that we will encounter where we can't achieve agreement or consensus. But we do know that it is a matter of great concern or high priority and that it may require considerable work especially on a legislative perspective or it may simply cost a lot of money. I mean we might come up with an idea that might seem to be relatively simple from a regulatory perspective but if you start adding up the costs of that, for example if we pay for all of the initial visits to the emergency room, that could add a few billion dollars of spending to the Medicare program each year that we're currently as, at least the last time I checked, we're not elected officials so I guess we're not really authorized to spend anybody's money. That would be a problem for the senior leadership of CMS.

    So those are things then that we would want to flag and send in with our final report along with our comments. And in this fashion then, I think what we can accomplish is we can make sure that we have all of the areas identified of high priority and we have provided at least some -- hopefully some helpful guidance to the Secretary as well as the senior leadership of HHS about the areas where we find concerns but don't have an immediate solution. At least then they'll know that it is an area that they can't simply resolve in a short period of time. We might have a few ideas that simply need more work to evaluate their relative risks and benefits before a final solution is considered.

    So that's the process and concept and the executive Committee talked about this on Friday in general terms but we wanted to have a chance also to have more Committee members see it. So let me stop here and then see first if there are any of the other members of the executive committee that have comments and then ask for Committee member comments. Eric, you didn't see this flow chart Friday when we were talking about it. So now that you've seen it, what reactions do you have about how we might do this?

    MR. FAY: Well, I did print it up after. As you might guess, I couldn't download it right. But anyway I am now. And that's one of the side benefits, I'm learning to use my computer better. Anyway, I guess the comments are this is in general what I've -- the general direction I think we need to go. I was wondering on the no consensus, the bottom right chart little, let's say -- it almost says to me let's say we voted 25 to 1 or whatever the number is, not to go forward with something. Can it still go forward?

    DR. WOOD: No, that one I would consider a consensus to not go forward and we would incorporate that actually. I mean that wouldn't be a recommendation but it would be something we could articulate as we strongly believe that this should not be done. I'm thinking more like this would be one where we're split.

    MR. FAY: I understand.

    DR. WOOD: Somehow we're split.

    MR. FAY: And I by the way, you know, the two-third vote that, you know, that sounds reasonable if you can't get -- we probably wouldn't want something we're 50-50 on maybe anyway. That sounds reasonable. And the other thing that we discussed and you seem to agree and I think it says up there that if we do have a dissent, it can be noted as it moves forward and that, you know, that you -- whatever that was.

    DR. WOOD: Tony.

    MALE VOICE: I didn't have a question.

    DR. WOOD: Any others? Jack or Heidi?

    MR. ROVNER: I think this is a very -- I unfortunately missed the call on Friday as I explained but I was on the earlier one --

    DR. WOOD: I forgot about that. You had told me that.

    MR. ROVNER: And -- but this does reflect I think the issue of process that we first addressed in the call two weeks ago and I think this works. I do have two kind of additional process questions.

    DR. WOOD: Sure.

    MR. ROVNER: One, this says we need to have a full Committee here before the Committee can make a recommendation. So that raises a mechanical question about -- because these hearings are public hearings, not technical full Committee hearings, about if we should schedule them and what does that mean prior to I think we had set for August I think it is.

    MS. SCHMIDT: June.

    MR. ROVNER: June.

    DR. WOOD: No, That's actually an important question because it says Committee discussion and review and one of the technical issues here is how many Committee members do we want to have in attendance before we would consider anything that we do to be technically official. That is what would be the definition of quorum.

    MR. ROVNER: My second point which is you do not have on the chart what we lawyers like to call the quorum rule. WE need to know what the quorum is that makes the full Committee a full Committee meeting. It has to be a number or something.

    DR. WOOD: That's right. And I don't --

    MR. ROVNER: So but that would mean then that the vote is actually, if you did two-thirds, two-thirds of that -- of the quorum --

    DR. WOOD: That's correct.

    MR. ROVNER:  -- plus whoever's in attendance.

    DR. WOOD: Absolutely correct.

    MS. NORWALK: And of course in order for you to have -- decide what a quorum is, I think the full Committee actually has to make that determination. So you actually have to have a full Committee either meeting or some other way to get the Committee together to determine in fact what a quorum would be going forward. It's a little tricky.

    DR. WOOD: It's always fun to have these little --

    MS. NORWALK: (indiscernible).

    DR. WOOD: (indiscernible).

    MS. RYAN: Does the meeting of the Committee, is it required to be face to face or could other alternatives be considered?

    DR. WOOD: Well, technically by and so I think my legal consultants, my counselor to my right, technically as I understand FACA, it needs to be a public meeting where we make those decisions.

    MS. NORWALK: So you have to have the appropriate notice in Federal Register --

    MR. WOOD: For a FACA meeting, right.

    MR. ROVNER: Now I think we would easily -- I think if we look at the scheduled dates, if we want full Committee meetings, I assume we can do it so that we have one day of public testimony, panel testimony, et cetera, and set the next day for the full Committee hearing to address issues that we want to address as a full Committee.

    DR. WOOD: That is correct. And the reason we need to have the discussion is to think about then how we want to plan the subsequent meetings. Now we have some general concepts of agenda topics for the subsequent meetings but remember that our current structure had been that we would have five regional meetings or hearings. One of those would be a full Committee hearing or meeting where as Jack suggests, what we would do is that at least probably half or more, like even a day, would be given to just Committee business with no testimony or no panel discussions.

    At the moment, we are currently scheduling or thinking about this full Committee meeting to be in June in Minneapolis and then we would not have another meeting until probably August which would be the final meeting. Now that means really that what we would have to do is to make sure that we're in a position that in Minneapolis we would have for you all of the issues that could be potentially then discussed and considered for approval.

    I also need to get you thinking about the long-term recommendations because we need to have an opportunity for ourselves as a Committee to look at those and make sure that we're in agreement. We could then potentially spend from June until August refining those based on comments or discussion at the June meeting so that everything is ready for the final meeting in August, the final approval, the final approval of a long-term structure before I send up to the Secretary.

    If you have any concerns that that time frame is a little bit too tight and you think that perhaps we ought to shift part of that meeting or we should make an earlier meeting as in the May regional hearing, part of the Committee meeting, we probably need to start thinking about that relatively quickly so that we can effectively plan an agenda and give the proper notice in the Federal Register. So now I recognize not all of the Committee is here but thoughts about what's in front of us and about that structure. Mr. Toby.

    MR. TOBY: I'm delighted that the two-thirds vote would carry the process forward and I'm assuming that because of no consensus that by having those issues reflected in the report, we won't have a dissenting report. I've been on committees where when there was no consensus that there was a dissenting report and it's just troublesome so I'm just delighted that this process is so rational and sensible. And I think it's wonderful.

    DR. WOOD: Christine.

    DR. CROSBY: I was wondering if in the meeting in Minneapolis, we should set the ground rules as we are required to do in public meetings about how we might do things in June and July. For example, we might want to agree that we could operate by e-mail and conference call as a full Committee rather than assembling physically on site and maybe we could accomplish more in June and July of those issues that weren't finished in the Minneapolis meeting by setting those ground rules.

    MS. NORWALK: In other words, if you could do it by the Federal Register -- and you have the same FACA issues is you're a public Committee, you have to have a Federal Register notice. If you do something via conference call for example, it would have to be open to the general public. The same sorts of things that --

    MS. SCHMIDT: We have just gone through this with our general council. One of the things you can do is you can share that information. The point is that you need to get it on the agenda and discuss it oral in public so you could discuss a group of recommendations at once and you could have read the background material beforehand. It just means that we have to do that oral when you discuss the recommendations, that all has to be done in public. Otherwise, we'd have to announce the phone call in the public and that would be (indiscernible) that.

    DR. WOOD: Did that make that little problem clear?

    DR. CROSBY: Well, it means we can't do it. Nice idea, but it won't fly.

    DR. WOOD: Well, I mean that it does mean that we have to think about how we structure the work because I think it means that by June we have to have a lot of the pieces put together and that the time between June and August we can use back and forth by e-mail and otherwise to do minor corrections of draft material but nothing would be final until we come back in August and had a chance to review it in the public.

    MS. MARTIN: I think we -- from everything that we're looking at and I know our subcommittee with Tony has been very busy looking at issues and the numbers that we have, that we're going to have to look for a full Committee meeting in May as opposed to waiting till June.

    DR. WOOD: Leslie.

    MS. NORWALK: Just one comment to add to that. All the subcommittees have been doing just a tremendous job of highlighting issues and whatnot and why I certainly commend you for all your work on that, at the same time, being the agency that responds to a significant number of these issues and providing for the technical advice, I have all sorts of staff who are trying desperately to get the things done to solve the MDS issue or the EMTALA issue, et cetera, and to take them off that to go through your hundreds of wonderful recommendations, I think we ought to consider or perhaps you ought to consider as a whole Committee where we ought to prioritize. And what I have told staff as far as please prioritize on things this Committee is already hearing in a public setting and if it is important enough for that Committee to discuss in the public setting and the surveys, something that ought to be a priority for CMS. So I just want folks to -- I want to both be sensitive to your needs and also given the realities of the staff that we currently have and their very busy workloads before even this Committee came to pass, how we can meet that balance in a way that is satisfactory to the Committee.

    DR. WOOD: Jack.

    MS. MARTIN: Which is why I think it needs to be May.

    DR. WOOD: Jack.

    MR. ROVNER: Well, sort of picking up on Christine's part but, you know, the subcommittees -- I know mine is and I get the impression the others are working have already identified issues. I think we have a challenge ahead of us to sort of triage those issues, look at what we learned from the public forum. We all have staff members to help us do that. I think that actually creates a process by which we can hone in on what we then would -- better prepare us for actually effectively dealing with the issues in the public hearing when the Committee makes a public meeting of a full Committee when the Committee will make its decisions and recommendations.

    So what I think we will need is (a) the discipline to do triage on our issues and then (b) to do it early enough to get the staff enough lead time to get us the feedback all in a sufficient time so we are prepared to effectively have the dialogue at the Committee, full committee hearing, whether That's June or May. But I think if we don't try to focus this in that way at the subcommittee level, we're just going to have too much and not be able to focus in on getting some real solutions and recommendations.

    DR. WOOD: Judith.

    MS. RYAN: Two other process questions. I'm not sure when the analysis of the public comment that has come in will be ready and I'm sure that there will be patterns and trends within that that we'll need to consider as well. And then a second piece is it's been most useful when staff has shared the issue papers between committees because many times issues that have come up in coordination or in consumer benefit information has been very directly related to some of those issues that were considered in the data and information subgroup.

    DR. WOOD: There are a couple of (indiscernible). Go ahead and then I'll make a comment.

    MR. TOBY: Mr. Chairman, I'd just like to put Leslie at ease a little bit to let her know that there are many of us who are thinking about the concern that she has in terms of a need for us to prioritize our issues much better. Otherwise, CMS is going to find itself even more overwhelmed I guess by a number of issues. I took a look last week with Heidi and the group. We took a look at this very issue knowing that CMS is feeling the heat from a lot of these issues that are flowing out and many of them are very far afield from what our charge is. So we went through them in our Committee last week and we had about 20 and we found out that -- and examined them very closely in relationship to our charge and maybe only six of them really related directly to our reform. And the rest of them, many of them, were related to statutory changes and so we knew we had a lot to do and Heidi had us go through a process in which we narrowed down the list down I believe to about six, Heidi, I'm not sure but out of 20. So Leslie, we're concerned about the impact.

    MS. SCHMIDT: Thank you and you also had the list that you had come up with one of the criteria for prioritizing all the issues so that should help the subcommittees --

    MR. TOBY: It's a wonderful --

    MS. SCHMIDT:  -- hone in even some more. That's what I wanted to say.

    MS. NORWALK: You want to address the public comments (indiscernible).

    MS. SCHMIDT: Okay. I'm sorry. In terms of the public comment, the data from the public comments are still being put into readable form on computers. Our hope is that we'll give you an update on what was in there particularly want to give you the highlights of what were the most frequently mentioned kinds of comments, what seemed to be bothering beneficiaries and their families the most, what would be bothering hospitals the most, what would be bothering pharmaceutical companies and device companies and so forth, the most. So we will have it broken down so that we'll be able to say these are the issue areas that we've picked up in public comment. At that point then, the Committee could also decide we want to add another panel or study something else or send the staff off to prepare more materials for you on a particular issue. But we will certainly be reporting to you on that in the April meeting and then in some more detail in the May meeting.

    DR. WOOD: Jack, would you like to offer the quorum rule since we didn't put it in the process but --

    MR. ROVNER: What exactly would you like me to offer you? The quorum rule, apparently the full Committee has to make a decision but the quorum rule is the number of Committee members that must be present at the start of the meeting in order for you to be -- have a meeting. And then so if the quorum rule for example we have 28 members or 19 or 20, you'd have to have 20 members show up in the flesh at the beginning of the meeting.

    DR. WOOD: Right.

    MR. ROVNER: Then you have a really constituted meeting. At that point, two-thirds if we're using that rule, two-thirds of the members present and voting would carry the vote. So it's the initial threshold that you must meet to start the meeting. If more come, that's fine. But if less come, you're a problem.

    On top of that, if somebody should leave to drop us below the quorum and a member of the Committee were to point that out, we would have to probably adjourn until the quorum was back in the room.

    DR. WOOD: Right. So does everyone understand then what the quorum rule requirements would be for when we need to do --

    MS. MARTIN: You could make a recommendation and that could be -- but you decide in the full meeting.

    MS. SCHMIDT: But you have to have a full face to face meeting in order to even get that far.

    MS. MARTIN: Face meeting.

    MR. ROVNER: Well at first, for example, let me address it because if our next full Committee meeting is going to be called for either May or June, and I believe we could today make a recommendation --

    DR. WOOD: That's correct.

    MR. ROVNER:  -- on what the quorum rule should be.

    DR. WOOD: Right.

    MR. ROVNER: That would then be on the agenda for that meeting. Hopefully, it would be helpful if staff and the subcommittee chairs meeting and our members will all be there at the meeting and then we can take a vote and get it done.

    MS. NORWALK: But if you look and consider how many people were both at this regional meeting as well as the one in Miami and take and I think it would behoove you to take into account the numbers that you're likely to have at other regional meetings, whether or not we would in fact have a quorum and how many of you might be compelled in fact because you don't have a quorum, gee, you ought to show up at more meetings, and your counterparts of course have that same pressure, just to consider how high you want that quorum number to be. How likely we're actually going to get --

    MS. MARGULIS: What would a usual number be in a situation like this? What does experience show?

    MR. ROVNER: In the world of corporate -- boy, it's all over the map, anywhere from 50 percent to two-thirds. It's what -- however you want to organize your company. Now in our situation, I think we're -- we need to consider -- I guess I'd put it this way for my fellow Committee members. We need to consider how many people we would like to have present at a minimum to feel comfortable that we had a true consensus in the vote. Now I think that that's in the vicinity of about two-thirds which is about 18 or 19.

    MS. NORWALK: We don't have that. We have to have that --

    MR. ROVNER: But the regional meetings were never -- were really set up for us to take testimony and to ask questions and not really set up to make decisions.

    DR. WOOD: That's right.

    MR. ROVNER: So I would not measure how many people have come to regional meetings as to how many will show up for a full meeting. That first meeting in Washington I think was fully attended. So assuming we get the information out fully, I don't think that'll be our problem. I think our problem -- well what I suggest is what we need to consider is how many of our fellow members do we want present at a minimum to feel comfortable that the vote taken is the consensus.

    DR. WOOD: I agree and I would hope that actually when we do the full meeting, we would have essentially everybody there and that's why we need to decide for the critical timing whether to choose May or June because we need to give busy people time to make commitments. So now Mary has actually suggested May rather than June. What do the rest of you think? I see a couple hands going up and down.

    DR. CROSBY: Logistics. Given the logistics, we just explicated earlier, I think it does need to be in May or we can't get the work done timely.

    DR. WOOD: Okay.

    MS. MARGULIS: I would recommend two-thirds.

    DR. WOOD: Yeah, actually my thought is we'll have everybody there but two-thirds seems to be pretty reasonable across the nation.

    MR. FAY: Thank you, Mr. Chairman. Is that two-thirds of the approval process or two-thirds to constitute a quorum.

    DR. WOOD: Quorum. And it has to be two-thirds of the two-thirds.

    MR. FAY: Well, I was (indiscernible) expression in voting.

    DR. WOOD: That's what I mean. Oh actually right, it could be --

    MR. ROVNER: Just if I may be very clear. In order to have a legally constituted meeting to begin, two-thirds of the 28 members must be present at the beginning. In order -- a vote which would carry the consensus of the Committee would be two-thirds of the members present and voting after a Committee meeting began with a quorum. I know that sounds complicated.

    DR. WOOD: I got it.

    MR. ROVNER: It's actually a lot more simpler than it is to explain.

    DR. WOOD: Got it.

    MR. RAY: I was going to suggest a majority but if the consensus is two-thirds.

    DR. WOOD: You mean a simple majority?

    MR. RAY: A simple majority for a quorum, two-thirds to pass any recommendations. And I would base that recommendation on a majority of the chartered members so there's 30 people in the charter even though I believe there's only 28 on the Committee so that -- a majority of the charter slots would be 16 to constitute a quorum and I just throw that out as a suggestion.

    MR. ROVNER: That would result in 16 people showing up would allow a legal meeting to go forward but then two-thirds of the 16 would become the consensus of the Committee which is actually a minority of the Committee. Or is it two-thirds of the Committee which would be -- who does math?

    MS. MARTIN: 19 members.

    MR. ROVNER: Or 20 if you want to use the full 30 members. Then you're talking about two-thirds of the 20 to have the consensus of the Committee for a quorum to vote on an issue.

    MS. RYAN: So a (indiscernible) is around this table today almost.

    MR. ROVNER: Still not a majority but pretty close.

    DR. WOOD: Is everybody comfortable with the direction here? Looks like May should be our call for a full meeting then. Okay. And now that would normally be Denver I mean the way we've got it currently configured.

    MS. SCHMIDT: That's correct.

    DR. OLSEN: Are we likely to add a day just so we are -- where we're part of the two days or what? Do you know or --

    DR. WOOD: We have to look --

    MS. SCHMIDT: We'll block it out and we'll send recommendations out to the subcommittee chairs and --

    DR. WOOD: And I'll start looking at the time –- we'll start looking on the timing.

    MS. SCHMIDT: Probably be a full two-day meeting.

    DR. WOOD: There are a couple of ways we could handle it. I think they'll go a full day meeting. Okay. Now just --

    DR. OLSEN: Yeah, I think more about this. I think I suggested that on Friday or an earlier meeting but it seems to me like what you might really want to use that as just to get the thing in motion with a meeting and it might not be -- have to be that long a meeting because you'd get the thing -- you'd get the approval of the quorum, you'd get the focus and whatever. So it might just be to get the start of that final process in motion.

    DR. WOOD: I'm not sure I want to ask this question but are you suggesting that we would need one more full Committee meeting between May and September?

    MR. ROVNER: Well, I actually have a question on that. Was is -- is it -- whether it's a budgetary constraint or what is -- is there a constraint? I mean why not call a full Committee meeting in each one of our regional hearings, for example, in the afternoon session of the second day or the morning session. Something like that. If we don't get the quorum present, we simply can't have that meeting but if we do and we have work to conduct, we can legally do it because the notice will be --

    DR. WOOD: Right. That's an option. And we may need to do that from the perspective of the work volume that we've got.

    MS. PATTEE: That would be possible to do for the April meeting because we aren't at the 30-day window for publication.

    MS. SCHMIDT: It's a two-week window. I think the April meeting would be pretty hard for the staff and CMS and FDA to get some of their things done but if we moved the full Committee meeting till May and then had an option for the Minneapolis one for the second day which we had always had as a full Committee meeting anyway, that should work out all right. You were looking to the budget implications and hopefully be able to deal with that.

    DR. WOOD: I think April puts it pretty tight.

    MS. SCHMIDT: It's that time and money issues.

    DR. WOOD: Time and money. You just need to know Mr. Lawyer's budget number, our account number.

    MS. RYAN: I know we've looked at the quorum issue and other things. I would just like to comment about the process for review. I would just, not as a Committee chair, but just asa member of the Committee, be very supportive of this because I think it both gets the full log of information to the Secretary for his information, it gives full opportunity for issues that this Committee cannot reach a consensus on to at least be noted and it gives opportunity from minority comment about one report. So I think it's just an excellent process.

    DR. WOOD: Okay. Yeah, let me give you an idea about how this will work. I have on the screen but each of you have at your places three issue statements that came out of the Miami hearing. And what I did with them was to quickly put them together using Power templates and effectively and affectionately known as the Fay templates by the way.

    I don't what it's like here but at the Mayo Clinic it's often considered that if you ever have a report named after you, it's a bad deal.

    MR. FAY: I second that.

    DR. WOOD: At any rate, I just want to give you an idea about this will work. So I pick EMTALA. So I think some of you remember actually what our discussion was in Miami and we're not going to -- I mean this is still a draft. I just want to leave it as an illustration of how it's gone up for technical review and back and we can kind of then see based on what we had from Miami where it is.

    So I simply wrote out what the issue was, the situation, what we heard from the public testimony, Leslie provided an extensive background at Miami meeting. We tried to crystallize the intent of the current law rule and this by the way represents what Leslie and her senior staff have looked at. So they've already put their technical advice into this. So what you're seeing is what would come back.

    And the proposed reform -- the changes in regulation and the enforcement processes and the new structure to guide the development of a comprehensive approach to emergency care availability. And the immediate things are numbered. And then there is one long-term recommendation which is our concept of the technical advisory panel, the expert panel, and that's the emergency services cooperative project. And then we finish with who would be affected.

    Now from the perspective of what we can and can't do, you may remember from the Miami discussion that one of the considerations was that we should pay for the screening and examination in the emergency room. Now that is either statutory or requires expenditure of a substantial amount of money that we're not authorized to do. So the technical advice was is we can't do that, take it out. It doesn't mean the agency's not going to -- I mean they were there, they heard it. So it's still sitting at the level of the steering Committee but it's not something that we can do in regulation. So that's how this basically works.

    MS. NORWALK: Let me put it another way. It's not about cutting red tape. I mean if the focus of the Committee is to cut red tape, increase funding, well there's no doubt it's an important component of how we regulate our providers. If they charge the Committee, it's to cut red tape that's outside the charge. So what we argue and it's loud and clear.

    DR. WOOD: Leslie, do you want to make any other comments about this?

    MS. NORWALK: Just generally in going through this. I thought you did an excellent job, you and whoever helped you put these three different pieces together and this one with the OASIS and the (indiscernible) proficiency ones. I mean the concept was to just we're going to take a look at everything that's here and since I did EMTALA, I find that you've made some good suggestions. I know it's not a formal Committee recommendation yet but my hope and one of the reasons I'd like very much for the Committee whether or not it's a full quorum and whether or not you're actually making some of the formal recommendation, I'd very much like to have these things discussed from one meeting to the next so that we at CMS and certainly others at the department if you're in a different agency if the issue was saying FDA, we can actually get to work on instituting reforms that we think you would ultimately recommend. I don't know whether or not from this particular list, you might recommend seven of the ten for example but we've heard lots of good testimony and I think I have a sense not only from the questions folks have asked but from the testimony, et cetera, of what we might need to do to go forward and my preference would be to not wait until you get a quorum and a majority vote to actually go ahead and do some of these things right now. There's such a concern that the government takes so long to do something. So inasmuch as we can make some tweaks and maybe even something that would be beyond that and go ahead and do that, then I don't want to be hamstrung by this process that we were discussing earlier.

    MS. SCHMIDT: Let me add to that because I know -- and then Dr. Olsen, I know what you're going to say.

    DR. OLSEN: I beg to differ. I do want you to be hamstrung by this process. I want to put that into the record because that's why we're here.

    MS. NORWALK: No, I don't doubt that's why you're here and that's not to say but if there are certain incremental changes -- if you want us to do nothing for example about EMTALA until September, then I'd like to be able to go back to (indiscernible) and say until the final report comes out or until you can actually vote our recommendations, we're going to hold back.

    DR. WOOD: Here's what I think he meant. If you look at where we are now, we've got (indiscernible) the technical advice and so we're here for some Committee discussion and review. We won't be able to take a final vote but the question here actually is to look at what we have, would it -- and I'll carry that from the technical advice. I think what we would like to do is to let you look at it and see if there -- anything is there that should be considered necessary for additional staff work or that you think have enough concern that we should do a more detailed preparation of the item before it goes to the Committee. If you otherwise think that it looks reasonably good, it still stays in terms of an issue area. Again, the Secretary and -- well the Secretary can make a decision any time he wants about anything that we might actually have seen. So that's basically the concept. You follow the process.

    MS. SCHMIDT: Let me clarify some of this because I think that's -- there are a couple of steps that are getting a little crossed here and I think that they will bring you some comfort, Dr. Olsen.

    What we're really talking about is we're up in the box that's really issue areas that are being identified. There were some that were identified in Miami. We made a summary of those issue areas at that time. That was sent to the Steering Committee. The Steering Committee can make a progress report to the Secretary saying this is the stuff that this Committee is interested in and the areas that they're studying. Within that, unknown to any of us in the room perhaps, are some ideas that the Secretary may look at and say I really like that CMS. I want you to go deal with that one now. That doesn't mean that necessarily this Committee has recommended it. It's something that you've taken testimony on and you think is interesting and the staff is working on.

    And the Secretary can choose when he wants to pick one of those off, indeed like the MSP one that was announced today. There was testimony on it, he also heard about it on his tour, he came back and said I want to move on that right now and therefore we had the press release and the announcement today.

    That does not mean that you don't get to the next part. You hear the response from the agencies in terms of whose effective? What does this do to the beneficiary? What does this do to the consumer? Is the intent of the regulation still taken care of? Those kinds of things that you all had said and is in your structure that you continue to want to hear. That you're going to hear in your full Committee meeting with the quorum and then move forward to any recommendation. Okay.

    You were skipping a step I think.

    DR. WOOD: So what we're trying to do here is make sure that as you get the technical advice back, we can see it and see if there are major areas of concern, particularly if they're things we need to send back for more staff work that's not clear but we have articulated carefully or clearly what it is we're trying to accomplish or that there are areas of significant concern that we need to flag for full Committee review. So that's what we're trying to accomplish and we're still in those boxes over here on Committee discussion and review. We're not anywhere close to making final decisions because we don't have either the full Committee and we've got another step in between.

    MS. NORWALK: And just one other thought is that for example with EMTALA, anything that we were to do with EMTALA would come out as a proposed regulation. So not just this Committee but any member of the public could comment on whether or not they approve with whatever changes we had. And yeah, some of those changes may have been generated through ideas that we heard at the Miami hearing for example or from testimony here today and hopefully that we'll ultimately get recommendations from you either in May or June. And anything additional if something wasn't picked up if we were to actually act that fast and if something wasn't picked up in May or June, we could continue to look at it if it's a formal recommendation going down the pike.

    But in any event, it's very important I mean obviously as you all know, our regulatory process is very much a public process. So I don't want -- in spite of the fact that this Committee is structured in a certain way to meet the FACA requirements, That's not to say that whatever we do as a recommendation of this Committee or on our own accord would still need to go through the public and comment period of the Federal Register, et cetera. So just so that you have additional comfort that just because we do something doesn't mean it's done. The fun of working for the government, it's much the same.

    DR. WOOD: Heidi.

    MS. MARGULIS: Mr. Chairman, is there an action that you would like for us to take on these today? In other words, in taking a look for example at EMTALA which might be the wrong one to look at but since it was the first one up there, there is a listing of nine, ten immediate reforms and it goes on. It is my understanding that then this would stand for formal discussion by the Committee at the May meeting --

    DR. WOOD: Correct.

    MS. MARGULIS:  -- unless we today would say gee, on item number three, we feel it needs some more technical review or I have questions on this. Is that the action that we need to --

    DR. WOOD: We still have time to refine it by May. So what I'd like you to do actually I don't want you to do anything with it today. I'm just going to show you example of how it would look since some of you just see it. Take it back tonight, look at it, see what you think and then tomorrow, if there is -- in this particular case we're going to add and we can do that. But the other question or thought that we haven't talked about is how to get it out to the other Committee members so they can see what the circumstances are because they haven't been able to see this and they won't in between. Jack.

    MR. ROVNER: That's why I think that the process has to really filter down through the subcommittees. This is to me two aspects of identifying these issue sheets with this or the other ones. (a) is in a sense assigning them to the subcommittees that have the best focus to deal with the particular issue, does not mean the rest of the group doesn't get to see it or comment on it, but it'd be nice to have a central way to deal with them more effectively. But I do think that the process is not just for us to read it tonight and talk about it tomorrow, but it needs to get back to the subcommittees. The subcommittee chairs and the fellow committee members have to insure that all the members of the subcommittees get these things, consider them and either get their comments in through the subcommittees so we are -- because that will come back up through the executive committee and we'll have a process in place to continually identify needs for more information or issues or inputs or whatever from all the committee members in a way that gets us ready to effectively address these when we have a full Committee.

    DR. WOOD: So that's also a reasonable way to do it and as we think about the public comment, the only thing that we'll have to do about the subcommittees, when we get specific ideas from the public comment, we'll need to assign and take some of those to specific subcommittees. So we certainly can do that.

    MR. ROVNER: There is obviously overlap among the subcommittees but they do actually have rather defined areas of their focus. I think that works.

    DR. WOOD: It's a reasonable idea. Eric.

    DR. OLSEN: I guess this thing focuses on of the part of the process that I guess I -- and I think that a part would be handled with what Jack said but I wouldn't be comfortable just getting a piece of paper now and voting that something go forward to the Secretary. I want an opportunity to read it, react to it and hopefully in writing somehow give me a little time. I mean I don't know. And there are of course members of the Committee that aren't here but so I think maybe part of the process has to be some kind of advance notification or knowledge of what the issues will be prior to the meetings.

    MR. TOBY: Mr. Chairman, if I may, this brings me to the question -- I guess the issue that Leslie had brought up. I'm just wondering at which point in the process or how quickly will CMS be interested in looking at an issue like the EMTALA one to tell us whether or not -- give us the technical advice as to whether or not it's something we can do something about.

    I wouldn't want to -- I mean I'm worried that at the end of this process, we really achieve something. Like you, Mr. Chairman, it's in the doing that we really have something in the process. For the last few weeks, I have seen a flood of issues that I've received which looking at them and having spent 31 years in Medicare and Medicaid, I know we can't do a thing about them. So they are very distracting. They're all good ideas. But they're things that should be turned over to CMS to operationalize in the future to make the process work better and it has very little to do with our Committee.

    So I would hate to put a lot of effort into these issues and at the end of the day, CMS tells us that nothing to be done. So I would like to get some of these issues as quickly as possible but they fit within the framework of our charter to CMS or whatever agency so they can look at them and tell us whether they're doable or not.

    DR. WOOD: But That's precisely the reason to actually get them up as issues. Not as definite recommendations, but issues. And the Secretary then can decide what he wants to do about that and the staff can tell us precisely whether there's a statutory reason we couldn't do anything. It's a nice idea but it's nothing really we can do anything about. But we still have identified the issue for other action.

    MS. SCHMIDT: That's the plan of what we would like to do is to be able to get back to you to say this would be a piece of guidance if you wanted to do this. This would be legislative, this would be regulatory and we'll format it so we can give you those kinds of pieces of advice.

    DR. WOOD: We'd even come back -- in the final report, you would end up with that entire list and you could clearly identify which of these are going to be long-term legislative things that we heard about, we need to work on but it's not an easy mandatory fix.

    MS. RYAN: It was Chare (phonetic) who said that one of the legacies you hope the Committee's work leaves is some kind of ongoing process whereby CMS might work more effectively with the stakeholders in the field that they serve and in many ways I see a difference between these issue statements that we're looking at which are issues on which this Committee has received testimony and has specifically invited and are kind of ready to move that forward and those issues which were being logged and categorized that have come in either as public comment or as very free thinking on the part of the individual members of the Committee. And I think it would be a shame not at least to record those and make those available so that the Secretary and the administration could consider or, you know, just --

    MS. SCHMIDT: The staff does intend to do a couple of things which is to prepare a draft based on your comments about the ongoing process and Dr. Wood and I have talked about that and there's some materials underway based on some of his ideas and what some of all of you have said. That addresses your first one. And then on the second one, there is going to be a report that comes out that talks about all of the public comment and analyzes that public comment and that will also be part of your report both in the short part and in an appendix so people will know what the public has also sent into you all.

    DR. WOOD: So for each of the subcommittee chairs, then what I would like you to do is to take this back to your subcommittee and share with them along with the discussion and get the thoughts of specific subcommittee members since they can't obviously all be here today.

    Now the last thing that I want to show you with respect to the executive committee is a discussion we had on Friday and that is how to keep colleagues engaged in some thinking about the future and engaged in the process of what's actually happening since there's a lot that has happened since our first meeting in Washington.

    Now the first discussion that we had was how we would know we were successful. And it's a question that several of you have asked me especially the last time around. Now I have my own thoughts about it but I actually engaged the subcommittee chairs who were on the call on Friday to give us their thoughts. Now I can't print this for you because I didn't bring my small disk. I'll hook up to a peripheral here in a minute and do it. But just quickly where are the thoughts of the executive committee members and I apologize -- my apologies to particularly Eric and Tony and Heidi. If I didn't exactly say this right, you'll correct me.

    But here's what we were thinking. We will have measurable, that is scorable recommendations for solutions. There will be recommendations for rapid or short term changes. We will achieve positive measurable effects for consumers, beneficiaries and other affected stakeholders in HHS programs. Our recommendation should simplify the administration of HHS programs. That's kind of redundant to say by HHS but I did it anyway. And its contractors reduce the cost of doing business and compliance with regulation and provide greater benefit to consumers and beneficiaries.

    And the last, and this is the legacy piece, we will provide a framework for long-term change that will achieve lasting improvements in the function of HHS programs that are measurable in the same timely fashion as our short-term success.

    These also are draft. So it's a starting point. And so what we'll do is we'll print this actually and get it to you. But the other comment that -- or the other concern we had was how do we communicate with our colleagues and so when you get this, you will see that it actually is in the form of a memo which is an update which we would get out to the Committee members and it just talks about a little bit of the process and we'll say that we're going to talk to them about that. The issue statements, a little bit about Miami. We could add what we have here. And then just a note of thanks at the end. So this is to try to improve communication and you got the rest -- keep the rest of the group engaged.

    So I don't want to have a longer discussion about success right today but I want you to take it back and think about it a little bit and engage your subcommittee members as another item of discussion and particularly as we head toward the last meetings of the group.

    Now again with apologies to those who were on the call, since I paraphrased your words, I'll give you a chance to publicly say that I misrepresented you or not. Eric.

    DR. OLSEN: The only thing I said -- I think in some ways everything is measurable. Everything. So we had that discussion and I want a little more time to think about it. Well I'll get back to you like any other member.

    DR. WOOD: Tony.

    MR. FAY: Mr. Chairman, I concur with you and you were much more articulate in your writeup than I was and trying to explain it.

    DR. WOOD: I'll second the motion. Heidi.

    MS. MARGULIS: I concur.

    DR. WOOD: Okay. Now we have a few minutes, like 15, before the first site visit goes, right, Christy?

    MS. SCHMIDT: That's right. The cars will be -- the vans will be outside the front door at 3:00 so we may want to take a five minute break or a ten minute recess before then or whatever you want to do.

    DR. WOOD: Okay.

    MS. SCHMIDT: And the vans could leave at five past 3:00, too.

    DR. WOOD: So we'll have an adequate amount of time, we'll take a little break right before we go to that but on the basis of the (indiscernible) discussion this morning, would anybody like to offer some thoughts about major concerns or areas where you think we could make some specific suggestions? Jack.

    MR. ROUNDER: I don't know that I have at this point a specific suggestions but I'm wanting to share with the Committee a reaction that I have and I'll preface it by saying long-term care is not an area I do a lot of practice in so a lot of this is new information to me.

    What struck me is there's really two things going on here. One is it was almost uniform this morning that the whole concept of MDS as a quality measurement tool and as sort of some sort of uniform standardized way to assess the needs of the patient or come up with a care plan inclusive, across disciplines involving the family and the patient, it's just outstanding. It was applauded by everyone.

    So something seems to have been done very right here by CMS and the industry to come up with this concept of the minimum data set and I will just add that the same kind of comments were made about OASIS as a care delivery process.

    Then there's another phase and I'm still not sure I understand what happens and that is somehow this data gets transmitted or not by some process that I don't understand because it wasn't talked about and it appears to other than for some payment purposes, fall into a black hole never to be seen again. And I really am at a loss because I don't know what happens there. I did talk to Ms. Ryan who has obviously a lot of expertise in this area to try to get a handle on that and what strikes me is two things. One, there seems to be in the burden resentment end of this seems to be in the latter process. What is going on with the need to input the data, what's it being used for, what happens to it and why does it have to be repeated over and over again? Which strikes me that and I don't know if this is a regulatory reform but it certainly seems to be something that involves both the industry and government. But there has to be a better more cooperative way to figure out how to manage this information flow better, cheaper, more effectively and I don't know if there are regulations that impede this. If there are, I certainly would think that we should consider that. But the apparent inability to figure out how to communicate this data to be able to not have to recreate it all the time and so forth is just creating a tremendous amount of inefficiency, waste and burden. It's not really adding anything to the system of a program that otherwise looks to be a tremendous way to improve care.

    DR. WOOD: Heidi.

    MS. MARGULIS: I believe this hooks onto what you were saying and we talked about it a little bit in the final statement. And that is as I sat here today and also as a result of the Miami OASIS presentation, it has become apparent that there are systems within each of our provider sectors that are very similar. But that information remains in the silo of that particular provider category or stakeholder category so we have the home health world conducting OASIS surveys. We have the long-term care industry conducting MDS's. We have Medicare Plus Choice doing population based quality improvement projects. And neither stakeholder knows what the other is doing, yet they're the same -- many of the same providers who are quote hassled by the collection of that data. And whether or not in the end the patient's health is improved, somehow I see the patient we'll hear -- we could hear tomorrow about this, the patient who is in the Medicare Plus Choice program who ends up with a bag full of meds having gone through each one of those different silos, the information not being connected. And I don't mean that as an assault on any particular provider category but it does lead to the sharing of information and the thought going forward more long-term than short-term that we have a system that is seriously broken and that in the end and respecting the privacy and the concerns of security, that we should have something akin to a smart card that has this information on it that allows us to move seamlessly through the system and that the systems do in some way connect. And I don't know that that leads me to any recommendation at this point but it does lead me to think long and hard about what the priorities for HHS really need to be in terms of a vision for healthcare in this country.

    DR. WOOD: I think there's a pretty striking intimation of whether just in the process of looking at where there are very expensive points in the care of patients to comment on later here this morning. Every time there is a change in provider or provider location, that's a very expensive break and if you can cover that with complete information, the impact here would be actually staggering because I bet we could pay for a lot of resources and we would put in place by letting a lot of other things. You might not think it would add up real quickly but if you could avoid doing lots of things like chest x-rays, a few electrocardiograms and things like that that don't mean anything, you'd save a lot of money in the short term. Even with them being paid at Medicare rates. Tony.

    MR. FAY: Mr. Chairman, one of the issues that I don't think was fully brought out during the testimony is still the issue of when the data is uploaded for payment purposes and there does appear to be a good deal of confusion in the industry that if your data isn't in on time, you're going to get a low payment rate and there's no opportunity to go back and clear that up. I think that's a very immediate term recommendation we could make concerning how that is handled.

    And I think another recommendation or at least in some of the testimony I heard today, there is sort of an informal working within CMS to eliminate or at least propose to eliminate up to 200 of the questions and so I don't know how real that is. It'd be good to get more information on that to see if that's a doable alternative.

    DR. WOOD: Eric.

    DR. OLSEN: I, of course, I made my stupid question this morning and I wanted to -- I love what they're saying about putting the systems together and maybe the way to look at it, maybe it all ought to be focused on the beneficiary, not on each silo of the provider and I don't think there's any, you know, and if we just would look at it a different way.

    DR. WOOD: That's really quite -- when you think about how people go through the system and it's not that just go one place there and you back out and you go here and it's totally new. It's the same patient. And maybe just the focus, a different focus.

    DR. OLSEN: Then the other thing I got out of this morning that hit me was this idea of using the MDS software, excuse me, this integrated software now in some predictive way.

    DR. WOOD: Yeah.

    DR. OLSEN: As a preventive. That really --

    DR. WOOD: So you know, I think the software issues that I think are actually quite strong as well because ultimately the greatest opportunity for us to improve performance in the system is to get an informed (indiscernible) together with an informed physician and in order to do that, you need to really capitalize on the information systems to be able to anticipate what's coming and know again what is appropriate.

    But the whole issue is to figure out how to get the appropriate care and the appropriate place at the appropriate time and to use the power of your information to develop then leanings which we heard this morning the concept of triggering, the concept of that if you're running this and this is where I think then the issue of integration toward the beneficiary is critical.

    If you find something in your questions as you're going through the interview in the training is done doing that so we saw an example in Miami on the form that actually had the triggers on the form. It wasn't just the old CMS form as it was configured and it had been redone and it had to live in this case idea boxes. Think about this. I mean that really is quite a proper way to do things. So if we can figure out a way that you can do even on paper or ultimately electrically if something gets put in that could be put obviously a dialog box that will pop up and say you should go to this question or this algorithm and that could be then pretty powerful in terms of making sure that we've actively improved the way that people get cared for. I think it's potentially pretty powerful.

    MS. NORWALK: I think what I am is supportive of the potential of integrating these data systems as all of the statements have just indicated. I think in the anxiety about trying to be supportive of the potential of the process this morning, I don't know if the testimony appropriately shared information about the impact of the way in which some of this data is being used, particularly in survey and certification process. And in many cases, like the stories about EMTALA where if the form has not been signed or if every component of a resident assessment profile has not been completed, certain survey teams are literally finding and finding long-term care settings for those reasons. And in some cases, just as you heard the stories this morning, Medicare reimbursement has been not denied and other things are happening.

    There's a great variability across different regions. Great variability sometimes even within states and I think it's the use and the confusion around the interpretation of the existing MDS and RAP's data systems that are adding the cost and the burden right now. As I say it because people really are so supportive of the potential of this process to help the whole. That wasn't spoken to very much.

    DR. WOOD: There's one other interesting thing I heard this morning. I think from listening to different people and one is that it's not really obvious who you should go to if you have a problem or a complaint. And I was struck by this actually from looking through Medicare and the physician edition. I read it on the plane on the way over and at the back of it, there area pages of who to go talk to depending on where you live. And you can go talk to one person if it's this kind of problem and go talk to another person if this kind of problem or go talk to that other person. That's kind of broad I mean maybe that's an expression that how complex has this gotten that you can't go just to one place and get consistent help in fixing the problems.

    MS. NORWALK: Until now.

    DR. WOOD: Do we have the solution?

    MS. NORWALK: Two, this addresses actually two comments, one from your well thought up memo that you'll be sending around to the Committee about what sort of lasting effect this can have and that second and then this additional point. One of the main paradigm shifts that Tom Scully has been most interested in since he arrived at CMS in addition to the name change is to open up the agency so that provider groups and other stakeholders can come to us in a way where they can get some meaningful changes to things such as geez, this form asks the same thing five times, can't you change it. As Tom calls it, they're singles. And what we have done although I expect that you guys probably all know this is we have 11 different open forums, open door groups for different typically provider based but also we've got one for diversity and one for disability. So some beneficiary based Committees as well.

    The concept is once a month we have a call with one person on senior staff leading the call and other folks from around the agency including our regional offices sitting on the call and actually hearing what these problems are that we could try and resolve immediately. And I sat on two of these -- I chair two of these groups, co-chair one and chair another one, and I have people come to me from different provider groups saying, gee, Leslie, we can't get this form -- we need a provider number to get reimbursed. I can't get this form filled out. We have no idea how to do it. They won't accept it once we've filled it out. Can you help us with this problem? The answer, yes. And it's half the time it's just getting the right people together and so one of the things that Tom hopes to do in his tenure is to really open up the agency so that this complaint not continue long term. Getting the word out is difficult, sometimes our calls only last 40 minutes because there aren't complaints to go around. I find that hard to believe. So it's simply a matter of getting it publicized but these calls are open to the public. You can call in, you can have someone from the front office staff actually listening to you and the idea is of course we don't want you to have to call a 100 places. We only want one place in the computer.

    DR. WOOD: This is great. Although I tell you I wasn't thinking about it that way of (indiscernible) that protective of the beneficiary.

    MS. NORWALK: We're looking at it under Medicare specifically what the beneficiary is supposed to do. So we've done it sort of from two different perspectives. Both the provider's prospective and the --

    DR. WOOD: Okay. My only concern about that actually again is (indiscernible) the expectations of performance, the rate of service. In the public sector, if I get that call, I own it. I get it fixed. And we don't have any slide about how effective the lines are for providers and if only 15 percent of the questions are being answered correctly, then what are we doing when the provider or on the beneficiary side.

    It's time for us to take our break so we can go to our site visits. But it is the perspective I want to get back in place so that we know that we've got a single mechanism for people that we can get their complaints. Not just information but their complaints taken care of.

(Proceedings Concluded at 2:58 p.m.)

Summary prepared by A/V TRONICS, INC., Professional Court Reporting & Transcription, Phoenix, AZ