Meeting Minutes, July 2022
Virtual Meeting
Contents
Summary
Call to Order and Approval of May 12, 2021, Meeting Summary
AHRQ Director’s Highlights
Discussion of Healthcare Quality in Different Care Settings
Discussion of Private Equity in Healthcare and AHRQ’s Role
Public Comment
Chair's Wrap-Up and Final NAC Input
Adjournment
Summary
NAC Members Present
Edmondo J. Robinson, M.D., M.B.A., M.S., Moffitt Cancer Center (NAC Chair)
Andrew D. Auerbach, M.D., M.P.H., University of San Francisco
Komal Bajaj, M.D., M.S.-H.P.Ed., Albert Einstein College of Medicine
Asaf Bitton, M.D., M.P.H., Ariadne Labs, Brigham and Women’s Hospital
Melinda B. Buntin, Ph.D., Vanderbilt University School of Medicine
Caroline Carney, M.D., M.Sc., Magellan Health
Susan Edgman-Levitan, P.A., Massachusetts General Hospital
Neil I. Goldfarb, Greater Philadelphia Business Coalition on Health
Krista Hughes, B.C.P.A., Hughes Advocacy
Catherine H. Ivory, Ph.D., R.N., Vanderbilt University School of Nursing
Mireille Jacobson, Ph.D., M.A., University of Southern California, Leonard Davis School of Gerontology
Hoangmai Huu Pham, M.D., M.P.H., Institute for Exceptional Care
Kannan Ramar, M.D., FAASM, FCCP, Mayo Clinic
Jeana A. Reyes, M.S.N., R.N., Horizon Blue Cross Blue Shield of New Jersey
Patrick S. Romano, M.D., M.P.H., University of California, Davis
David F. Schmitz, M.D., FAAFP, University of North Dakota
Joedrecka S. Brown Speights, M.D., Florida State University College of Medicine
Henry H. Ting, M.D., M.B.A., Delta Air Lines
Yanling Yu, Ph.D., Washington Advocates for Patient Safety
Jiajie Zhang, Ph.D., The University of Texas Health Science Center at Houston
Ex Officio Members and Alternates Present
Liza Catucci, M.P.H., U.S. Department of Veterans Affairs (for David Atkins)
Michael Lauer, M.D., National Institutes of Health
Shari M. Ling, M.D., Centers for Medicare & Medicaid Services
AHRQ Staff Members Present
Robert Otto Valdez, Ph.D., M.H.S.A., Director
Jaime Zimmerman, M.P.H., PMP, Designated Management Official
Susan Kerin, NAC Coordinator
Call to Order and Approval of May 12, 2021, Meeting Summary
Edmondo J. Robinson, M.D., M.B.A., M.S. (NAC Chair)
Dr. Edmondo Robinson called the meeting to order at 12:34 p.m. Eastern and introduced himself and six new NAC members: Komal Bajaj, M.D., Neil I. Goldfarb, Krista Hughes, B.C.P.A., Kannan Ramar, M.D., FAASM, Jean Reyes, M.S.N., R.N., and Jiajie Zhang, Ph.D. He noted that the meeting was being recorded and will be made available on AHRQ’s website. He asked all NAC attendees to introduce themselves and then referred to the draft minutes of the previous NAC meeting (May 12, 2022) and asked for changes and approval. The NAC members voted unanimously to approve the May minutes with no changes. Dr. Robinson reviewed the meeting agenda and introduced AHRQ’s director, Robert Otto Valdez, Ph.D., M.H.S.A.
AHRQ Director’s Highlights
Robert Otto Valdez, Ph.D., M.H.S.A., Director, AHRQ
Dr. Valdez expressed his appreciation for the fact that the NAC now is fully constituted, and he thanked the members for bringing their various areas of expertise to the meeting. He stated that the bold mission of AHRQ is to improve healthcare in all of its dimensions in the United States and that he has been working to ensure that the mission of AHRQ is better understood within the Department of Health and Human Services (HHS). He also noted that the crises that we face today can be considered an opportunity for the agency to continue to do its job.
He continued by remarking that because AHRQ is a nonregulatory agency, it must operate using carrots rather than sticks, and that after AHRQ identifies the needed tools, the NAC members can offer guidance in establishing and using those tools. He emphasized that AHRQ supports both an intramural research program and an extramural research program., and he stressed the importance of better recognizing the significant research that is being conducted.
Dr. Valdez said that in November 2021, AHRQ published a research article about low-value care in individual health services that indicated which systems provide such care and which do not. He added that the article revealed much about the structure of primary care and care outcomes. In addition, an AHRQ July 2020 research article described the effects of the COVID-19 pandemic on racial and ethnic minorities and provided information about household composition, job characteristics, living circumstances, and more. The article revealed that many essential workers were being exposed to the virus, which led to higher rates of hospitalization and mortality among those workers and to many children becoming orphans.
Dr. Valdez asked the NAC members to consider the following questions:
- How do we make healthcare more equitable?
- How do we produce the needed scientific evidence for healthcare delivery systems?
He said that AHRQ is working to establish the means to answer these questions. He also remarked that President Biden’s priorities include not just transforming the healthcare system but dismantling structural racism to achieve equity and he emphasized that AHRQ can seek to complement the work of private-sector organizations in this respect. Dr. Valdez proposed that the NAC create a subcommittee (a SNAC) to make recommendations to the NAC regarding opportunities to advance equity in healthcare. He also noted that AHRQ will hold a health equity summit next week to jumpstart action.
Discussion About the Subcommittee
Dr. Robinson stated that such a subcommittee can serve as a tool for the NAC by focusing on a particular topic and leveraging the capacity of the NAC around that topic. He encouraged any of the NAC members who would like to serve on the subcommittee to contact Jaime Zimmerman, M.P.H., PMP, at AHRQ.
Dr. Ramar asked about mandates, goals, and the timeframe for the new subcommittee. Ms. Zimmerman responded that a SNAC usually can operate up to a year, at which point it reports to the NAC, and she noted that the NAC can vote to extend the SNAC’s term if deemed necessary. Dr. Bajaj wondered whether, because equity is a cross-cutting issue, the subcommittee work would focus on the range of issues and concerns across AHRQ. Dr. Valdez responded that the SNAC structure allows for a series of multifaceted discussions that includes individuals from outside the agency. Patrick Romano, M.D., M.P.H., encouraged the new subcommittee to build on the work of a previous subcommittee on quality measurement.
Dr. Robinson asked for a vote, and the NAC members voted and agreed unanimously to create a subcommittee of the NAC (a SNAC) that would be focused on health equity.
Discussion of Healthcare Quality in Different Care Settings
Robert Otto Valdez, Ph.D., M.H.S.A., Director, AHRQ
Dr. Valdez reported that the NAC previously discussed issues of quality of care in healthcare and specifically had a subcommittee devoted to quality measurement. Recommendations from the subcommittee report included thinking about quality in different care settings.
The director asked NAC members to think about issues of care quality in nursing home care, home healthcare, hospice care, and behavioral healthcare, and the participants considered the following three questions:
- What does it mean to deliver quality care in these environments?
- What does it mean to receive quality care in these environments?
- What will the quality of care in these environments mean in the future (what will high-quality care be)?
Dr. Bajaj reported for the group that addressed nursing home care, which recognized the need for caregivers, staff, and patients to work together to deliver and realize high-quality care. The group acknowledged that there are limitations on speaking about the patient perspective goals, which can differ, especially depending on the length of stay and the various patient populations, such as end-of-life patients and patients experiencing cognitive disability. The group agreed that nursing home quality differs from quality in other settings and that structural barriers are causing a gap in access to care. Transparency in the transformation process and measurement are crucial for moving to the next level of quality care. Catherine H. Ivory, Ph.D., R.N., noted that the group stressed a need to focus less on process measures. To facilitate innovation, outcome measures would be more valuable.
The provision of high-quality long-term care requires a trustworthy and home-like setting that promotes healing, dignity, and choice. An equity-based technology structure is crucial for addressing issues such as accessibility and safety. Patient-family advisory councils can be helpful in this regard. It is also important to consider issues involving long-term needs, possible changes in the payment model, and coordination of care and to seek processes that provide choices for patients. Also, the focus of measurement should depend on the type of patient and should take into consideration what matters to the specific patient. Additionally, it is important to recognize that meaningful outcomes will vary and that measures of well-being are needed.
Asaf Bitton, M.D., M.P.H., pointed to workforce issues in long-term care, stating that AHRQ may have an opportunity to fund research in this area by examining the four layers of the critical workforce—general staff, temporary physicians, private duty staff, and family/caregivers—who all must communicate across the different layers to improve healthcare quality. Yanling Yu, Ph.D., added that the lack of sufficient staff in nursing homes and long-term care facilities has been exacerbated by COVID-19. Dr. Romano agreed, and emphasized the importance of workforce issues such as staff retention and insufficient backup and the need for incentives. Dr. Ivory noted that the word “person” rather than the word “patient” should be used when talking about long-term care.
Melinda B. Buntin, Ph.D., reported for the group that addressed home healthcare. She noted that the focus of discussion among this group strongly overlapped with the quality issues outlined in the previous discussion. Regarding care delivery, the group agreed that care should be provided at the right time and should enhance the patient’s experience. Care also should be unbiased and delivered with clear communication that addresses the needs of the patient and earns the patient’s trust, which is key to delivering (and receiving) high-quality care, especially as it attends to the patient’s needs (trust and feeling cared for). She also remarked that the right performance metrics must be used and that although new metrics are forthcoming, their use might prove to be challenging for home healthcare agencies. Dr. Buntin said that we need to reduce readmissions and unplanned emergency visits and contribute to clinical trials in the home healthcare setting, which has unique safety issues, including issues related to infection control. There should be a goal of using a minimum number of quality metrics (personalized with good technology) to get actionable data and improved organization is needed to help make the data usable. Caregivers require time to be trained. It was also noted that perhaps home healthcare agencies can facilitate the use of telehealth advancing family contributions and continuity of care. She concluded by emphasizing that we must align payment with what patients value.
Hoangmai Huu Pham, M.D., M.P.H., applauded the emphasis on culturally appropriate care in the home setting and suggested that having a stranger enter one’s home to provide personal services is a profound act. Susan Edgman-Levitan, P.A., said that a survey should be conducted on patient safety culture in home healthcare settings and that this could help in retaining staff.
Andrew D. Auerbach, M.D., M.P.H., reported for the group that addressed hospice care, which features many settings. He stressed the burdensome transitions that are involved in providing this care and issues involving communication and said that it can be difficult to seek goal-focused care management because outcomes can be very individual. Measures of care are complicated by the decisions of patients, and it is important to consider how to capture the patient perspective. Dr. Auerbach suggested that service availability could constitute a quality measure and that staff satisfaction is important but difficult to measure. He concluded by noting that it is difficult to imagine measures that are actionable and that we should focus on studying the structures, processes, and technologies used for measurement.
Ms. Reyes stressed the importance of integrating palliative care with hospice care. Dr. Ivory added that it is important to emphasize the value of palliative care along with addressing how such care is perceived, noting the issue of delayed referrals. Ms. Edgman-Levitan agreed there is a need to reduce the negative connotations of palliative care.
Dr. Goldfarb reported for the group that addressed behavioral health and stated that this is a broad topic and that the group agreed that the area of behavioral health includes processes and outcomes measures that also can apply to other healthcare sectors. The group emphasized the need for the integration of physical health and mental health in primary care and also stressed the need to integrate health plans and pharmacy benefits management, which would involve structuring payment and finance systems and addressing barriers to the coordination of services. He emphasized that patient experience with care is a key outcome, and that patient engagement and satisfaction must be measured. The many challenges include access to care in a timely fashion, which is key, and the group considered a range of outcomes that could be measured, such as recidivism. The group agreed that AHRQ could play a role in establishing risk adjustments for outcomes metrics in behavioral health and that this would be important for value-based payments. Finally, Dr. Goldfarb noted that the behavioral health system is riddled with fraud, abuse, and waste, and that determining how this can be measured and controlled is important in relation to quality of care.
Discussion
Dr. Yu emphasized the importance of integrated care and team care and said that evidence-based treatments, coordination of care, and outcomes measurement are needed. Michael Lauer, M.D., had some questions about the fraud, waste, and abuse mentioned earlier, and in response Dr. Goldfarb provided the example of a payor offering a new medical procedure that in turn gives rise to a large number of providers suddenly making the procedure available. Dr. Romano cited a need to move to the next generation of outcome measures in behavioral health—measures that focus on longer term outcomes such as quality of life, role functioning, and pain management. He stated that the HHS agencies should work together in this regard.
Dr. Robinson asked about common themes across groups. Shari Ling, M.D., cited the broad issue of intentional continuity and capturing quality and said that the overlap includes the importance of what matters to the patient, especially in the Medicaid community. Henry H. Ting, M.D., M.B.A., noted differences between the previously described care settings and the settings involved with procedures/surgery in terms of measures, complications, safety, and reimbursement. He encouraged harmonization of measures across settings to enhance wellness.
Ms. Edgman-Levitan mentioned the themes of family/patient partnership in designing care and quality improvement, workforce safety/engagement, and measuring hygiene, and she identified some measures that are and are not helpful, actionable, and meaningful. Dr. Goldfarb added the themes of equity and disparities, and other common themes that were noted included payment structures, accessibility, and coordination in care transitions. Dr. Auerbach added the issue of workforce.
Dr. Pham referred to metrics around hygiene and the need to move away from clinical guidelines and framing and toward the idea of goal attainment, which addresses patient flexibility. She said that the anatomy of care coordination needs to be dissected to understand the many components and functions and that this burden should not be placed on patients and families. Dr. Zhang wondered who will collect the data for harmonization in a meaningful way.
Dr. Buntin suggested that the future will be one of more home-based care, both diagnostic and therapeutic, and will feature telehealth. Mireille Jacobson, Ph.D., M.A., suggested contemplating different structures such as those involved with care transitions. Dr. Ling stressed the importance of bringing certain populations into the conversation involving access to care, such as people who need access to care for opioid use. Dr. Buntin added the common themes of workforce issues, aligned incentives, and the leveraging of information and technology.
Dr. Robinson ended the discussion by noting that AHRQ can engage in further discussion in a blogpost online and encouraged the NAC members to contact Ms. Zimmerman about contributing. Dr. Valdez thanked the NAC members and assured them that these discussions will help guide AHRQ in its plans regarding investigator-initiated research. He also remarked that some of the discussion will be useful for prioritizing intramural work (e.g., telehealth).
Discussion of Private Equity in Healthcare and AHRQ’s Role
Adaeze Enekwechi, Ph.D., M.P.P., Welsh, Carson, Anderson & Stowe, and Avi Sarma, GRIL Ventures
Dr. Adaeze Enekwechi, who spent many years in the public sector engaged in policy research and administration, is now with a private investment firm, Welsh, Carson, Anderson & Stowe, which focuses on technology and healthcare. She talked about private equity investments and trends in healthcare and said that her firm has a unique relationship with the Health Management Academy, an organization of peer-CEOs, COOs, CFOs, and others from large U.S. health systems. Dr. Enekwechi also noted that many of the groups interested in writing large checks to private equity firms such as Welsh, Carson, Anderson & Stowe are pension fund systems, and she described the economic environment in which these firms operate.
In the global buyout market, healthcare recently has composed about 15 percent regarding private equity. Dr. Enekwechi noted the recent consolidation in orthopedics, cardiology, and other areas and wondered what this movement toward consolidation means for physicians being able to act independently. She added that digital health and healthcare information technology continue to be important and that although technology companies are acquiring data, it is not clear how these data should be used.
From the investor perspective, it was noted that COVID-19 has led to the use of alternative sites of care, such as home healthcare and telemedicine. Dr. Enekwechi cited the need for a more diverse group of clinical trial participants and emphasized that Medicare and value-based care are huge drivers regarding dollars and energy and transforming the healthcare system. Also, there is a desire among some large players to break the healthcare system and build something better. It was mentioned that workforce and staffing concerns are also big drivers and challenges that require technology solutions and investments; that specialty services such as dental services are important; that government cannot fund everything in healthcare; that cross-pollination is needed among investors; and that there is great promise in women’s health moving forward. It was commented that there is not much activity in private equity work in the social determinants of health at this time—yet the money is out there.
Avi Sarma built on Dr. Enekwechi’s comments and spoke of the early steps taken in investing in young health technology companies. His company invests in areas such as education, food/agriculture, energy, transportation, financial services, and health/mental health wellness. In the area of health/mental health wellness, investments have been made in companies offering insurance based on data-driven intervention models and in companies that are establishing automated remote health centers.
Regarding the role that venture capital can play in healthcare innovation, Mr. Sarma said that his company, GRIL Ventures, focuses on new companies that offer solutions through the application of technology, such as by providing digital tools for healthcare and wellness, and supports telemedicine, open data systems, and artificial intelligence. He stated that his company hopes that these innovations will result in improvements in quality and lower costs in healthcare but that while venture capital can encourage innovation, the desire for investors to exit after a brief time is a limitation. Another limitation is the complexity of the national healthcare system. He emphasized that there are opportunities in mental healthcare for venture capital investment, with the usual limitations, and that perhaps AHRQ can work with some young companies that could make a large impact in this area.
Discussion
Dr. Robinson stated that there are opportunities for AHRQ in these areas and asked if there were any responses. Dr. Zhang remarked that these are complex problems that require studies of hospitals and clinics, and he wondered if there will ever be a Google-like system for dealing with problems related to health quality. He said that there are fundamental questions for technology companies. Dr. Enekwechi responded that the problems in healthcare do not rest entirely on data or technology; rather, they are multipronged and multidimensional. For example, a problem could involve a patient expressing a mundane need, such as the need to find the right floor in a hospital. She added that navigators are needed to address fragmentation. Efforts by large firms meets hurdles, greater work needs to be done. Mr. Sarma agreed and stated that building technology and bringing it to market are difficult processes and that interoperable, general activities are needed to organize systems into services.
Dr. Ramar asked about the timing of discussions regarding quality outcomes and wondered if a proactive approach could be taken and how AHRQ might play a role in encouraging such an approach. Mr. Sarma responded that the approach mainly depends on the founder of the company and that staff motivation also is important. He said that AHRQ could help by showcasing, in the early stages, certain work and evidence/data related to outcomes.
Dr. Robinson asked about the role of an evidence-generating body and how investors can be encouraged to push the evidence forward. Dr. Enekwechi responded that this depends on the company—and especially its stage. In the early stages, founders making pitches do not tend to address valuation sufficiently, but they do demonstrate a winning enthusiasm. She added that founders should be asked to suggest how data can be used to provide information about efficacy, effectiveness, and engagement with users. She also observed that obtaining quality data is challenging and that data and quality standardization are needed.
Dr. Yu asked about technological efforts to support the integration of quality with coordinated care, team care, and access to care. Dr. Robinson added that at times new companies will seek a rapid result that fails to address integration. Mr. Sarma responded that it can be easier to envision a solution focusing on one technology, but this, like complexity and integration, also can be challenging. Dr. Enekwechi added that the demand is there for integration, but it is a slow process rather than a revolution. Mr. Sarma mentioned a company that deals in metabolics and obesity therapeutics that is involved in addressing integration of care.
Dr. Auerbach cited the difficulty of quickly getting support to companies that are seeking innovation and results when a technology is evolving rapidly. Dr. Enekwechi suggested that evidence collection should not necessarily be tied to funding and that researchers should speak to AHRQ during the earliest stages. Also, companies should work to maximize their performance and findings.
Dr. Romano recognized the benefits of private equity investment in working toward results but wondered about provider behavior. He noted that there is an emphasis on generating revenue rather than in improving services in a way that also improves population health outcomes. He asked the following questions:
- How are we influencing physician behavior?
- Are we influencing physician behavior to increase revenue?
- Is fraudulent billing occurring through coding?
- What should public policy be in this area?
Dr. Enekwechi responded that private equity companies bear some responsibility and that conversations on these topics have begun. She also said that data are needed as well as data and explanations for health outcomes. She added that policymakers often do not understand private equity strategies; however, at the same time market forces are making these strategies attractive.
Dr. Robinson asked for any final comments. Mr. Sarma stated that capital incentive is designed to be efficient at making money for investors, while healthcare is about improving health—two concerns that will always clash. Yet there are many advantages to having access to private sources of capital. He noted that truth in data shines through and that AHRQ can help. Dr. Enekwechi added that policymakers who deny a profit motive in healthcare are making a mistake and that healthcare companies should be encouraged to understand the business, the incentives, and the needed public structures, as in data.
Public Comment
There were no public comments.
Chair's Wrap-Up and Final NAC Input
Dr. Robinson asked for final comments, especially about common themes related to health equity, diverse healthcare settings, and the role of healthcare investment in capital markets. Dr. Bitton noted that earlier the conversation highlighted the promises, perils, and limitations of the production model to address areas of healthcare that are in need of inquiry and innovation. He said that challenges remain in integration and collaboration that go beyond narrow technical solutions. Also, funds can make money from healthcare inefficiencies, and it is important to ask if such business models should be in use. He emphasized that AHRQ could work to improve how research findings are developed to get to breakthroughs and follow-through innovations. Dr. Robinson emphasized AHRQ’s convening function, and Dr. Buntin cited the role of government in capital investments, such as in health information technology, and wondered if private equity investments could complement this role with an emphasis on equity and patient-centeredness. Dr. Romano stated that the healthcare system has been underperforming and that private capital might be helpful, but only if it leads to improved output. Dr. Bajaj stated that health equity requires payment reform and unique partnerships. Ms. Edgman-Levitan noted that there are workforce shortages across the spectrum of care. Dr. Ivory added the common need for pragmatic clinical trials.
Adjournment
Dr. Robinson thanked participants and adjourned the meeting at 4:30 p.m. Eastern.
Respectfully submitted,
Edmondo J. Robinson, M.D., M.B.A., M.S., Chair
National Advisory Council
Agency for Healthcare Research and Quality
