PTAC Meeting, Day 2, The COPD and Asthma Monitoring Project (CAMP) Part 2

By Adem Lewis / in , , , , , , , , , , , /

CHAIR BAILET: Thank you. We’re now at that moment in time when we’re
actually going to start our deliberations. What we are going to do is we have an electronic
voting system for us, and as we walk through all of the Secretary’s criteria and as the
PRT shared the report shared earlier, we’re going to look at each criteria individually,
and we are going to score them as a Committee to help sharpen our thinking, and ultimately
we’re going to make a recommendation to the Secretary. Also, I’m asking our DFO, Ann, to read — because
there are people on the phone who will not be able to see the screen. As we go through each criteria, she will read
the results as we move through the process. Are there any other comments from folks before
we start deliberating? Is the Committee prepared to begin deliberating
at this point? [No response.] CHAIR BAILET: I think we’re ready to go then. So let’s start with the first criteria, Scope
of the Proposed PFPM, one of the three designated high-priority criteria. The proposal aims to broaden or expand CMS�s
alternative payment model portfolio by either: one, addressing an issue in payment policy
in a new way; or, two, including alternative payment model entities whose opportunities
to participate in APMs have been limited. So a score of 1 to 2, Does Not Meet; a score
of 3 to 4, Meets; a score of 5 to 6, Meets and Deserves Priority Consideration. And for the purposes of this portion of our
deliberation, this is a simple majority? MS. STAHLMAN: Yes. MS. PAGE: Yes. CHAIR BAILET: So we are ready to vote. Yes, please, Paul? DR. CASALE: Just a question. On the opportunity to participate in other
APMs — and I brought up the question about BPCI — did the PRT think about whether this
could be incorporated into the BPCI with COPD/asthma, you know, condition? DR. NICHOLS: We didn’t think so much about BPCI
for the reasons anticipated, but we did talk about another payment model, fee-at-risk. But we talked about it, and it’s an idea that
would be on the table going forward. CHAIR BAILET: I want to make one other comment
before we vote. Folks who are looking at the screen will see
that there are 11. Although there are 10 of us voting, the 11th
person is the person behind the curtain controlling the electronics, and they are doing a good
job. I’m sure that was just a fat finger. MS. STAHLMAN: Somebody voted. CHAIR BAILET: All right. So we’re going to go ahead and start over. Ready to go. Ann? MS. PAGE: We have zero members voting 1, Does
Not Meet. We have one member voting 2, Does Not Meet. We have zero members voting 3, Meets. We have four Committee members voting 4, Meets. We have five Committee members voting Meets
and Deserves Priority Consideration, and zero members voting 6, Meets and Deserves Priority
Consideration. According to the rules of the Committee, if
a proposal is found to meet a criteria, it rolls down to when we have a majority of six
votes, so this would be found to meet the first criterion, Scope of Proposed PFPM. CHAIR BAILET: Thank you, Ann. Any comments from the Committee based on the
results? We’re going to go ahead to the second criterion,
Quality and Cost, which is — oh, Bob? DR. BERENSON: We can do comments, right [off microphone]? CHAIR BAILET: Yeah, that’s right. DR. BERENSON: I thought we were deliberating. I have great concerns about the diffusion,
potential diffusion of accountability in abnormal disease management finding. And I know the Committee — the PRT has identified
that issue and put it down under lack of integration. But I think this is fundamental to the model. In some places, the model is a disease management
intervention with little role, frankly, for pulmonary physicians. I even had — I still have concerns that it’s
not really a physician-focused payment model. But assuming it is, then I think the lack
of attention to that interaction and who’s really responsible and what happens when a
pulmonary physician gets a seriously abnormal result but doesn’t have the patient’s medical
records, et cetera, et cetera, needed more attention. And so that’s why I would elevate that concern
from whatever, number 7 or number 8, into a fundamental concern that I would have. CHAIR BAILET: Harold? MR. MILLER: One of the things I’m struggling with,
and I think we were struggling with partly yesterday on all of these, is that whatever
the issue may be actually cuts across multiple criteria, and it’s kind of hard to figure
out whether you — where you put that. And I was trying to do this yesterday, having
reflected on all that, was to try to go back to what the criterion says. And the criterion says it anticipated to be
able to improve quality and reduce costs. And my conclusion from that is that this is
clearly anticipated to do that. There’s an intervention that it’s supposed
to support that will do that. There is varying degrees of experience that
it can, in fact, do that because we know that this population does get hospitalized a lot. And we know that efforts to try to contact
them to encourage them to identify problems early does work. So, to me, I find that it meets this because
it’s anticipated to do that. And I think that the quality aspect, it seems
to me, is addressed. This issue came up yesterday. I think that if you’re focusing on trying
to keep people out of the hospital, that that is a quality improvement. It may not be the full set of measures that
are needed to be able to do that. And so I just wanted to say at least the way
I’m thinking about this, because I think we ultimately will have to figure out exactly
in the future how we apply all these criteria, is that’s how I’m thinking about the criteria. My concerns about some of the other issues
really I’m sort of going to put into the second — the third bucket, which is how well is
the payment methodology structured to try to protect against potential problems of some
kind, et cetera. CHAIR BAILET: Thank you. Bob, your card is up, but you’re done, right? Any other comments? [No response.] CHAIR BAILET: So this is the second criteria. The proposal’s anticipated to improve health
care quality at no additional cost, maintain health care quality while decreasing cost,
or do both, which would be improving health care quality and decreasing cost. Again, a high priority, and we are ready to
vote. Ann? MS. PAGE: Zero committee members have voted 1,
Does Not Meet. Two Committee members voted 2, Does Not Meet. Five Committee members voted 3, Meets. Three Committee members vote 4, Meets. And zero Committee members voted for 5 or
6, Meets and Deserves Priority Consideration. So the majority has determined that this proposal
meets Criterion 2. CHAIR BAILET: Thank you, Ann. Any additional comments from the Committee
based on the results? [No response.] CHAIR BAILET: We’ll go ahead and move to Criterion
3, Payment Methodology, which is also high priority. Pay alternative payment models entities with
a payment methodology designed to achieve the goals of the PFPM Criteria. Addresses in detail through this methodology
how Medicare, and other payers if applicable, pay APM entities, how the payment methodology
differs from current payment methodologies, and why the PFPM cannot be tested under current
payment methodologies. We’re ready to vote. Oh, Harold. I’m sorry. Harold has a comment before we vote. MR. MILLER: I’m sorry to disrupt the rapid flow
to voting. I wanted to make the observation that I think
this risk adjustment issue is going to come up frequently with a lot of models, and we,
I think, probably would all agree that the risk adjustment systems that exist today don’t
work very well, which means that in almost any case it’s going to be difficult to say
that somebody can bring in something that we know will work. This one, I was struck particularly with the
follow-on letter that we got today. I was originally sort of in the camp that
said that — that is not a pun, “camp” — in the camp that said that COPD we ought to be
risk-adjusting based on the severity of COPD, not the other things that they have. But I was struck by the argument from the
applicant, and I’m recalling my own experience in having run a project focused on COPD, that
it was, A, very difficult to measure the severity of COPD. There is no code for that. And, moreover, what we tend to define was
that the patients who were the easiest to keep out of the hospital, were, in fact, the
patients who sort of just had COPD, and it was the others who had other problems that
were the most difficult to keep out. And so it struck me that it becomes an interesting
thing when the criteria applies to couldn’t be tested otherwise, is that if, in fact,
it’s a different approach to risk adjustment, that it merits testing in some fashion, and
it’s difficult to figure out whether it will work without actually testing it. But I do think that some of the other questions
that came up yesterday about a total cost model become more problematic whenever you
have a risk adjustment structure based on number of chronic conditions, because if all
of a sudden one of those chronic conditions is rheumatoid arthritis and you suddenly have
biologic drugs coming in or inflammatory bowel disease or whatever, that’s a very different
issue than saying the goal is to try to keep people out of the hospital regardless of what
their conditions are. So I do think that there is going to have
to be some — if the risk adjustment structure is going to be different, there’s also going
to be a different way of measuring the accountability, the total cost or whatever measure, to be
attached to that. Otherwise, it could potentially lead to some
patient problems and require more quality measures, et cetera, to go along with it. CHAIR BAILET: Thank you, Harold. Len. DR. NICHOLS: So I agree with Harold that the risk
adjustment is novel and the proposal is novel and it needs work. And I think the fundamental question we have
is: Do we want to do the work before we start running money through it, or do we want to
do the work maybe after? And I must say I come down on the side of
I think there’s enough creativity here, this is worth investing resources in. I don’t think it’s ready to run money through
it. I just feel too queasy about the variation
that would go with using this system as it is without it having been run through a lot
more testing and alternative ways of capturing that severity, including combining electronic
health record data with the claims, if we can get that far, at least for a pilot. So that’s kind of where I come out. MR. MILLER: If I could ask, what is in your mind
about what would be the next steps then? There would be more work on the model done
before it would be appropriate for actual testing? DR. NICHOLS: So we have this letter to the Secretary,
and I think what we put in a letter to the Secretary — I mean, to me, the most surprising
thing in the last four hours is that somebody said it didn’t meet the scope test. To me, this is big — five or six of us had
it way over here to very high scope, merit, preponderance of evidence for quality. But I think there’s concern about lining up
and having this very willing gentleman bear this risk without having kicked the tires
a great deal more. And so what I think we do first is we give
the task of designing a risk adjuster to CMS. That would be my suggestion for the letter. And in the meantime, we work out more of the
accountability details with the submitter, and in a sense we start the process of modifying
the proposal, but let’s come back to that second conversation with a much more robust
risk adjuster proposal. There may be two or three, by the way, that
we might test. MR. MILLER: So if I may, again, the point I made
yesterday is I’m trying to think about whether or not the revision to the model could be
done without actually trying it somewhere. And I’m not convinced in this particular case
that it could because it would in many cases rely on clinical data that would be hard to
get without actually doing it. I think the issue about putting the applicant
at excessive risk it seems to me could be dealt with by structuring a limited test with
a fairly narrow risk order around it, to say we’re not quite sure yet and we want to try
this initially, anyway, to see how it goes before adjusting that, because, I mean, that
would be the way most models, in fact, do start, is kind of with a narrower risk band
and then expanding it over time once one is more confident. So it doesn’t seem to me that we should not
propose something because of that, because I think the initial phase of a model could
be structured, particularly in a limited testing phase, to be able to protect the applicant
from that as a limited tester. CHAIR BAILET: Kavita. DR. PATEL: So the great thing about this is that
we’re all doing this like live, and we’ve never done this before, so it’s like someone
has a camera on one of our family dinners and we’re all starting to talk about things
that you didn’t actually realize we would talk about. My issue with that, Harold, is that I feel
like then — this goes back to something Paul and I and Rhonda struggled with in our PRT. We had to walk the line of kind of doing what
was right in front of us. So I kind of read this myself, the black and
white. I will say that the additional information
helped to change a little bit of my thinking. But I read what was written in front of me,
and I feel like what you just said, Harold, is not what was written in front of me. So I don’t know how to — I’m struggling a
bit with how much can we do to do what I think Len is suggesting, which is right in my mind,
you know, if there was a little more technical — if there was some vehicle by which there
were other people to kind of help with thinking through risk adjustment or a refinement of
the payment methodology, that would impact my — you know, maybe a later decision. But today I have what’s in front of me, and
I feel like what you articulated is not what�s in the proposal. But I also don’t want to be so over-interpretive
and punitive that we’re limited to this 20 pages and not to something else. And I just don’t know how to react to that. CHAIR BAILET: Harold? MR. MILLER: So if I can respond to that, because
I think that’s an excellent point. What I guess I was looking at is saying the
applicant has proposed a risk adjustment model. We are concerned about how it would work. It’s not — we were originally saying we think
it needs to be changed. Now I’m saying, well, maybe it doesn’t need
to be changed. But the problem is there’s risks associated
with a risk adjustment model, and what I was trying to think through was, well, could you
actually figure out what those risks of the risk adjustment model are without actually
putting it in place and trying it in some fashion? I’m on the fence about that, but what I was
saying was it seems to me that if, in fact, one leaned toward the basic concept here needs
to be tried, that we could — and the concern is simply that the applicant would be at very
high financial risk, we could protect them against that if we felt that the model should
be tried. I was sort of making that statement independent
of whether one agrees with this specific proposal that they have made, but it does seem that
in a case like that, if — but you’re absolutely right, it wouldn’t be go invent a whole new
risk adjustment model and then try it. My argument was if, in fact, something like
this — if our concern about it is not that the proposal is bad but that because it has
never been tried, we have no idea whether it’s going to send them into bankruptcy. We could protect them against that in a trial. That was my point. So thank you for that clarification. CHAIR BAILET: Elizabeth? VICE CHAIR MITCHELL: Along the lines of health
policy reality TV — [Laughter.] DR. PATEL: [Off microphone]. VICE CHAIR MITCHELL: — we are sort of exploring
this out loud. And I was going to save these comments for
later, but I have a very similar dilemma. I have no doubt that your practice could test
this and probably be very successful. I have not been convinced that others could
or would, and we are limited in what we can recommend, our options. So I’m leaning more towards very strong comments
to the Secretary that this has a lot of merit, but the readiness question to me is really
significant. So I just — I’m struggling with the same
thing, but I really worry about our range of options. CHAIR BAILET: Tim. DR. FERRIS: I think to address Harold’s point
about whether or not this requires testing to be improved, from my perspective it is
very clear that one could do computer simulations of lots of different risk codes at the practice
level. We do it all the time, health policy researchers
do it all the time. There’s no question that you could get an
enormous amount of information without actually going through the testing process in this
particular case. It may end up in the same place, but that’s
not a question in my mind. CHAIR BAILET: Len? DR. NICHOLS: Ditto, and I think my point would
be, Harold, while, yes, we could protect this applicant from the risk, I don’t think there’s
enough confidence that that particular model is going to be the end game that we should
do that. I think we should do the simulations, do the
experiments, find different ways to calibrate these different variances, not just the means,
and then come back with a very stratified structure in order to deal with the exact
patients Dr. Ikeda has focused on. And that’s what I think would serve us all
much better than starting before we’re ready. CHAIR BAILET: Bob. DR. BERENSON: This, I guess, is going to be most
useful just as a process point, because it’s a little late in the game, but one of the
Medicare MAPCP — what does MAPCP stand for? Multi-Payer Advanced Primary Care demos use
a number of chronic conditions as their risk adjustor, and there is experience at least
there. I don’t believe — well, I won’t say what
I believe, because I don’t — I might be wrong, but there is some experience, and the process
point is that I think we need to do more surveillance when we have issues like this that come up
and we just assume that nobody has ever tested this before. I think it has been tested, and so I would
just throw that out. CHAIR BAILET: Len, did you have an additional
comment? DR. NICHOLS: In a primary care setting? DR. BERENSON: In a primary care setting. CHAIR BAILET: Okay. Seeing no other comments from the Committee,
we will go ahead and vote on Criterion No. 3. Ann. MS. PAGE: Three Committee members have voted 1,
that the proposal Does Not Meet the criteria. Five Committee members voted 2, proposal Does
Not Meet criteria. Two Committee members voted 3, Meets the Criteria,
and zero Committee members voted for 4, and zero voted for 5, and zero voted for 6. So the majority of the Committee has determined
that the proposal Does Not Meet Criterion 3. CHAIR BAILET: Any other comments from the
Committee on this criterion based on the outcome? [No response.] CHAIR BAILET: Seeing none, we are going to
move forward with Criterion No. 4, Value over Volume. The proposal is anticipated to provide incentives
to practitioners to deliver high-quality health care. Comments from the Committee? Deliberations before we vote? [No response.] CHAIR BAILET: Let’s go ahead and vote, then. Ann? MS. PAGE: Zero Committee members have voted 1,
Does Not Meet. Zero Committee members have voted 2, Does
Not meet. Four Committee members voted 3, Meets. Six Committee members voted 4, Meets, and
zero Committee members voted 5, and zero Committee members voted 6, Meets and Deserves Priority
Consideration. So the majority of the Committee has found
that the proposal Does Meet Criterion 4. CHAIR BAILET: Any comments based on the results? [No response.] CHAIR BAILET: We’re going to move forward
with Criterion No. 5, Flexibility. Provide the flexibility needed for practitioners
to deliver high-quality health care. Any comments before we vote? [No response.] CHAIR BAILET: Let’s move forward. Ann? MS. PAGE: Zero Committee members have voted 1,
Does Not Meet. One Committee member voted 2, Does Not Meet. Seven Committee members voted 3, Meets. Two Committee members voted 4, Meets; and
zero Committee members voted 5 or 6 for Meets and Deserves Priority Consideration. So the majority of the Committee has found
that the proposal Meets Criterion 5 for Flexibility. CHAIR BAILET: Thank you, Ann. Any comments from the Committee based on the
results? [No response.] CHAIR BAILET: We’re going to move forward
with Criterion No. 6, Ability to Be Evaluated, have valuable goals for quality of care cost
and other goals of the PFPM. Any comments? [No response.] CHAIR BAILET: Ready to vote. Ann? MS. PAGE: Zero Committee members have voted 1
or 2, Does Not Meet. Four Committee members voted 3, Meets the
criterion. Six Committee members voted 4, Meets the criterion,
and zero Committee members voted 5 or 6, Meets and Deserves Priority Consideration. So the majority of the Committee has determined
that the proposal Meets Criterion 6. CHAIR BAILET: Thank you. Any comments from the Committee? [No response.] CHAIR BAILET: We’re going to move forward
then with Criterion No. 7, Integration and Care Coordination, encourage greater integration
and care coordination among practitioners and across settings where multiple practitioners
or settings are relevant to delivering care to the populated treated under the PFPM. Any Committee members? Harold and then Grace. MR. MILLER: I just wanted to comment on this because,
again, I think some of this is going to be relevant for future things, but the criterion
says encourage and not require. So an interesting question, it seems to me,
is that this, if it was structured the way it was structured, would certainly encourage
it because it might be very difficult for anyone to be successful unless they, in fact,
integrated and coordinated care, which I think is sort of where the PRT came down in terms
of encouraging it without saying exactly how it would be achieved, which in some sense
is okay for a payment model if, in fact, you believe that that can be done. DR. TERRELL: One of the things that we need to
be thinking about is the ambiguity of the word “care coordination” with respect to this
criterion. So it can be thought about within the context
of the care coordination for an individual patient with all the resources that a nurse
navigator or other type or telemedicine or any of these types of things can potentially
do this, basically, coordinating resources versus care coordination between providers,
which I believe we’re using within the context of integration here. But this is just an acknowledgement or something
for the PRT to be thinking about, because we’re now seeing two proposals in a row that
I think are very much focused on care coordination for the patient in their model that they’re
proposing, but not necessarily as focused upon the whole integration of care. So, as we’re thinking through this in the
future, we may want to either make a distinction in our own criteria or at least be more explicit
with that for the applicants, so they can comment on both aspects of it. CHAIR BAILET: And I guess, Grace, adding to
that comment, in this particular condition with the comorbidities being high touch and
requiring expertise from a multiple set of disciplines, I do think that while I do acknowledge
the patient coordination, which is extremely heavy here, to really maximize the benefit
of this model, it is that integration with the other clinical teammates who would be
taking care of these patients, so I do think that’s important. Kavita. DR. PATEL: So, again, I’ll just verbalize the
things I’m struggling with. When I read what was originally kind of proposed,
I arrived at the same — independently the same conclusion the PRT did. I think when I hear Dr. Ikeda and kind of
any colleagues that work with him on this putting into the kind of paper response that
we have — and I’ll read it: We’ve decided that this concern about the coordination is
a valid argument and in our evolving care plan will expand monitoring to other chronic
conditions, et cetera. We will consult with other and offer care
coordination of other chronic diseases in our population of patients with COPD and asthma. So I’m trying to kind of read to the letter
of we don’t know what care coordination is, or at least we think we do, but it’s not specified
in the Secretary’s criterion how maybe the PRT might respond to that, or I’ll say my
response to that is that he is — or at least the proposal is trying to encourage, even
though the intentionality was expressed in this kind of late-breaking document, that
there is actually an encouragement of this coordination, although the details have to
be fleshed out. So I would almost just put forward that this
could potentially meet the criterion just based on this added inclusion. CHAIR BAILET: Bob and then Paul. DR. BERENSON: Well, I’m going to disagree with
Kavita. I think that added inclusion gives me more
concerns. We’re going to have a pulmonary practice essentially
coordinating care for a patient’s diabetes and heart failure when the patient is being
cared for by a different physician. The whole thing doesn’t hang together. I mean, I think this is added to recognize
the need for care coordination, but again, I’ll just say a separate disease management
program, which is what this is, with perhaps some pulmonary physician involvement to deal
with COPD exacerbations is not the place to be doing overall care coordination divorced
from the patient’s regular source of care. DR. CASALE: Yeah. Just to comment again, as you pointed out,
this Criterion 7 is specifically around coordination among practitioners, so I understand coordination
— care coordination for the patient is critical, but this criterion is around practitioners. And although in that add-on statement, there
is encouragement that there would be more, as Dr. Ikeda said, right now it’s relying
on faxing. Again, I think you need more detail to try
to understand how this would — or experience on how this would actually work other than
the traditional methods which are currently being used, which we know are ineffective. CHAIR BAILET: Thank you, Paul. Len and then Harold. DR. NICHOLS: So a great thing about being a non-physician
is you get to learn from physicians on the PRT, and what we talked about in more detail
than anything else on this criterion was a distinction between care coordination and
care integration. And, actually, it was integration that we
unanimously concluded it was lacking. Care coordination definitely is encouraged
in all kinds of ways, but I think it’s integration that we were worried about. CHAIR BAILET: Harold. MR. MILLER: So the fact that this applicant said
that they were planning to coordinate care does not necessarily mean anything about the
model. It’s sort of that this applicant was saying
that they would do it. But what it does seem to me to indicate is
that, in fact, they felt that the model would, in fact, sort of push them in that direction. I would distinguish, I guess, if the model
was saying, “We are going to prevent COPD hospitalizations, and that’s all. We don’t care about anything else. And if the patient is going in for something
else, not our problem,” and you would have the ordinary food fight that goes on in trying
to figure out, so why did that patient get hospitalized, then I would be worried about
it. But the fact that they are saying, “It doesn’t
matter. Whatever they end up in the hospital for,
we’re going to be accountable for that,” certainly to me says you’re going to have to figure
out somehow how to coordinate care with all those other physicians that are taking care
of those things because the pulmonologists aren’t going to be terribly expert at managing
all that. So, to me, if it’s encouraged, does the model
encourage it? Yes. And the fact that the applicant said, “You’re
right. We’re going to have to do that,” sort of reinforces
that notion for me. CHAIR BAILET: Tim. DR. FERRIS: I guess I would ask Harold. We heard from the applicant that they would
do it because they think it’s the right thing to do. What specifically about the model encourages
that behavior? MR. MILLER: Well, what I just said was that, in
fact, if they — if the patient is hospitalized for an exacerbation of their heart failure,
of their rheumatoid arthritis, of their whatever, they will be accountable for that. So if they’re not figuring out how to manage
that, then they are going to be at significant financial risk. That seems to me to encourage that. That’s at least my interpretation of it. That’s why I was trying to distinguish it
that I don’t think that a model that said we are only going to be accountable for COPD-
or asthma-related things would, in fact, have that same level of encouragement. In fact, it could encourage the opposite,
which is finger-pointing to say, “No, it wasn’t my problem.” CHAIR BAILET: Paul. DR. CASALE: As I think about it, just because
somebody is willing to accept the risk doesn’t guarantee that there is going to be integration
or coordination of care, in my mind, without at least seeing some ideas on how that would
actually happen in the model, not just “We’ll take the risk.” To me, that doesn’t guarantee. I think the model should describe a little
more fully around how all that would work for me to feel comfortable with this. CHAIR BAILET: Grace. DR. TERRELL: So that’s going to be a crucial question,
I believe, this afternoon, is a crucial question in this one as well, which is, is a payment
model itself going to, therefore, naturally lead to certain behaviors or a priori are
we going to expect certain aspects of the Secretary’s criteria to be explicit in the
models? What I just heard you say is that you don’t
believe that one payment model methodology naturally leads to the other, and it does
need to be explicit. We need to be thinking as a committee about
that, not only for this model, but for others that are going to come forth. That’s one of the crucial things that we need
to understand, each of us individually, what is the relationship between the payment model
and the Secretary’s criteria for all these other things. Does it naturally lead to it, or are we going
to insist, as we make a recommendation going forward that are being explicit, you know,
tie, if you will, to that? So I think that, Paul, your comments are actually
extremely relevant to our broader issues that we’re going to be struggling with. CHAIR BAILET: Thank you, Grace. Any other comments from the Committee before
we vote? [No response.] CHAIR BAILET: Then let’s go ahead and vote. Ann. MS. PAGE: Four Committee members have voted 1
that the proposal Does Not Meet the criteria. Another four members have voted 2, the proposal
Does Not Meet the criteria. One Committee member voted 3; it Meets the
criteria. Zero Committee members voted 4, Meets the
criteria. One Committee member voted 5, Meets and Deserves
Priority Consideration, and zero Committee members voted 6, Meets and Deserves Priority
Consideration. The majority of the Committee has voted that
the proposal Does Not Meet Criterion 7. CHAIR BAILET: Thank you, Ann. Any comments from the Committee based on the
results? [No response.] CHAIR BAILET: We are going to move forward,
then, with Criterion No. 8, Patient Choice. Encourage greater attention to the health
of the population served while also supporting the unique needs and preferences of individual
patients. Any comments before a vote from the Committee? [No response.] CHAIR BAILET: Let’s go ahead and vote. Ann? MS. PAGE: Zero Committee members have voted 1. Zero Committee members have voted 2, Does
Not Meet. Four Committee members vote 3, Meets the criterion. Five Committee members voted 4, Meets the
criterion. One Committee member voted 5, Meets and Deserves
Priority Consideration, and zero Committee members voted Meets and Deserves Priority
Consideration. The majority has voted that the proposal Meets
Criterion 8, Patient Choice. CHAIR BAILET: Any comments from the Committee
based on the results? [No response.] CHAIR BAILET: We’ll move to Criterion No.
9, Patient Safety. How well does the proposal aim to maintain
or improve standards of patient safety? Any comments from the Committee before we
vote? Bob. DR. BERENSON: Yeah. This is the place, I guess, I get to say what
my fundamental problem is, which is that we have an intervention, which I would love it
to work, but it hasn’t been proved effective, except in one German study. So I do not know whether it would achieve
its aim. I mean, the thing says to aim. It certainly aims to do the right thing, and
it could do the right thing, or it could result in diffusion of accountability with primary
care physicians no longer — I mean, I’ve got a pulmonary doc who is going to deal with
this, and I don’t have to worry about it, and a pulmonary doc who doesn’t have the relevant
information. I want to know that the intervention works,
and then I can worry about a payment model. And I don’t think we’re at the stage. I don’t think we should be using the PTAC
offices to do basic clinical research, I guess is what I would say, and that’s my concern. So I have difficulty. The aim is exactly right, but I don’t have
any confidence that it will be achieved or not achieved. CHAIR BAILET: Thank you, Bob. Harold? MR. MILLER: I think an interesting aspect of this
proposal is I don’t think we can sort of criticism them on both sides. They actually are not taking accountability
and payment for all of the payment associated with the patient. So there are going to be other clinicians
still responsible for those patients under whatever payment model applies to those other
patients. This model, at least as I understand it, is
designed to try to provide an extra overlay layer of help to the patient beyond what they
can get today. It is possible, as you say, that that might
lead other people to sort of pass the blame or the responsibility on to these folks, but
it doesn’t seem to me that that is inherent in the model. That adding an extra layer of protection on
top would seem to me to be a good thing to do rather than otherwise. I mean, the converse would be to say that
everybody who is responsible for the patient is suddenly in this risk-based model that
we’re a bit uncomfortable with would be, to me, a higher level of concern about patient
safety. CHAIR BAILET: Bob. DR. BERENSON: So I would just respond. So why don’t we find out by doing a clinical
— doing some clinical research and what the impact is before we decide to do a national
payment model? MR. MILLER: Well, I would just say, I think you
keep referring to national payment models. That’s why we are talking about limited scale
testing, and I think the issue ends being, in some cases, what does clinical research
mean? We’ve seen that some of the grant programs,
to simply fund an intervention, don’t really get at the issue very effectively of how do
you structure a payment model to support them. So I do think we have to figure out how to
create the bridge between the health care innovation award approach and payment models. And I would respectfully disagree with my
colleague, Tim, that you cannot do all this stuff through simulations, because the whole
problem is that if you are running simulations you are running simulations against past existing
behavior, not how care would change under a different model, and that is one of the
fundamental problems in recalibrating risk adjustment models, is because you can only
calibrate them against the behavior you’re trying to change, which is not a good thing
to do. DR. BERENSON: I didn’t think we were talking about
limited scale testing, necessarily. I thought that was one of the options we had,
and maybe that is where this fits. But I do think one of our options is to even
give it high priority for broad testing. So maybe we can — we will agree — I don’t
know; we haven’t voted yet — but your point is what we’re talking about is limited-scale
testing. I didn’t think that is what we were talking
about. CHAIR BAILET: Thank you, Bob. Tim. DR. FERRIS: Harold, once again you’ve mischaracterized
my comments, and so I just want to point out that what I said was that we could improve
the understanding of the variance associated with the practice level. I stand by that statement. Thanks. MR. MILLER: With that clarification, I would agree
with that. Thank you. CHAIR BAILET: All righty then. We�re going to go ahead and vote. Ann. MS. PAGE: Zero Committee members have voted 1,
Does Not Meet; two Committee members have voted 2, Does Not Meet; seven Committee members
have voted 3, Meets the criterion; one Committee member voted 4, Meets the criterion; and zero
Committee members voted for 5 or 6, Meets and Deserves Priority Consideration. The majority of the Committee has voted that
this proposal Meets Criterion 9. CHAIR BAILET: Thank you, Ann. Any additional comments from the Committee? I see Grace. DR. TERRELL: For the next one. CHAIR BAILET: Oh, for the next one. Okay. Then we’re going to move forward, for Criterion
10 — you guys are rushing me here — Health Information Technology. Encourage use of health information technology
to inform care. Grace. DR. TERRELL: This issue came up yesterday, when
we were talking about this criteria of encouraging the use of health information technology. Everybody went off on interoperability in
electronic health records and that aspect of technology. But I think that this particular proposal
really talks about other ways of thinking about health care technology. In this case a Bluetooth device that is providing
the information back to providers is not integrated across some Epic system, although this was
discussed as something that might need to be planned for. And as we’re thinking about this particular
criteria in the future, I suspect that we’re going to get far more types of beta and innovative
new types of technology that are going to be coming as part of these models, that are
not going to be mature, they are not going to necessarily have anything except a study
from Germany, because that’s the nature of innovation. And so much of the innovation that’s happening
right now is happening in health care within the context of care delivery at the individual
patient level and how to enable their experience, particularly, to not be so facility-based
and to be based much more on chronic care management type of enablement tools. So this particular criterion, over time, we
may find ends up being one that we spend more time thinking through, as a committee, than
some of the others. I may be wrong about that but we�ve now
had two in a row that are very much in the same mode of a technology that’s important
in it. And with this particular one, it’s right there
on the edge of the way a lot of the investment in technology is going. So we just need to make sure that as we are
talking about our own thought processes, that we don’t get trapped in today’s technology
and the health systems and the population tools that are out there now. It may or may not be mature but it’s going
to be something that, I think, is going to continue to come up. CHAIR BAILET: Elizabeth. VICE CHAIR MITCHELL: Thank you. I actually am impressed and like the innovative
technology aspect of this proposal, but the more we’ve talked about integration across
specialists and others, the more concerned I am about the information-sharing aspect
of this, which, I mean, we’re talking about HIT to inform care. And, again, through no fault of the applicant,
I don’t think the answer can be just universal adoption of Epic, because we’ve got to find
ways to get information shared across practices, particularly for something that assumes coordination
across multiple practices and specialties. So I’m actually more concerned about this
than I was. CHAIR BAILET: Len. DR. NICHOLS: So I’ll pick upon Elizabeth’s point
about Epic. I know quite a few systems in Virginia that
all have Epic and they can’t talk to each other, so trust me, that ain’t going to be
the solution. What needs to be worked out, therefore, is
a way to parallel track the development of the risk adjust or the development of the
interfaces that are going to make this kind of creative technology actually operational
across a wide range, and we need to be working on that simultaneously. CHAIR BAILET: Thank you. Grace, do you have another comment? Your card is up. DR. TERRELL: Sorry, no. CHAIR BAILET: So we’re going to go ahead and
vote. If you think you voted, you may not have,
so you may want to push your button again. There we go. Ann? MS. PAGE: Zero Committee members have voted 1,
Does Not Meet; two Committee members voted 2, Does Not Meet; three Committee members
voted 3, Meets; five Committee members voted 4, Meets; and zero Committee members voted
for 5 or 6, Meets and Deserves Priority Consideration. The majority of the Committee has voted that
this proposal Meets Criterion 10, Health Information Technology. CHAIR BAILET: Thank you, Ann. Any comments on this criteria? Any additional comments, based on the results? [No response.] CHAIR BAILET: So what we’re going to do now
is the folks on the information technology side for us are going to provide a summary
slide, which we’ll review in a minute, which summates the voting through these 10 criteria,
and while we’re doing that, if there’s any other committee comments, in general, about
this proposal, before we actually begin deliberations and vote relative to the recommendation to
the Secretary, which is the next phase of our process. And again, I’d like to just walk the Committee
members through that. We are going to use electronic voting, and
then we are also going to voice vote by member, because we believe it is important for the
community submitters and the public stakeholders to know where we came down on this particular
recommendation for the Secretary. So a vote of 1 means does not recommend to
the Secretary. A vote of 2 means recommend the payment model
to the Secretary for limited-scale testing. A vote of 3 means recommend the proposed payment
model to the Secretary for implementation. And a vote of 4 means to recommend the proposed
payment model to the Secretary for implementation as a high priority. So those are the four categories, and if we�re
ready we could provide the summation of our criterion voting, that would be helpful. Yeah, it just takes a minute for them to transition. Yes, Kavita. DR. PATEL: Maybe I can ask now, not just the PRT
but I’m thinking out loud. I know we’ll see all of our criterion and
perhaps I’m too, kind of, colored by yesterday. If we feel like they really met a number of
the criteria, with the exception of one of the high-priority criterion, that we are all
kind of dancing around, like some form of technical assistance, which this committee
is not allowed to provide — we have already covered that — I actually don’t feel — I
struggle because the criterion and the way we voted on them is eerily similar to kind
of how we arrived on yesterday’s proposal, but that we moved forward for different reasons,
for limited-scale testing. My hesitation is that I think this is like
still short of qualifying for limited-scale testing yet offers so much promise and opportunity. So I’m curious, as we only have the three
options. We don’t have a 2A, you know, technical assistance
before limited-scale testing, then pass Go. I’m kind of struggling with how we take something
that has a real — obviously, by our voting, we think there’s some real merits to the actual
proposal, novelty, some interesting potential around risk adjustment, inclusion of a high-priority
condition, et cetera, et cetera. And what do we do with that? We’re kind of in an in-between category space,
and that’s where I’m struggling, myself, to be out loud about it. So is there a 1, 2, 3, and then like a 4,
you know, I’m still struggling, kind of question, because that’s where I’m at. CHAIR BAILET: Thank you, Kavita. Harold? I think — well, I’ll speak for myself. Many of us are struggling with that. I guess I’m struggling with that. I think the — we’ve said before that even
if we do not recommend we will provide comments, suggesting the nature of that, to distinguish
between we really didn’t think this was a good idea at all versus it’s a great idea
but it’s got some weaknesses in it. At least the way I am thinking about it is
that if there is a sufficiently high level of technical assistance or revisions needed
to get it to the point where limited-scale testing would be desirable, then I would put
it in the no category, that it really needs to have that done. If it’s in the category where maybe a little
bit of technical assistance but, frankly, most of the stuff it needs is going to have
to be worked out in an actual test, then I would lean on the — which is where I leaned
yesterday, which was I didn’t think that the revisions were of sufficient scale to really
stop it, and I felt it could move forward. I feel in the other direction on this. I think, to me, that there are enough things
that really have to be refined and clarified about this that you couldn’t just say, take
that, do a little bit of tweaking, and go test it. But I do think that, ultimately, that no matter
what we do, in terms of — or what they do in terms of revising the methodology, I still
think it would need to go limited-scale testing, if it stays in this same kind of category,
because it’s so different and so potentially — raises issues that have never been tested
before. That’s at least where I am. CHAIR BAILET: Thank you, Harold. Elizabeth. VICE CHAIR MITCHELL: Actually, I may have
just agreed with Harold. I am so intrigued and impressed by the innovative
nature of this but I’m with you, Kavita. I don’t see the readiness for testing. And so I’m wishing we had more categories,
but really, I think, going to be relying on the comments to make that point that technical
assistance, data, everything we’ve already identified that is needed is exemplified here. CHAIR BAILET: Thank you, Elizabeth. Len. DR. NICHOLS: So I agree. I think — I like the way you framed it and
I think of everything as a continuum. And to me the question is: What are the elements
of work that need to be done before I would feel comfortable having it tested anywhere? And, here I see three. I see the risk adjuster issue, I see the information
technology connection issue, and I see the integration pathway protocol issue. And to me, CMS can do the first two. The clinicians have to do the pathway, but
that’s precisely what I mean by parallel track, to get us to a better proposal with the technical
assistance in hand. CHAIR BAILET: Bruce. MR. STEINWALD: You know, we’ve talked a lot about
making recommendations for implementing a model, and wondered about how often those
would be accepted by the Secretary. Now wouldn’t it be something if we recommended
against implementation and they said, “No, we think we will implement it.” We never considered that. [Laughter.] MR. STEINWALD: All of that is just background
to saying that we have to rely on our comments, and to the extent that we think there is substantial
merit to this approach, we want to get that clearly in the record, and hope that CMS could
find a way, if not through a re-proposal through PTAC but maybe another mechanism for pursuing
that approach. CHAIR BAILET: Thank you, Bruce. Grace. DR. TERRELL: It might be useful for us to say
here, in public, that the way we set up the PRTs, if any of the three high priorities
was recommended against by the PRT, then the PRT did not recommend it to go forward, is
sort of the way we’ve set it up. What happened yesterday is — and as we have
reiterated — is that the PTAC can overrule that. It can determine that those three high priorities
do not, in and of themselves, mean that it can’t move forward if there’s other merit,
and that’s what we did yesterday. So to get to the point that everybody is making
with respect to the continuum, we don’t recommend but yet we may think that there are some things
out there that could make it better, then there is the likelihood that we can recommend
for limited-scale testing because it’s far enough along, versus the, let’s go forward
with this with all — you know, all deliberate speed. Those types of things are not necessarily
constrained by the don’t recommend but they do imply a certain level of readiness that’s
out there. What we’re now talking about today is in the
ability to comment we may be able to provide broader thoughts, even if we don’t recommend,
it could move something forward, but it’s not actually part of the process that we’ve
got right now, and it doesn’t mean that the PRT process that has been put in place actually
speaks to that per se, although it probably does signal about what some of the strategies
are going to be. CHAIR BAILET: Thank you, Grace. Bruce, did you have an additional comment,
or — MR. STEINWALD: Sorry. CHAIR BAILET: Any other comments from the
Committee? [No response.] CHAIR BAILET: So, like yesterday, we are only
able to do a voice vote, but I wanted to just remind folks, and folks on the phone, because
they can’t see the summary slide that is now up. Ann, if you could just summate where we are,
and then we will go ahead and do a voice vote, and we’ll start on this side of the room,
with Paul, and go around, just to keep it balanced. Ann? MS. PAGE: Do you want me to read —
CHAIR BAILET: Yeah, if you could. Yeah, just the summation. MS. PAGE: Okay. This is the summary of the voting that just
occurred on the proposal, whether or not it meets the individual criteria. For Criterion 3 and Criterion 7. Criterion 3 is Payment Methodology, high priority. The Committee voted it Does Not Meet that
criterion. And for Criterion 7, Integration and Care
Coordination, the Committee voted that it Does Not Meet the criterion. For all the other criterion — Criterion 1,
2, 4, 5, 6, 8, 9, and 10 — the Committee voted that the proposal Does Meet those criterion. So 2 out of the 10 criteria were found to
not meet the Secretary’s criteria, and the remaining eight, the PTAC voted that it does
meet those criterion. CHAIR BAILET: Thank you, Ann. So now we�re going to start with Dr. Casale,
for rendering a recommendation opinion. DR. CASALE: Yeah. My vote is a 1, do not recommend. CHAIR BAILET: Bob? DR. BERENSON: Do not recommend. CHAIR BAILET: Kavita. DR. PATEL: One, do not recommend. DR. FERRIS: One, do not recommend. VICE CHAIR MITCHELL: One, do not recommend. CHAIR BAILET: My vote is one, do not recommend,
and one thing we did yesterday that we’re not doing today was we provided a little backstop
for our thinking on the vote, and I guess I’ll maybe — I feel compelled. I feel compelled to do that. We can do it afterwards? Okay. MR. STEINWALD: One. DR. TERRELL: One. DR. NICHOLS: One. MR. MILLER: One, because of what I said earlier,
which is that I think it does need more technical assistance, but I do think that something
like this should be — if that proves successful, moved forward. CHAIR BAILET: So maybe we’ll come back around
starting with you, Len, and provide that background. DR. NICHOLS: I couldn’t agree more. I think this proposal is so creative, we need
to nurture it. But I think we need to protect it from itself,
and that’s what that technical assistance would do, in my view. And, again, I see three strands. I see the — I would just say the risk adjustment
sector, the information technology connection, that is not trivial. And while some people can do it, not everybody
can. And working out how more could do it would
be a worthwhile investment. And, third, I really think this care integration
pathway stuff is pretty crucial. It could be specialty societies involved and
all kinds of stuff. CHAIR BAILET: Thank you. Grace? DR. TERRELL: The aspect of technical assistance
is something that we’re going to have to understand in far more detail and explore. One of the things that was said in testimony
today is how helpful he found some of the tables and he wished that he had had access
to some of that information prior to being able — prior to writing the proposal or in
the process of that. And if we’re really going to get a lot of
this type of creative proposals from the medical community, that’s going to be something that
we’re going to have to understand at the level of PTAC but also CMS, is that what type of
information that could be available can we provide the broader community, not particularly
an individual but the broader community, that would allow a far more creative process and
once that’s iterative that could go on forward from this. So as we’re making those comments in this
proposal, I would suggest that at our next time to communicate with one another that
we also be thinking about how we would do that much more explicitly and understand what
the constraints might be on the part of CMS. CHAIR BAILET: Bruce? MR. STEINWALD: Despite our unanimous vote on do
not recommend, I think the comments should be framed very positively, as others have
said as well. CHAIR BAILET: I agree, Bruce. I again commend Dr. Ikeda for his innovative
approach to something that is extremely needed in this population of patients. But I do want to make the distinction of our
comment about the grades of sort of hitting the hurdle where we think we could support
a recommendation for limited-scale testing. And I think in this particular proposal there
are still enough unanswered questions relative to the payment methodology reasons we’ve discussed. I agree with you, Len, relative to the information
technology and the dissemination of that information, again, because of the complexity of these
patients. But I also want to underscore the challenges
that this model will have with implementation relative to coordinating with other specialists
using the backdrop that we have now, which is this Bluetooth technology. So I do think that that needs more work, and
I completely agree, again, with you, Bruce, that this has to be — I feel compelled that
we should frame this up as something that needs to be supported to the point where we
can get it into the field. It’s just not ready at this point. Elizabeth? VICE CHAIR MITCHELL: Thank you. One of the things I liked best about Dr. Ikeda’s
letter was his wish list, and if we had a wish list, I would — sort of a PTAC incubator
for really promising models. But we don’t have that. So I’m going to, again, just reiterate my
appreciation for the innovative and really just forward-thinking approach, but my concern
about readiness, and I will pile on to the very positive comments. DR. FERRIS: The problem with being on this side
of the table is that you’ve already made all the comments, so I don’t have to make any. Grace says go to lunch. Right. I did want to, in addition to agreeing with
everyone, just highlight what Bruce said about, you know, CMS saying even though PTAC didn’t
recommend it, actually it’s so important we should do it. That is actually the message that CMS should
take from this because if you look at the scale of the problem with hospital admissions
in the United States from COPD as a large fraction of those being avoidable, which we’ve
clearly shown in our setting, there actually are few epidemiologic targets as rich as this
one is. And so it should be a priority to — and in
addition, one can’t imagine — or I should say it in the positive: One would imagine
that whatever solution comes to address that problem is going to look a whole lot like
what is in this proposal. And so you take those two things together,
and you come to the unavoidable conclusion that this should be a priority to develop
and test this model or some model that comes out of something similar to this. And that should be actually at the very highest
priority for Medicare. Thanks. CHAIR BAILET: Kavita? DR. PATEL: The only additional comment I would
make, I guess our own wish list, because we had Dr. Ikeda’s, is that with the care coordination,
we spoke yesterday — I’m not sure if you were able to hear it. We spoke yesterday about kind of distinctions
between a novel payment — or a physician-focused payment model such as this one and kind of
these concepts like a specialty medical home. Or we even asked today about kind of what
are the inadequacies of a chronic care management fee, which is an existing kind of model. In the proposal itself, it references the
oncology care model. Just to help think through potentially in
whatever next version of this there is, to help think through how can the actual functions
of that care coordination, which I think as a clinician you almost take for granted because
you know you have to do it, you don’t have a choice in any clinical setting, but how
that directly ties to the payment model, to the quality metrics. And just as bold as you were about the novelty
in the HIT and the novelty in the risk adjustment, think through kind of how to tie that novelty
back to what we’re tasked with, which is looking at the payment models. CHAIR BAILET: Bob, final comments? Paul? DR. CASALE: Yeah, just to — and, again, at the
end it’s hard to add much. But, you know, as I think about it, this model,
as everyone has said, is incredibly creative and innovative. This is the type of thing that gets physicians
jazzed. I mean, they really get excited because, as
Bob related about his relative ending up on a ventilator and Dr. Ikeda said, yeah, he
sees this every day, people end up on a ventilator that he could presumably have prevented. And, you know, so this is the type of creative,
innovative model that we would encourage. And again, I think the problems, I think Len
has highlighted the three areas that really need improvement. But I think that message to the Secretary
should be clear about the positive aspects of this model. CHAIR BAILET: Thank you. Elizabeth, do you have a final comment? VICE CHAIR MITCHELL: I don’t really want the
last word, but this isn’t meant as an afterthought, but something that hasn’t been said that I
think is really important in our comments is that I think the savings from avoided hospitalizations
is really important. And so I guess building on your point, Paul,
we are getting folks at the right time, and I think the potential for savings are also
really significant. So I just wouldn’t want that to not be included
in the comments. CHAIR BAILET: Thank you, Elizabeth, and I
thank the members of the Committee for a very rich, engaged, spirited discussion. At this point a lot of the comments that we’ve
made along the way I know will be incorporated into the recommendation to the Secretary. But at this point, if there are other comments
as we — one of the next steps now is for the staff to work with us to frame up the
actual letter, and that’s an iterative process that we’ll all be able to participate in. But if there are additional comments that
haven’t been made that you think are important for the staff to hear at this point in time,
this would be a good time to share them. Len? DR. NICHOLS: I guess the only thought really is
picking up on what Dr. Ikeda said about how useful — and we discussed it today — how
useful those tables were, we need to figure out a way to get there quicker, and I think
we should put that in a letter to the Secretary, that we’re working on ways to be more proactive. And, you know, we know why we didn’t — why
we got stymied before. We wanted to do — and we couldn’t. We got to find a way to get tables to people
in the middle of the preparation of the proposal. CHAIR BAILET: Thank you, Len. Any other comments? [No response.] CHAIR BAILET: So that concludes the deliberation
and the recommendation process for the proposal, the CAMP proposal, and, again, I want to thank
Dr. Ikeda for coming all the way out from Sacramento. I cannot underscore the value in having you
here and hearing from the proposer directly live. I certainly know that — speak personally
that I found it tremendously helpful yesterday and today, and I hope that we can continue
as a Committee to keep that bridge and encourage folks and actually work with them to make
sure that they can come, because it is invaluable to this Committee and our process. So, again, thank you. I do want to say at the end, because of your
comment about BlueShield, I do think it’s important for the folks in the room to know
that, yes, I am an executive with BlueShield and, yes, I am sure that your practice has
relationships, contractual relationships with BlueShield. But I personally have not been involved or
talked with your group about this particular model, and it did not influence my voting
and reflections on it. But we can have an offline conversation about
ways that potentially we could leverage the assets of the plan to work with your practice,
again, because I agree with the point made earlier about the invaluable efforts that
this will provide to this community and, more importantly, to the patients. So if I in my position with BlueShield can
do something that can help accelerate this process, I’m all in. So I’ll be following up with you after as
well. Thank you. So we are not quite at lunch, and because
of the amount of work required to review these processes, I’m going to make a recommendation
for my teammates to consider. We could break for lunch now, or we could
begin the next review process with the PRT report. We could break at that point. We could potentially — because we have a
number of public comments, we could potentially begin that process and then break. I look to my Committee for their input on
what you’d like to do. Bob? DR. BERENSON: I think we just should break for
lunch and move the schedule up with the extra 20 minutes we have so that we begin at 20
to 1:00 instead of 1:00, if the people are all around. That’s what I’d recommend. CHAIR BAILET: Yeah, okay. And I guess I’d also float out we could take
a shorter lunch, too. We probably should, given all the work that’s
in front of us. Elizabeth, you had a —
VICE CHAIR MITCHELL: Yeah, my only concern is if people are coming for the scheduled
1 o’clock that we — MS. STAHLMAN: It wasn’t scheduled at 1:00. It was scheduled immediately following the
first one. VICE CHAIR MITCHELL: Oh, okay. Then I would recommend a short lunch break,
and starting as soon as we can. CHAIR BAILET: Okay. Say that again? MS. STAHLMAN: 12:30 would be 45 minutes. CHAIR BAILET: 12:30 would be 45 minutes, so
we’ll reconvene at 12:30. Thank you.

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