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TRANSFORMING MEDICAID THROUGH INFORMATION TECHNOLOGY 1 SAS Medicaid Managed Care Summit May 9, 2012 Gayle Harrell Member of the Health Information Technology Policy Committee
TRANSFORMING MEDICAID
THROUGH INFORMATION TECHNOLOGY
1
SAS Medicaid Managed Care Summit
May 9, 2012
Gayle Harrell
Member of the Health Information Technology Policy Committee
• 60 Million Americans covered under Medicaid and
CHIP
• 2008 -$339 billion
• 2009 - $380.6 billion 50.1 million enrollees
• > 6 million people between the recession's start in
December 2007 and the end of 2009
• Costs predicted to increase 7.9 percent per year
• $674 billion by 2017
• BEFORE Healthcare Reform
• Increase eligibility to 133% of poverty
2
Medicaid Costs
Is it really possible to ensure access to
quality healthcare and reduce cost
and the same time??
HMO’s?
PPO’s
ACO’s?
MSSP?
Bundled Payments?
P4P?
3
Question of the Day???
4
Value = Cost
Quality __________
Question of the Day???
EHR + HIE +MC + PA
= IO + RC
Electronic Health Records + Health Information
Exchange + Managing Care + Predictive Analysis
= Improved Outcomes + Reduced Costs
5
YES!!!
6
The Health Information
Technology Policy Committee
• Established under American Recovery and
Reinvestment Act 2009 (ARRA 2009)
• A Federal Advisor Committee
• 13 Members appointed by GAO in designated areas
• 4 Members appointed by the US Congress
• 3 Members appointed by the Secretary of HHS
HITECH
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Committee Members
Chair: Dr. David Blumenthal , HHS/Office of the National Coordinator for Health Information Technology
Co-Chair: Dr. Paul Tang, Palo Alto Medical Foundation
Members: • David Bates, Brigham & Women’s Hospital
• Christine Bechtel, National Partnership for Women & Families
• Neil Calman, The Institute for Family Health
• Rick Chapman, Kindred Healthcare
• Adam Clark, Lance Armstrong Foundation
• Art Davidson, Denver Public Health Department
• Connie Delaney, University of Minnesota, School of Nursing
• Paul Egerman, retired CEO
• Judith Faulkner, Epic Systems Corp.
• Gayle Harrell, Former Florida State Legislator
• Charles Kennedy, WellPoint, Inc.
• Michael Klag, Johns Hopkins University, Bloomberg School of Public Health
• David Lansky, Pacific Business Group on Health
• Deven McGraw, Center for Democracy & Technology
• Marc Probst, Intermountain Healthcare
• Latanya Sweeney, Carnegie Mellon University
• Micky Tripathi, Massachusetts eHealth Collaborative
• Charlene Underwood, Siemens
• Scott White, 1199 SEIU Training & Employment Fund
ONC Lead:
• John Glaser
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• Ultimate vision is to enable significant and measurable
improvements in population health through a
transformed health care delivery system.
• Key goals*:
– Improve quality, safety, & efficiency
– Engage patients & their families
– Improve care coordination
– Improve population and public health; reduce disparities
– Ensure privacy and security protections
*Adapted from National Priorities Partnership. National Priorities and Goals: Aligning Our Efforts
to Transform America‟s Healthcare. Washington, DC: National Quality Forum; 2008
Health IT and Transformed Health Care
Data capture and sharing
Advanced clinical processes
Improved outcomes
Bending the Curve Towards Transformed Health Achieving Meaningful Use of Health Data
“Phased-in series of improved
clinical data capture supporting
more rigorous and robust quality
measurement and improvement.”
“These goals can be achieved
only through the effective use
of information to support better
decision-making and more
effective care processes that
improve health outcomes and
reduce cost growth”
Connecting for Health, Markle Foundation “Achieving the Health IT Objectives of the American Recovery and
Reinvestment Act” April 2009
• $20 Billion allocated to individual physician (non
hospital based) incentives to purchase qualified
EHR’s that
• meet Meaningful Use criteria
• Are certified
• Report specific criteria to CMS
• Based on amount of billable charges for Medicare
billed through EHR’s
• Maximum of $44,000 per physicians over 5 year
period if adopt before December 31, 2012
• Incentives begin in January 2011
10
HITECH Incentive Program
• Incentives for Medicaid physicians
• Non hospital based
• 30 % of patient base must be Medicaid
• 20 % of patient base must be Medicaid –
Pediatricians
• 20 % of patient base must be Medicaid – Federally
Qualified Health Centers
• 30 % of patient base must be Medicaid - Rural
Health Centers
• Up to $ $63,750 over 5 years
• Can not qualify for both Medicare and Medicaid
incentives 11
HITECH Incentive Program
• Medicare EP’s
– $44,000 Distributed over 5 years
– First year may receive up to $18,000
– Second year may receive up to $12,000
– Third year may receive up to $8,000
– Fourth year may receive up to $4,000
– Fifth year may receive up to $ 2,000
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HITECH Incentive Program
• Physicians who adopt after 2012 will
receive less incentive reimbursement
• If first payment year is $15,000 instead of
$18,000
• Subsequent payments $12,000, $8,000
$4,000 and $2,000
• If adopt EHR will not receive additional
incentives for E-prescribing
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HITECH Incentive Program
• Penalties for non adoption begin in 2015
• 1% reduction in Medicare payments in 2015
• 2% reduction in Medicare payments in 2016
• 3$ reduction in Medicare payments in 2017
• Secretary of HHS has authority to increase
penalties up to 5% following 2017
• Hardship exemptions only apply for 5 years
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HOW WILL HITECH IMPACT A PRACTICE?
CMS Final Rule Stages of Meaningful Use Timeline
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First
Payment
Year
CY 2011 CY 2012 CY 2013 CY 2014 CY 2015
and later**
2011 Stage 1 Stage 1 Stage 2 Stage 2 Stage 3
2012 Stage 1 Stage 1 Stage 2 Stage 3
2013 Stage 1 Stage 2 Stage 3
2014 Stage 1 Stage 3
2015 and
later*
Stage 3
*Avoids payment adjustments only for EPs in Medicare EHR Incentive Program
**Stage 3 criteria of meaningful use or a subsequent update to criteria if one is established
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Medicare & Medicaid Payments for April 2012 DRAFT ESTIMATES ONLY
Providers Paid April-12 LTD
Medicare EPs – Full & Partial Payments
[ESTIMATED] 13,000 57,000
Medicare EPs – HPSA Bonus Payments
[ESTIMATED] 4,200 4,200
Medicaid EPs [ESTIMATED] 4,500 34,400
Medicaid/Medicare Hospitals**
[ESTIMATED] 280 2,250
Total Number of Providers Paid 17,780 93,650
Medicare & Medicaid Payments
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Medicare & Medicaid Payments for April 2012 DRAFT ESTIMATES ONLY
Payments April-12 LTD
Medicare EPs – Full & Partial Payments [ESTIMATED] $150,000,000 $942,000,000
Medicare EPs – HPSA Bonus Payments
[ESTIMATED] $7,000,000 $7,000,000
Medicaid EPs [ESTIMATED] $94,000,000 $722,000,000
Medicaid/Medicare Hospitals (Medicare Pymt) [ESTIMATED] $130,000,000 $1,700,000,000
Medicaid/Medicare Hospitals (Medicaid Pymt) [ESTIMATED] $205,000,000 $1,669,000,000
Total $586,000,000 $5,040,000,000
ACHIEVING MEANINGFUL USE
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2009 2011 2013 2015
HIT-Enabled Health Reform
Me
an
ing
ful U
se
Cri
teria
HITECH
Policies 2011 Meaningful
Use Criteria
(Capture/share
data) 2013 Meaningful
Use Criteria
(Advanced care
processes with
decision support)
2015 Meaningful
Use Criteria
(Improved
Outcomes)
HIT-Enabled Health (Medicaid) Reform Achieving Meaningful Use and COST CONTAINMENT
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• EPs
– 25 Objectives and Measures
– 8 Measures require „Yes‟ or „No‟ as structured data
– 17 Measures require numerator and denominator
• Eligible Hospitals and CAHs
– 23 Objectives and Measures
– 10 Measures require „Yes‟ or „No‟ as structured data
– 13 Measures require numerator and denominator
• Reporting Period – 90 days for first year; one year
subsequently
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CMS Final Rule Meaningful Use Stage 1 Summary
Principles Guiding Development of Recommendations for
Stage 2 Meaningful Use
• Positioning stage 2 as stepping stone to stage 3
– Provides trajectory and roadmap
• Move towards outcomes, where possible
• Parsimony
• Ensure functionality “floor”
• Promote innovation
• NPRM issues, Comment Period ended May 7, 2012
• Final Rule due mid summer
Stage 2 Escalator Principle: Slope = Rise/Run
Add in key
elements of
NQS/delivery
system reforms
Exchanging Data:
Key to Cost
Containment
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• More than 40 percent of outpatient visits involve a
transition
• Almost three quarters of the time (73 percent) PCPs do
not get discharge info within two days. Almost always
sent by paper or fax (2009, Commonwealth)
• Referring physicians receive feedback from consultants
only 55 percent of time
• Physicians make purpose of referral clear 74 percent of
time
• 1 in 5 discharged Medicare enrollees is readmitted with a
month
Exchanging Data: Key to Cost Containment
We Are …
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Receipt of Discharge Information by PCPs
*Respondents could select multiple responses. Base excludes those who
do not receive report. Source: 2009 Commonwealth Fund International
Health Policy Survey of Primary Care Physicians.
27%
Less than 48 Hours
29%
2 to 4 Days
26%
5 to 14 Days
1%
More than 30 Days
6%
Rarely/Never Receive Adequate Support
4%
Not Sure/Decline to Answer
15 to 30 Days
6%
Time Frame (n=1,442)
62%
Fax
30%
8%
Remote Access
15%
1%
Not Sure/ Decline to Answer
11%
Other
Delivery Method (n=1,290)*
19 percent of hospitals
are exchanging clinical
care records with
ambulatory providers
outside system (2010)
Exchanging Data: Key to Cost Containment
Exchanging Data: Key to Cost Containment
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Poised to grow rapidly, spurred by new payment approaches
• New payment models are the business case for exchange
• More than 70 percent of hospitals plan to invest in HIE services
(2011, CapSite)
• Number of active “private” HIE entities tripled from 52 in 2009 to 161
in 2010 (KLAS)
Many approaches and models
• In addition to RHIOs, many other approaches emerging, including
local models advanced by newly emerging ACOs, exchange options
offered by EHR vendors, and services provided by national
exchange networks
• Seeing a full portfolio of exchange options, meeting different needs
Exchanging Data: Key to Cost Containment
Stage I - ePrescribing
- Lab results into EHRs
- Send clinical summary
to providers and patient
- Public health reporting
- Quality reporting (2012)
Stage 2 - Patient PHR access
- ePrescribing refills
- Electronic summary record
- Receive health alerts
- Immunization information
Stage 3 - Access comprehensive patient data
- Automated real-time surveillance
Goal: This is part of an evolutionary path There will be incremental growth All journeys start with a few steps
Strength of health information exchange objectives in
current version of MU rises substantially by 2014
• Lab results delivery
• Prescribing
• Claims and eligibility checking
• Quality & immunization reporting, if
available
2011
Increases volume of transactions that are most
commonly happening today
– Lab to provider
– Provider to pharmacy
• Patient: education info
• Electronic clinical summary & care plan
•Care Team members
• Secure messaging
•Lab orders & structured lab results in
LOINC
• HP – Discharge instructions
• > e-Prescribing to 50%
• Patient ability to download PHI
2013
Substantially steps up exchange
– Provider to lab
– Pharmacy to provider
– Office to hospital & vice versa
– Office to office
– Hospital/office to public health & vice versa
– Hospital to patient
– Office to patient & vice versa
– Hospital/office to reporting entities
• Access comprehensive data from all
available sources
• Experience of care reporting
• Medical device interoperability
2015 Starts to envision routine availability of
relatively rich exchange transactions
– “Anyone to anyone”
– Patient to reporting entities
Meaningful Use objectives requiring health exchange
EXCHANGING PATIENT DATA
Vocabulary/ Document/
Message Standards Directories
Authentication /
certificates Delivery Protocols
Security
Trust Relationships
Team
convened to
solve problem
Solutions
& Usability
Accuracy &
Compliance
Enable
stakeholders
to come up
with simple,
shared
solutions to
common
information
exchange
challenges
Curate a
portfolio of
standards,
services, and
policies that
accelerate
information
exchange
Enforce compliance with
validated information
exchange standards,
services and policies to
assure interoperability
between validated systems
Achieving Interoperability
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Value
Cost
Trust
• Standards: identify and urge adoption of scalable, highly
adoptable standards that solve core interoperability issues
for full portfolio of exchange options
• Market: Encourage business practices and policies that
allow information to follow patients to support patient care
• HIE Program: Jump start needed services and policies
• Payment reforms
• Professional & patient
expectations
• Meaningful use
Identify and urge adoption of policies needed for trusted
information exchange
ONC Role
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• The Direct Project began as an independent, open government project to specify a standard for secure, directed health information exchange.
• More than 35 vendors implemented Direct by Fall of 2011, with several more (10 at last count, but the count is old) publicly announcing that Direct specifications are included in their product roadmap .
• Direct is part of the core strategy of 40+ State HIE Grantees, 4 of whom already started implementing it in late 2011
Exchanging Data with DIRECT
Direct Project Metrics - Ecosystem
Direct Project Ecosystem Survey
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Exchanging Data with DIRECT
NwHIN Direct
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A project to create the set of
standards and services that
with a policy framework enable
simple, directed, routed,
scalable transport over the
Internet to be used for secure
and meaningful exchange
between known participants in
support of meaningful use
NwHIN Exchange
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Exchange is currently operational and demonstrating value to participants,
including:
Federal agency benefit determination is expedited (shortened turnaround time by 45%)
Expedited benefit payments to disabled
Improved benefits in clinical decision making, including avoiding prescribing multiple narcotics
based on information shared
As of January 2012, 22 organizations are exchanging data in production,
representing:
500 hospitals
4,000+ provider organizations
30,000 users
1 million shared patients
Population coverage~65 million people
90,000 transaction as of Sept 2011, and growing dramatically each month
Exchange CC is developing business and transitional plan to guide the
Exchange to a sustainable, scalable and efficient public-private model
Exchange can serve as basis for HIE innovation and critical element in
nationwide health information infrastructure
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Current Exchange Activities Alaska HIE and Medical
University of South Carolina
(MUSC) in conformance testing
phase
Quality Health Network (QHN)
has completed Conformance
testing and currently in the
Interoperability testing phase
Health Information Partnership
for Tennessee (HIP-TN) and
Redwood MedNet are preparing
for conformance testing
• NRAA is currently working on
setting up their production
environment (partner with CMS)
Number of Organizations in
Production
Number of Organizations
currently On Boarding
Estimated Number of Organizations in Production for Q1-
2012
22 (14 Federal, 6 HIEs, 2
Beacons)
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Federal: An organization that is a Federal Agency or has a contract or other agreement with a Federal Agency.
HIE: An organization that is part of a State HIE or has a cooperative agreement with a State HIE
Beacon: An organization that received grant money for the program
Exchange Organizations in Production
Summary
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• Journey to 21st century transformed health system
requires
– Meaningful use of transformation-capable HIT,
– Real exchange of data
– Standards that provide true interoperability
– and the confidence of the public that the system is secure and
will protect their privacy
• ARRA makes a major investment in HIT
– Over $44 Billion of taxpayer dollars will be spent
– One opportunity to do it “right”
• HIT saves lives and money while improving care.
QUESTIONS AND DISCUSSION
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