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Michael Lundberg, Executive Director
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VHI’s MissionVHI’s Mission
To create and disseminate health care information
To promote informed decision making by Virginia consumers and purchasers, and
To enhance the quality of health care delivery
VHI Represents VHI Represents all Health Care Stakeholdersall Health Care Stakeholders
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VHI is an independent, nonprofit,
501(c)(3) health information
organization established in 1993
Formed to administer Virginia
Health Care Data Reporting
Initiatives to benefit Virginians
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VHI Publishes Business and Consumer Guides, Reports and VHI Publishes Business and Consumer Guides, Reports and Information at Information at www.vhi.orgwww.vhi.org
Information VHI Collects & PublishesInformation VHI Collects & Publishes
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APCD Implementation ProcessAPCD Implementation Process
Source Data to Milliman for Initial
Review
Send Threshold Results to Data Submitters
Complete Data Mapping and Data
Audit
Data Roll-Up and Validation Complete
Data Available To Customer
Membership (Patient, Group,
Provider)
Medical Claims Data
Pharmacy Data
MEDINSIGHT DATA
WAREHOUSE
Other Data
We are Here
Slide 8
APCD Quality AuditsAPCD Quality Audits
Exemption Summary May 2015Exemption Summary May 2015
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Field Level Exemptions
Provider DEA Number 27
Provider State License Number 25
Provider Specialty 23
Provider Office Zip 19
Provider Office State 19
Categories of Exemption
Accommodation for historical data 29
Improvement plan in place 49
Not applicable for Medicare/Medicaid 42
Not collected 82
Submitted when collected 216
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MedInsight® Analytic PlatformMedInsight® Analytic Platform
Population and benefit driven including:
Age Gender Geography Benefit design
Benchmark detail: DRG Procedures Drugs Episodes Chronic conditions
Based on Milliman Health Research Database of 45M members
Methodologies Benchmarks
*Courtesy of Milliman MedInsight
• Health Cost Guidelines• Evidence Based Measures• Milliman Advanced Risk Adjustors• Chronic Conditions Hierarchical Groups
(Disease Identification)• Global RVUs (Standardized Proxy
Reimbursement)• Member and Provider Crosswalking• Provider Attribution• Provider Affiliation into Group Practices • NYU Avoidable Emergency Dept. visits• Episode Grouping - Truven MEGs
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Milliman, Top-ranked for H.C. Industry AnalyticsMilliman, Top-ranked for H.C. Industry Analytics
Section 4.3 – Scope – Data Submission: Section 4.3 – Scope – Data Submission:
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Amendment to Data Submission and Use Agreement. Each of the plans that participates in the APCD executed a Data Submission and Use Agreement (“DSUA”) with VHI effective as of January 1, 2013. The enclosed draft Amendment to the DSUA is intended to amend the original DSUA as follows:
1. The DSUA currently provides that Data Suppliers are not required to submit Data Claims files related to Medicare Advantage or FEHBP. However some of the plans have submitted claims data related to both Medicare Advantage and FEHBP. VHI suggests that the parties remove the exclusion of Medicare Advantage data and change the language surrounding FEHBP data to include such data unless the US OPM otherwise prohibits its inclusion.
2. Section 4.3 requires each participating plan to submit to VHI an updated Health Plan Adoption Form in the form of Schedule A to the Amendment. As you will recall, each plan submitted a similar form at the time the DSUA was executed.
The new form provides more examples of categories of types of business in response to questions to Data Suppliers. See next slide
Revised form for determining % of population covered by APCDRevised form for determining % of population covered by APCD
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Could be revised to indicate covered Virginia resident lives to clarify differences between this and reporting to SCC.
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Section 5.1 (e) – Uses and Disclosures; Section 5.1 (e) – Uses and Disclosures; Review Period and CorrectionsReview Period and Corrections
Adds the phrase “to the general public”
to clarify that Reports can be released to
the Data Suppliers and Data Subscribers
prior to the expiration of the 60 day
review period provided their use of the
data is otherwise in compliance with the
DSUA or DSA, as applicable.
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Section 7.1 – Term. Section 7.1 – Term.
Extends the term of the Agreement from July
1, 2015 through June 30, 2018 to match the
updated APCD Expense Budget.
Exhibit 2 (2015) – Business Associate
Agreement. The form of Business Associate
Agreement executed between VHI and each
of the Data Suppliers has been updated to
incorporate certain changes from the HIPAA
Omnibus Rule.
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Exhibit 3 (2015) – Data Subscriber AgreementExhibit 3 (2015) – Data Subscriber Agreement
The form of Data Subscriber Agreement (“DSA”) attached to the original DSUA as
Exhibit 3 has been revised as follows:
Section 2.C. - Rights on Termination of License: Adds more specific requirements and processes for return or destruction of De-Identified Data or reports when a DSA is terminated.
Section 3.B. – Disclosure of De-Identified Data: Adds language to ensure that subcontractors or independent contractors of Data Subscribers are bound to a Confidentiality Agreement restricting their use and disclosure of data and further confirms that written permission from VHI is necessary for disclosures to third parties.
Section 3.E – Responsibility for Data Subscriber’s Users and Unauthorized Users. Adds language to specifically prohibit any attempt by Data Subscribers or their Users or agents to identify individuals whose data resides in the APCD.
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Exhibits to Data Subscriber AgreementExhibits to Data Subscriber Agreement
Exhibit A to DSA - Data Subscribers Authorized Users to APCD: Exhibit A was
revised to allow for more detailed User and contact person information.
Exhibit B to DSA – Vendor Confidentiality Agreement: This new Exhibit is
the form of Confidentiality Agreement that Data Subscribers are required to
enter into with “vendors” – their subcontractors and independent
contractors (accompanies changes to language in Section 3.B.).
Exhibit C to the DSA - Equipment Specifications: Additions to this Exhibit
detail minimum computer equipment specifications for access to online
system.
Exhibits to Data Subscriber Agreement - Exhibits to Data Subscriber Agreement - ContinuedContinued
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Exhibit 4 (2015) – Permitted Uses of Actual Reimbursement Data: This
revised Exhibit retains the prohibition on disclosure of provider-specific,
facility-specific or payer-specific reimbursement information or any
information capable of being reverse-engineered, combined, or otherwise
used to calculate or derive such reimbursement information.
However to assist in measuring the impact of VDH population health improvement efforts, reports may currently be generated by VHI for VDH on the cost burden of a disease, chronic disease, injury or health condition across the state and by Health Planning Region.
The revision, requested by VDH expands the geographic areas to also include as appropriate Health Planning District, City, County or Zip Code as long as the prohibitions described above are adhered to.
Section 6.1 – FundingSection 6.1 – Funding
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Section 6.1 - Funding: this section has been updated since initially provided to Data Suppliers and reflects a reduction in the subcontract with Milliman.
As now modified, this section will be revised to updates the Data Supplier’s individual APCD expense funding obligation for the 36 month period commencing July 1, 2015. New Section 6.1 provides that the Data Supplier’s aggregate funding obligation for the 36 month period is $ 189,976. As you may know, pursuant to the Participation Agreement, the plans that chose to participate in the APCD were responsible, as a group, to fund 40% of the APCD expense budget for the initial 30 months of the APCD.
At the time that the DSUA’s were prepared, it was believed that 10 plans would participate; however only 9 plans ended up participating. As a result, the funding provided by the participating plans for the initial 30 months of the APCD was short of the plans’ aggregate 40% obligation.
The $189,976 includes a one-time, catch-up payment of $14,591 and 12 quarterly payments of $14,615 (assuming only 9 plans participate). In the event 10 plans participated each plans allocable portion of the expense would be reduced to $170,978 ($13,153 per quarter).
1st Contract vs Renewal Contract Costs by Stakeholder Group 1st Contract vs Renewal Contract Costs by Stakeholder Group
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VAHP VHI VHHA
Individual Member Payment
(Quarterly)*
Individual Member
Payment (Total)
Total for all Members Quarterly Total Quarterly Total
1st Contract- 30 months (1/1/2013-
6/30/2015) $ 14,584.44 $ 145,844.44 $ 1,312,600.00 $ 65,630.00 $ 656,300.00 $ 131,260.00 $ 1,312,600.00
Renewal- 36 months (7/1/15-6/30/18) $ 14,615.42 $ 175,385.07 $ 1,578,465.60 $ 65,769.00 $ 789,232.80 $ 131,538.00 $ 1,578,465.60
% Difference 0.2% 20.3% 20.3% 0.2% 20.3% 0.2% 20.3%
*1st Contract number includes 1 time catch up as 10 health insurance companies were budgeted but 9 plans actually participated
Category
FY 2016 Ongoing Development,
Submission of Data, Operation and
Reporting
FY 2017 Ongoing Development,
Submission of Data, Operation and
Reporting
FY 2018 Ongoing
Development, Submission of
Data, Operation and Reporting
Totals
Legal $29,000 $25,000 $25,000 $79,000
VHI Staff-Existing 2.5 FTEs: Analyst, Program Manager, Sr. Management/Indirect
389,241 327,615 343,995 $1,060,851
Data Processing and Analytics – negotiated amount
906,000 $906,000 $906,000 $2,718,000
Travel $3,500 $3,500 $3,500 $10,500
Insurance- based on current amounts $25,000 $25,250 $27,563 $77,813
Totals $1,352,741 $1,287,365 $1,306,058 $3,946,164
REVISED APCD Budget for FY 2016 – 2018 (July 1, 2015-June 30, REVISED APCD Budget for FY 2016 – 2018 (July 1, 2015-June 30, 2018) 2018)
Category Total 30 Month Budget
(Jul 11-Jun 15) Actual Direct Expenses as of
May 19, 2015 with projections and indirect
$ Difference
Budget vs Actual
% Difference Actual to Budget
*Data Processing – subject to vendor contract negotiations $ 1,600,000 $ 764,250 $ 835,750 -52%
Consultants- RFP development & evaluation for data processing, hosting & analytics $ 70,000 $ 46,450 $ 23,550 -34%
Analytics – reports, access to data, data extracts – subject to vendor contract negotiations $ 1,000,000 $ 764,250 $ 235,750 -24%
Travel $ 4,500 $ 4,698 $ (198) 4%
*VHI Staff-Existing 1st 6 months Up to 2 FTEs + .35 for second and third twelve month periods $ 562,000 $ 812,160 $ (250,160) 45%
Legal- for Data Submission and Use Agreements $ 45,000 $ 150,878 $ (105,878) 235%
Accounting (indirect of non-restricted) unbudgeted $ 3,749 $ 3,749 unbudgeted
Depreciation (indirect of non-restricted) unbudgeted $ 14,164 $ (14,164) unbudgeted
Insurance (direct for E&O, indirect of non-restricted) unbudgeted $ 62,727 $ (62,727) unbudgeted
Marketing (indirect of non-restricted) unbudgeted $ 3,004 $ (3,004) unbudgeted
Office Expenses (indirect of ie copier, graphic design & printing, network, postage, building, supplies, website) unbudgeted $ 2,068 $ (2,068) unbudgeted
Consultants (indirect of database mgr & govt relations) unbudgeted $ 27,209 $ (27,209) unbudgeted
Total $ 3,281,500 $ 2,655,607 $ 633,392 -19%
Minus Health Plan Unbilled $ (131,260)
Adjusted Total $ 3,150,240 $ 2,655,607 $ 494,633 -16%
Budget for Thirty Month APCD Expenses Comparison to Actual Budget for Thirty Month APCD Expenses Comparison to Actual Amount SpentAmount Spent
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Next StepsNext Steps
VHI will incorporate any revisions to the documents and send them to representatives.
Please review each of the referenced documents in their entirety. Upon acceptance, please:Execute the Amendment to the Data Submission and Use Agreement;
Complete the Health Plan Adoption Form attached to the Amendment as Schedule A;
Execute the Business Associate Agreement attached to the Amendment as Exhibit 2 (2015); and
Return the foregoing documents to Wyatt Beazley at [email protected]
Closing RemarksClosing Remarks
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Budget for Thirty Month APCD Expenses Budget for Thirty Month APCD Expenses Comparison to Actual Amount SpentComparison to Actual Amount Spent
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Category
1st Six months After Signing of Data Submission and
Use Agreements*
(Jul 13-Jun 14) Next 12 months
Development , Submission of Data,
Operation and Report Design
(Jul 14-Jun 15) Next 12 months of
Operation and Report
Development
Total 30 Month Budget
(Jul 11-Jun 15) Actual Direct
Expenses as of May 19, 2015 with
projections and indirect
% Difference Actual to Budget$ Difference Budget
vs Actual
*Data Processing – subject to vendor contract negotiations N/A $ 800,000 $ 800,000 $ 1,600,000 $ 764,250 $ 835,750 -52%
Analytics – reports, access to data, data extracts – subject to vendor contract negotiations N/A $ 500,000 $ 500,000 $ 1,000,000 $ 764,250 $ 235,750 -24%
Consultants- RFP development & evaluation for data processing, hosting & analytics $ 30,000 $ 25,000 $ 15,000 $ 70,000 $ 46,450 $ 23,550 -34%
Travel $ 1,500 $ 1,500 $ 1,500 $ 4,500 $ 4,698 $ (198) 4%
*VHI Staff-Existing 1st 6 months Up to 2 FTEs + .35 for second and third twelve month periods $ 62,000 $ 250,000 $ 250,000 $ 562,000 $ 812,160 $ (250,160) 45%
Legal- for Data Submission and Use Agreements $ 25,000 $ 10,000 $ 10,000 $ 45,000 $ 150,878 $ (105,878) 235%
Accounting (indirect of non-restricted) $ 703 $ 1,479 $ 1,567 unbudgeted $ 3,749 $ 3,749 unbudgeted
Depreciation (indirect of non-restricted) $ 3,373 $ 5,327 $ 5,465 unbudgeted $ 14,164 $ (14,164) unbudgeted
Insurance (direct for E&O, indirect of non-restricted) $ 1,300 $ 31,747 $ 29,680 unbudgeted $ 62,727 $ (62,727) unbudgeted
Marketing (indirect of non-restricted) $ 538 $ 1,296 $ 1,170 unbudgeted $ 3,004 $ (3,004) unbudgeted
Office Expenses (indirect of ie copier, graphic design & printing, network, postage, building, supplies, website) $ 18,545 $ 36,043 $ 32,088 unbudgeted $ 2,068 $ (2,068) unbudgeted
Consultants (indirect of database mgr & govt relations) $ 4,258 $ 10,842 $ 12,108 unbudgeted $ 27,209 $ (27,209) unbudgeted
Total $ 147,216 $ 1,673,234 $ 1,658,579 $ 3,281,500 $ 2,655,607 $ 633,392 -19%
Minus Health Plan Unbilled $ (131,260)
Adjusted Total $ 147,216 $ 1,673,234 $ 1,658,579 $ 3,150,240 $ 2,655,607 $ 494,633 -16%
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APCD Heath Plan FundingAPCD Heath Plan Funding
9 plans 10 plans
VAHP Total 1,578,465.60 1,578,465.60
Per plan 175,385.07 157,846.56
Plus 1 time payment 189,976.07 170,978.46
APCD Budget FY16-18 36 Months VHHA (40%) VAHP (40%) VHI (20%)
FY16 1,352,741.00 541,096.40 541,096.40 270,548.20
FY17 1,287,365.00 514,946.00 514,946.00 257,473.00
FY18 1,306,058.00 522,423.20 522,423.20 261,211.60
Total 3,946,164.00 1,578,465.60 1,578,465.60 789,232.80
# of Plans # of Payments 1x Payment 12x Total 12x-1x Total Total
(36 months)
9 12 14,591.00 14,615.42 175,385.07 189,976.07 1,709,784.60
10 12 13,131.90 13,153.88 157,846.56 170,978.46 1,709,784.60
Total 131,320.00
Plus One Time $131,319.00
Total 1,709,784.60