All Payer Claims Database and Health Information Exchange ARRA Opportunities and Challenges

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All Payer Claims Database and Health Information
Exchange ARRA Opportunities and Challenges

• Anthony Rodgers, Director
• Arizona Health Care Cost Containment System

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Challenges of Linking Health Information
Exchanges with All Payer Administrative and
Clinical Data Bases
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The Connected Healthcare System
Hospital Care Coordination
Diagnostics
Specialist Referral
Primary Care Medical Home Provider
Order Entry Lab Result Reporting
EHR/HIE
Research Comparative Effectiveness
E-Prescribing
Remote Patient Self Monitoring
MCO Medical Medical Mgmt. Administrative Data
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Rational for Building a Clinical Administrative
Data Repository

• Facilitates Cost and Quality Transparency
• Essential for Continuity of Care Records
• Facilitates Population Health Management
• Improves Medical Management
• Improve Program Evaluation and Decision Making
• Facilitates Comparative Effectiveness Research
• Enhances Health Policy Formulation Simulation

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Focus Building the State Level HIT Infrastructure
EHR1
HIE
EHR2
EHR3
EHRn
Labs
EHR1
EHR2
EHR3
Rxs
EHR4
PHR5
Aggregated Clinical Database
Other
PHRn

• Repository Couple with HIE

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Basic Health Information Exchange with Data
Repository
Clinical Data Repository
HIE
Interfaces
HIE Utility Applications
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Federated Model for Data Exchange
Distributed Data Marts
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Health Information Exchange Platform Architecture
Collaborative Knowledge Management
Value Added Web Services
Web Services Application
Data Analysis Applications
Security and Consent Policy
Health Data Integration and Translation Layer
Platform Services
Health Data Management Layer
Health Data Publication Layer
Radiology



Clinical Lab
Data Sources
Administrative
EHR
Rx History
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HIT Infrastructure Platform Design
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Mapping Data Partners and Data Utilities
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Administrative Data Sets
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Methodology for Reconciling Encounter Data
Completeness

• Number Claims Converted to encounters
• New day encounters
• Adjudicated new day encounter
• Pended encounter
• Resolved pended encounter
• Total adjudicated and percent adjudicated
• Paid member months
• Claims per member per month
• Adjudicated encounter per member month

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Methods of Aggregating Data

• There are four different form types of
  claims/encounters types
• ? HCFA 1500 Encounters (Form A) - Used primarily
  for professional services, including physician
  visits, nursing visits, surgical services,
  anesthesia services, laboratory tests, radiology
  services, home and community based services,
  therapy services, Durable Medical Equipment
  (DME), medical supplies and transportation
  services. Services must be reported using
  appropriate HCPCS procedure codes.
• ? UB-92 Encounters (Form B) - For facility
  medical services, such as inpatient or outpatient
  hospital services, dialysis centers, hospice,
  nursing facility services, and other
  institutional services. Services must be
  reported through the use of revenue codes and
  bill types.
• ? Universal Drug Encounters (Form C) - For
  prescription medicines and medically necessary
  over the counter items.
• ? Dental Encounters (Form D) - For dental
  services.

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UB92 Encounter Types

• Beneficiary member ID
• Service provider ID
• Bill type
• Total bill amount (from the last encounter detail
  line containing revenue code 001)
• Service begin date
• Service end date

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Breakdown of Key Data ElementsHCFA 1500,
Universal Drug Encounters, Dental EncountersKey
Encounter Fields

• Beneficiary member ID
• Service provider ID
• Procedure code
• National Drug Code (Form Drug only)
• Procedure modifier (HCFA 1500 only)
• Diagnosis code (Form HCFA 1500 only)
• Service begin date
• Service end date
• Tooth number (Form Dental only)
• Tooth surface number (Form Dental only)

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Common Claims Data Fields

• Coding definitions are provided for the following
  data fields
• Admission Types
• Admission Source
• Bill Type Codes
• Category of Service
• County Codes
• Diagnosis Codes
• EPSDT Type Codes
• Patient Status
• Pharmacy Codes (NDC)
• Place of Service Codes
• Procedure Codes
• Procedure Modifier Codes
• Revenue Codes
• Sub-capitation Codes
• Units of Service

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Provider Data Sets

• For each provider, the following information is
  included
• Provider Demographic data
• Provider status
• Categories of service type
• Service rates
• Licenses/certifications
• Specialties
• Medicare coverage
• Restrictions
• Service/billing addresses

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Provider Types

• 19ARespiratory Therapist
• 20ANursing Home
• 22BHome Health Agency
• 23APersonal Care Attendant
• 24AGroup Home (Developmentally Disabled)
• 25AAdult Day Health
• 27ANon-Emergency Transportation Providers
• 28ACommunity/Rural Health Center
• 29ADME Supplier
• 30AOsteopath
• 31ARehabilitation Center
• 33AHospice
• 35BAdult Care Home
• 36AHomemaker
• 37ADevelopmentally Disabled Day Care

• 01 Hospitals
• 02BPharmacy
• 03CLaboratory
• 04AClinic
• 05AEmergency Transportation
• 06ADentist
• 07DPhysician
• 08ANurse-Midwife
• 09APodiatrist
• 10APsychologist
• 11ACertified Registered Nurse Anesthetist
• 12AOccupational Therapist
• 13APhysical Therapist
• 14ASpeech/Hearing Therapist
• 15AChiropractor
• 16ANaturopath
• 17APhysicians Assistant

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Categories of Services

• 01Medicine
• 02Surgery
• 03Respiratory Therapy
• 05Occupational Therapy
• 06Physical Therapy
• 07Speech/Hearing Therapy
• 08EPSDT
• 09Pharmacy
• 10Inpatient Hospital (Room Board and ancillary)
• 11Dental
• 12Pathology Laboratory
• 13Radiology
• 14Emergency Transportation
• 15DME and Appliances
• 16Out-Patient Facility Fees
• 17ICF
• 18SNF
• 19ICF/MR

• 20Hospice Inpatient Care
• 21Hospice Home Care
• 22Home Delivered Meals
• 23Homemaker Service
• 24Adult Day Health Service
• 26Respite Care Services
• 27IHS Outpatient Services
• 28Attendant Care29Home Health Aid Service
• 30Home Health Nurse Service
• 31Non-Emergency Transportation
• 32Habilitation
• 37Chiropractic Services
• 39Personal Care Services
• 40Medical Supplies
• 42DD Programs (DD Day Care Programs)
• 44Home Community Based Services (Other)
• 45Rehabilitation46Environmental
• 47Mental Health Services
• 48Licensed Midwife

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Methodology Aggregating Data for Categories of
Service Report

• By creating a two-digit coding definition called
  a Category Of Service (COS) can perform cost and
  utilization comparisons. The COS is determined
  based on an encounters procedure code, bill
  type, revenue code, or pharmacy NDC code. This
  is not part of the encounter but is determined by
  the business user.
• For HCFA-1500 and Dental encounters, the COS
  assignment is determined by the range or
  description of each HCPCS procedure code.
• For example, AHCCCSA assigns COS 12 (pathology
  laboratory) to HCPCS procedure code G0001
  (Routine venipuncture of finger/heel/ear for
  collection of specimen/s).
• For UB-92 encounters, the COS assignment is
  based on the bill type and revenue codes used on
  the individual encounter.
• For Universal drug form encounters, the COS is
  based on the NDC code. A current list of the
  AHCCCSA assigned COS is summarized in the
  following table.

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Cost Performance Score by MCOHypothetical
Illustration
Significant Lower Cost per EPC
Expected Cost Performance
Low PI Means Higher than Expected Cost per EPC
Performance Index equals the Expected Paid
divided by the Actual Paid and is controlled by
ETG Case mix.
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Cost and Quality Value Performance
(hypothetical illustration)
Value Performance Target
Low Cost But Low Quality Outcome
High Quality but High Cost
Cost Target
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Enterprise Level Data Repository and Decision
Support Infrastructure

• Methods/Analytics
• Episodes of Care
• Performance Measures
• Disease Staging

Decision Support Reporting Applications
External Data / Profiles
Public Health
Evidence-Based Medicine
Medical Management

• Data Management
• Process
• Security Protection
• Integration
• Translation
• Standardization
• Data Validation
• Profile and Screens

Comparative Data Sets
Fraud Detection
Data Warehouse
Data Architecture And Data Cubes
Beneficiary Data Sources
Performance Analysis
Eligibility Analysis
Claims/Encounter
Clinical Data Sets
Cost and Quality Analysis
Demographic Data
Prescription Drug
Chronic Illness Sub-databases Registries
EHR Data
Eligibility Data
Health Plan Provider Decision Support
Program Data
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Creating Key Performance Transparency

• Inpatient Cost and Utilization
• Pharmacy PMPM cost
• Diagnostic PMPM cost
• Percent LTC members in home and community based
  settings
• Bed days and admissions per 1000
• ER Cost and Utilization Per 1000
• Overall for long term care PMPM cost
• Member satisfaction level
• Provider satisfaction level
• Enrollee healthcare access
• Quality of care rates against HEDIS targets
• MCO program cost effectiveness level
• Health plan administrative performance and
  efficiency levels claims and business process
  cycle times and per transaction cost for
  administrative activities (e.g. claims,
  eligibility screening, etc.)

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Map of Strategic Outcomes for EHR Adoption Efforts
Performance Outcomes
Strategic HIT Focus Areas
HIT Strategic Performance Metrics
Reduced Unnecessary Cost/Utilization Reduced
PMPM Lower Admin Cost
Meaningful Use of EHR to reduce Duplication,
Errors and improve Admin Efficiency
Cost Containment
Quality Improvement
Meaningful Use of EHR to better coordinate care
and Quality Performance
Improved Quality Against HEDIS and Other
Benchmarks
Strategic Planning Logic Map
Higher Provider Satisfaction Reduction in
Admin. Cost
Administrative Efficiency
Meaningful use of EHR to Reduce Admin. Process
Cycle Times
Public Health Research
Meaningful Use of EHR to build Population Health
Mgmt. Research
Public Health Responsiveness Reduction in
Health Disparities
Meaningful USE Barrier
PERFORMANCE Management Barrier
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Clinical Data Repository
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Strategies and Approaches

• Big Bang building the mother of all clinical and
  administrative data repositories interface via
  HIE.
• Incremental Start with well defined electronic
  clinical data sets from a common EHR for example
• Build around the Medicaid or other payer claims
  database
• Build a clinical data repository from linked
  EHRs,
• Build a data mart with public health database,
• Build around an integrated hospital system with
  EHR)
• Data Mart to Data Mart Start with a smaller
  distributed data mart approach linking each data
  mart and pull data to run data analysis or other
  applications.
• Centralized Data Warehouse Use clinical data
  repository and administrative data repository
  under the management of a trusted authority.

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New State Level Roles and Responsibilities

• Governors role
• Decide who will lead state level development of
  HIE ( State Designate Entity (SDE))
• Appoint a HIT Coordinator for the state (agency
  level position)
• Assign and accountable party to develop and
  implement Strategic HIT plan for the state
• Ensure effective governance of HIE in the state
• Develop state level directories and enable
  technical services for HIE
• Remove barriers and create enablers for HIE (Lab,
  hospitals, clinicians, health plans, and other
  information data partners)
• Convene stakeholders
• Assure the participation and integration of
  public health programs, Medicaid, and private
  delivery systems in health information exchange
• Assure the development of effective privacy and
  security requirements for HIE
• States will be awarded grants in the range of
  4.0 to 40.0 million.
• (

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New CMS Roles and Responsibilities

• CMSO
• Set expectations for public accountability and
  transparency,
• Develop a Medicaid Roadmap and Strategic
  Framework for wide-spread adoption of EHR
  technology in Medicaid and integrating planning
  with other federal agencies,
• Set overall state Medicaid performance standards,
• Establish the policy and HIT standards for
  Medicaid,
• Provide evaluation and dissemination of best
  practices,
• Participate in national policy and consensus
  standard making bodies,
• Leverage successful HIT Medicaid Transformation
  grantee initiatives and provide continued
  support,
• Support the work of the Multi-Collaborative for
  Medicaid Transformation and other
• Provide adequate technical support for Medicaid
  programs and Medicaid providers

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New Medicaid Roles and Responsibilities

• State Medicaid Agency Role
• Participation in development of a specific State
  roadmap for HIT adoption and use as it relates to
  Medicaid as well as the states plan of HIE,
• Set Medicaid-specific performance goals related
  to EHR technology adoption, use, and expected
  outcome,
• Establish leadership accountability for assuring
  return on investment and provider public
  reporting on clinical quality,
• Arrange or provide technical assistance and
  training of Medicaid providers in planning,
  adoption, and use of EHR,
• Provide forums and opportunities for input from
  stakeholders,
• Collaborate and coordinate with other HIT
  initiatives in the public and private sector,
• Continue to bring successful Medicaid
  Transformation Grant initiatives to scale,
• Initiate, where appropriate, State legislation to
  create legal and regulatory authorities for HIT,
• Ensure existing quality reporting processes are
  aligned

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Questions?