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The Changing Health Care Landscape: Affordable Care Act, Payment Reform and EMR Adoption

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The Changing Health Care Landscape: Affordable Care Act, Payment Reform and EMR Adoption HIPPA-COW Fall Conference Friday October 15, 2010 Karen Timberlake – PowerPoint PPT presentation

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Title: The Changing Health Care Landscape: Affordable Care Act, Payment Reform and EMR Adoption


1
The Changing Health Care Landscape Affordable
Care Act, Payment Reform and EMR Adoption
  • HIPPA-COW Fall Conference
  • Friday October 15, 2010
  • Karen Timberlake
  • Wisconsin Department of Health Services

2
Why Reform is Needed
  • 16 of GDP Spent on Health Care
  • Most of the industrialized world spends less than
    10
  • 50.6 Million People Uninsured
  • 6.6 million lost employer sponsored coverage
  • 5.2 million more enrolled in Medicaid
  • Growth in Premium Crowding out Wage Increases

3
Big Picture Impacts of Reform
  • More than 125,000 Wisconsin citizens will gain
    access to health care
  • More than a million who are underinsured will see
    policies improved and costs reduced
  • Tax credits and lowered costs for small business
    owners
  • Increase affordability of prescription drugs for
    Wisconsins seniors
  • 750 - 980 million Increased federal funding
    saves state taxpayer dollars

4
Office of Health Care Reform
  • Health care reform puts decision making power in
    the hands of the states
  • We can set up health care reform in a way that
    works best for Wisconsin if we act now
  • Our focus is
  • Implementing significant changes taking effect
    right away and begin work on major components of
    reform
  • Raising awareness of reform in Wisconsin
  • Influencing reforms at national level

5
  • Health Insurance
  • Purchasing Exchange

6
Wisconsins Current Insurance Landscape
  • Large group market
  • 95 of large employers in Wisconsin offer health
    care coverage
  • Small group insurance market
  • Less than 40 offer health care coverage
  • Small business employ 1/3 of the states
    workforce (approx. 685,278 individuals)
  • Non-group insurance market
  • Estimated 125K to 150K individuals in non-group
    market
  • Completing survey of market to obtain detail on
    level of benefits offered and premiums charged

7
Guiding Principles
  • Keep it simple
  • One front door
  • Make the exchange truly transformative
  • Dont just do the Minimum
  • Build off regional strengths
  • Recognize regional providers/insurers and allow
    them to effectively compete
  • Focus on customer service
  • Brokers and most community based partners must be
    engaged and part of the solution
  • Coordinate with other existing health care reform
    initiatives
  • Wisconsin Payment Reform Initiative, WHIO, WIRED,
    WCHQ, WHA, WMS and other reform efforts

8
Important Decisions
  • FEDERAL REQUIREMENTS
  • States must prove by January 1, 2013 that they
    will be ready to successfully implement an
    exchange by January 1, 2014
  • If states do not participate the federal
    government will implement an exchange in those
    states
  • STATE OPTIONS
  • WI can establish a state based exchange, or
    partner with other states to create a regional
    exchange
  • WI can structure the governance of the exchange
    as a private, governmental, or quasi-governmental
    entity

9
Important Questions on the Exchange Design
  • Should there be one or two exchanges?
  • How will the exchange be governed?
  • What are most important features for employers?
  • How will the benefit be designed?
  • What role will brokers play in the exchange?
  • How will the exchange advance payment reform?

10
  • PAYMENT REFORM OPPORTUNITIES

11
ACA Creates Opportunities for Payment Reform
  • Exchange will advance payment reform
  • Partner with Medicaid, Medicare, ETF and other
    large payers
  • Create strong economic incentives for insurers
    and providers to better align around value
  • Drive real improvement in health care quality and
    efficiency

12
ACA Creates Opportunities for Payment Reform
  • Medical Homes
  • Medical homes for Medicaid beneficiaries with
    chronic conditions
  • Accountable Care Organizations
  • Incentive payments under Medicaid for
    pediatricians meeting certain criteria such as
    expenditure and services savings and quality of
    care
  • Health Care Quality initiatives
  • Delivery System reform
  • Comparative Effectiveness Research
  • Establish non-profit Patient-Centered Outcomes
    Research Institute
  • Independent Payment Advisory Board
  • Recommend ways to reduce costs in Medicare
    spending, as well as private sector cost growth
    and promote quality
  • Medicare Payment Bundling Pilot Program
  • Incentives to providers to coordinate patient
    care and be jointly accountable for the entire
    episode of care.

13
WHIO Update Data Mart
  • WHIOs Health Analytics Exchange (Data Mart)
    provides the tools to answer key questions about
    health care delivered in Wisconsin
  • WHIO went live with Data Mart V3 in April 2010

WHIO Data Mart V2 vs. Data Mart V3
Data Mart V2 Data Mart V3
Reporting Period 10/1/06 - 9/30/08 10/1/07 - 9/30/09
Members Included 1,507,846 2,651,947
Claims Included 72.7M 136.8M
WI Population 26.8 47.1
Commercial Claims 92 52
Medicaid Claims 0 42
Medicare Claims 8 6
Episodes of Care 7.3M 11.1M
14
MDC Diseases of Total Standard Cost Total Inpatnt Admits Standard Cost per Admission 30 Day Re-admit rate 30 Day Re-admit count
Circulatory System 459,768,184 24,398 18,845 0.09 2,212
Musculoskeletal System and Connective Tissue 335,984,835 20,204 17,620 0.08 1,619
Digestive System 191,815,255 15,818 12,126 0.09 1,451
Respiratory System 151,991,283 12,171 12,488 0.10 1,194
Pregnancy 148,241,587 19,982 7,417 0.03 571
15
Type Of Service Provider Performance Frequency Cost per episode Peer Group Performance Frequency Cost per episode Provider Performance Index
Laboratory 696 40.89 968 52.83 .72 .77
Radiology 129 46.09 228 59.15 .57 .78
Pharmacy 2868 197.38 4626 298.45 .62 .66
16
Condition Category National Standard for Care pts meeting selection criteria for testing of pts receiving test(s) pts not receiving test(s) Frequency national std of care for pts is met
Diabetes (Endocrine) Adults with LDL cholesterol in last 12 mo 155,449 96,904 58,595 0.62
Preventive Breast Cancer Screening 321,126 218,942 102,184 0.68
Cardiology Pts with lipid profile during yr 71,929 28,591 43,338 0.40
17
Measure Practice Group Performance Peer Practice Group Performance Best Practice Provider Group Performance / compliance target
Diabetes Pts with LDL Cholesterol Test in last 12 mo. .97 .80 .97/1.00
Preventative Pts with Mammogram screening in last 12 mo. .71 .81 .95/1.00
Cardiology Pts with lipid test in measurement year .87 .77 .93/1.00
18
WHIO Update Health Reform
  • Wisconsin Payment Reform Initiative (WPRI)

WPRI Workgroup Pilot Condition Subgroups
Acute Care Knee Replacement Quality, Efficiency, Outcomes Measures for recommended for knee replacement Payment Model Recommendations and Questions Pilot Metrics and Site Selection Recommendations
Chronic Care Diabetes Childhood Asthma Pilot Measures and Payment Methodology Pilot Metrics and Site Selection
Preventive Care Composite Measures of Breast, Cervical and Colorectal Cancer Screenings (adult) Childhood Immunizations Blood Pressure Screening Obesity Screening (pediatric) Payment Model Recommendations and Questions
19
  • WHY THIS MATTERS TO WISCONSIN

20
Important Public Health Investments
  • Wisconsin has work to do
  • 43 of adults fail to meet physical activity
    recommendations
  • 76 do not consume 5 or more fruits or vegetables
    per day
  • 22 of women 40 and older hadnt had a recent
    mammogram
  • 36 of men over 50 have never had a colonoscopy
  • 19.8 of adults still smoke
  • 65 of adults are overweight or obese
  • Health care reform goes beyond direct treatment
    for disease and also focuses heavily on
    prevention.
  • Many synergies with Healthiest Wisconsin 2020
  • http//dhs.wisconsin.gov/hw2020/report2010.htm

21
General Wellness and Prevention 20 different
sections that address
  • Breastfeeding
  • Oral health
  • Childhood obesity
  • Teen pregnancy prevention
  • STI and HIV/AIDs prevention
  • Home visiting
  • Employee wellness
  • Immunizations
  • Chronic disease prevention
  • Disparities
  • Womens health
  • School health clinics
  • Community Health

22
Prevention and Public Health Investment Fund
  • 500 million for FY 10
  • 750 million for FY 11
  • 1 billion for FY 12
  • 1.25 billion for FY 13
  • 1.5 billion for FY 14
  • 2 billion for FY 15 and every year thereafter

23
Grants Wisconsin has Received
  • 1.16 M/18 months for Maternal, Infant and Early
    Childhood Home Visiting programs
  • 1.7 M to support training for personal and home
    health aides
  • 3.25 M over five years to establish a Public
    Health Training Center
  • 2.1 M to improve public health infrastructure
    and expand epidemiological and lab capacity

24
Grants Wisconsin has Received
  • 2 M to support health care workforce training
    for nurses and geriatric specialists
  • 3.8 M for primary care residency expansion
  • 7.2 M for Health Profession Opportunity Grants
    which help train low-income workers and tribal
    members for careers in health care
  • Grants have gone to Marshfield Clinic,
    UW-Madison, Milwaukee, LaCrosse, and Eau Claire,
    Marquette University, Gateway Tech, College of
    the Menominee Nation, Medical College of WI and
    many more

25
Workforce Development
  • 4.5 M per year from 2010-2014 to establish state
    and regional Centers for Health Care Workforce
    Analysis
  • 10.8 M per year from FY 2011-2014 to support
    geriatric education and training
  • 125 M for accredited professional training
    programs, including training for physician
    assistants
  • 35 M per year from 2010-2013 for student
    recruitment and training for social workers,
    psychologists, professional child adolescent
    mental health
  • 50 M per year in 2011 and 2012 to establish new
    accredited or expanded primary care residency
    programs
  • 230 M in 2011 for teaching health centers for
    graduate medical education programs

26
Primary Care
  • Future opportunities
  • 11 B appropriated over 5 years for expansion of
    Community Health Centers
  • 1.5 billion to expand the National Health
    Service Corps provider loan repayment and student
    scholarship programs for primary care providers
  • 120 M to develop and establish primary care
    extension program

27
Primary Care
  • Future opportunities
  • 43 M for the Preventive Medicine and Public
    Health Training Grant program
  • 5 M to develop and implement physician and nurse
    practitioner home-based primary care
    demonstration program
  • 1.5 M to develop and implement nurse-managed
    clinics

28
Office of Health Care Reform
  • Please visit www.healthcarereform.wi.gov for more
    information

29
  • HIE/HIT
  • PROGRESS REPORT

30
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31
WHIE Update Results
  • Preliminary questionnaire results indicate that
    the information provided by the WHIE ED Linking
    Project has an impact on clinical care.
    Additional data collection is planned to further
    delineate the effects of specific types of
    information. Dr. Jonathan Rubin
  • Work up or treatment of the patient altered?

31
32
WHIE Update Results
  • Preliminary Results Evaluation Impact on MD
    Ordering

33
WHIE Update Results
  • Preliminary Results Impact on Efficiency Study

34
WIRED for Health Vision and Mission
Vision
Promote and improve the health of individuals and
communities in Wisconsin through the development
of health information exchange that facilitates
electronic sharing of the right health
information at the right place and right time.
Mission
Develop and sustain a trusted, secure statewide
health information network and HIE services that
provide value to participants.
35
WIRED for Health Plan Development
  • Transparent and open process
  • Broad, multi-disciplinary group of stakeholders
    serving on the WIRED for Health Board and its
    Committees
  • Spanned over 5 months with thousands of labor
    hours volunteered
  • http//wiredboard.wisconsin.gov

36
How Electronic Medical Records Save Money
  • National estimate suggests that up to 30 percent
    (30) of health care is unnecessary1
  • Wisconsins level of inefficiency and amount of
    unnecessary health care is likely lower due to
    the high EHR adoption rate
  • Hypothetically, if even 1 percent (1) of the
    inefficiency and waste is eliminated through HIE,
    this would equate to a reduction of
  • 69 million in annual health care costs in
    Wisconsin

WI Healthcare Spending Estimated Waste (National Avg.) Estimated Total Waste Estimated Waste (Adjusted Avg.) Estimated Total Waste
Total 46B 30 13.8B 15 6.9B
Per Capita 8,143 30 2,443 15 1,221
37
Overarching Goals
  • By 2016, all ambulatory care providers and
    hospitals will have and use nationally certified
    EHR systems and HIE
  • By 2020, all health care consumers, providers,
    and public health agencies will have access to
    nationally certified EHR systems and HIT
  • By 2020, most patients, health care providers,
    and public health agencies will use electronic
    health records and information exchange to
    improve outcomes related to the effectiveness,
    quality, efficiency, and safety of health care
    and population health services

38
Key HIE Capabilities
  • The ONCs guidance outlines three HIE
    capabilities that must be addressed
  • E-prescribing
  • Receipt of structured lab results
  • Sharing patient care summaries across
    unaffiliated organizations
  • A strategy must be set to establish the baseline
    and close the gaps in these capabilities

39
FinanceApproach to Sustainability
  • Identified an approach to achieve financial
    sustainability that includes several tenets
  • Voluntary participation model
  • Subscription-based revenue model
  • Conservative, value-based adoption and benefit
    estimates
  • Recognition of existing level of data exchange
  • Leverage revenue mechanisms from multiple sources
  • Investments in support of the SHIN viewed from
    the following perspectives
  • Public good
  • Meaningful Use requirements
  • Cost and revenue estimates serve as a point of
    reference to develop the Sustainability Plan (due
    to the ONC in February 2011)

40
Technical Infrastructure and Services
  • Secure and reliable electronic exchange of health
    information through a network-of-networks
    architecture for statewide and interstate HIE
    comprised of a three-layered model
  • Layer 3 Nationwide connectivity through the
    Nationwide Health Information Network (NHIN)
  • Layer 2 Services delivered via the state-level
    exchange network and connectivity to other
    neighboring state networks
  • Layer 1 - Participating medical trading areas or
    non-geographic exchange networks (e.g., IDNs)
  • Key aspects of the recommended architecture and
    services include
  • A hybrid model that includes both distributed and
    centralized data architectures
  • An ability to accurately identify patient
    information and providers (e.g., directory
    services)
  • An ability to push and pull medical information
    (e.g., information look-up, query, and delivery
    services)
  • A security framework that reliably identifies
    users and protects information consistent with
    various legal and regulatory requirements

41
Legal and Policy
  • Key Components
  • Developed a Legal and Policy Framework
  • Examined consent model options for HIE
  • Selected a centrally managed opt-out consent
    (will require changes to state statutesChapters
    146 and 51.30)
  • Provided recommendation on data use agreement
    development
  • Addressed interstate collaboration, State
    purchasing power, and federal HIE alignment
  • Provided public health participation
    recommendations

Legal and Policy Framework
42
What is Meaningful Use?
  • Meaningful Use is using certified EHR technology
    to
  • Improve quality, safety, efficiency, and reduce
    health disparities
  • Engage patients and families in their health care
  • Improve care coordination
  • Improve population and public health
  • All the while maintaining privacy and security
  • Providers must meet meaningful use requirements
    to qualify for ARRA-funded Medicare and Medicaid
    HIT incentive payments
  • Payments begin in 2011 and run through 2016 for
    Medicare and 2021 for Medicaid
  • Payments are estimated to be worth up to 860M to
    Wisconsin health care providers

43
Stage 1 Meaningful Use HIE Objectives/Measures
  • Core Set (required) HIE Objectives
  • Electronic Prescribing - Generate and transmit
    40 of permissible prescriptions electronically
    using certified EHR technology to the pharmacy
    (does not apply to hospitals)
  • Clinical Information Exchange - Implement
    capability to exchange key clinical information
    (ex problem list, medication list, medication
    allergies, diagnostic test results), among
    unaffiliated providers of care and
    patient-authorized entities electronically
  • Must conduct at least one test of clinical
    information exchange

44
Stage 1 Meaningful Use HIE Objectives/Measures
Objective Description Measure
Lab Results Incorporate clinical lab-test results into certified EHR technology as structured data More than 40 of all clinical lab test results ordered by the EP, or an authorized provider of the eligible hospital or CAH, for patients admitted during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data
Care Summary Record Exchange Across Providers The EP, eligible hospital or CAH who receives a patient from another setting of care or provider of care or refers their patient to another provider of care should provide a summary of care record for each transition of care or referral The EP, eligible hospital or CAH who transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50 of transitions of care and referral
Immunizations Capability to submit electronic data to immunization registries or Immunization Information Systems and actual submission in accordance with applicable law and practice Performed at least one test of the certified EHR technologys capacity to submit electronic data to immunization registries and follow-up submission if the test is successful
Lab Results Capability hospitals only to submit electronic data on reportable (as required by state or local law) lab results to public health agencies and actual submission in accordance with applicable law and practice Performed at least one test of certified EHR technologys capacity to provide submission of reportable lab results to public health agencies and follow-up submission if the test is successful
Syndromic Surveillance Capability to submit electronic syndromic surveillance data to public health agencies and actual submission in accordance with applicable law and practice Performed at least one test of certified EHR technologys capacity to provide electronic syndromic surveillance data to public health agencies and follow-up submission if the test is successful
44
45
Supporting Providers Achievement of Meaningful Use
Meaningful Use Requirements
Technical Assistance REC Program
Health Information Exchange State HIE Program
Health Information Exchange NHIN Activities
Human Resources Workforce Training Programs
SHIN will aid providers
  • By August 31, 2011, technical infrastructure will
    be available to help support eligible health
    professionals and hospitals in meeting the Stage
    1 meaningful use criteria for HIE.
  • By June 1, 2012, the statewide health information
    network and HIE services will be available to
    help support eligible health professionals and
    hospitals in meeting the Stage 1 meaningful use
    criteria for HIE.

45
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