ehealth initiative april connecting communities call implications of health care reform on state...

eHealth InitiativeApril Connecting Communities Call

Implications of Health Care Reform on State HIEs

April 12, 2010

William BernsteinChair, Healthcare DivisionManatt, Phelps & Phillips, [email protected]

Brenda PawlakSenior ManagerManatt Health [email protected]

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Health Reform and Health IT

Health Care Reform Legislation:• Patient Protection and Affordable Care Act (HR 3590)• Health Care and Education Reconciliation Act (HR 4872)

Includes:• Coverage expansion, insurance regulation, coverage

mandates, Medicare and Medicaid changes, Part D prescription program additions, long term care plans, workforce training, tax changes, creation of insurance exchanges, wellness plan incentives, CHIP provisions, expanded comparative effectiveness research (CER) support, and numerous demonstrations, pilot programs, payment adjustments, grants and other tools around quality and integrated care (many health IT enabled).

Key Changes in Health Reform Law –Health Insurance Practices & Innovations in Medicare & Medicaid

Status Quo • Health Costs Exceed General Inflation• Sub-Optimal Population Health• Unexplained Variations in Practice Patterns• Questions About Evidence Base of Some Procedures

National Goals • Expand Access to Health Insurance to 95% CBO estimate of Insurance Coverage in 2019 • 92% of all residents will be insured• 94%, if unauthorized immigrants are not counted • Lower Health Spending Growth Rate• Incentivize Delivery System Change

Health InsuranceReform

• Expand Insurance Coverage• Expand Consumer Protections• Reform Industry Practices

Payment Reform• Evolve Medicare Payment Systems from Fee-For-Service to Value Based Payment • Test new payment methodologies and patient care delivery models for Medicare, Medicaid & CHIP

Bend the Curve

ARRA Infrastructure Investments • Health Information Technology

•Comparative Effectiveness Research

Medicare Payment Reforms --- Attempting to Encourage Value More than Volume

Reduce Cost of Care

• Stimulate Administrative Efficiencies • HIT incentives

• Limit FFS Payment Updates • Medicare captures productivity gains• FFS becomes less attractive

• Reduce MA Payments• Payments based on FFS rates

Improve Coordination of Care

• Encourage creation of new delivery organizations including: • Medical Homes, particularly for chronic care populations• Accountable Care Organizations• Tie Payments to Broader Units of Services • Hospital and Physician Payment Bundles• Episode Based Payment Bundles

Alter Content of Care

• Improving Scientific Basis of Healthcare Decisions • Based on Comparative Effectiveness Research

• Payment Tied to Patient Outcomes • Based on Quality Measures

•$196 billion lessdue to productivity savingseliminated from updates

• $ 206 billion less• due to Medicare Advantage cuts

$ 66.1 billion lessin other Medicare and Medicaid savings

Value-Based Incentive Payments

Delivery System Reform: Medicare and Medicaid Initiatives

Medicare Initiatives Medicare shared savings program –

including Accountable Care Organizations (ACOs)

National pilot program on payment bundling

Independence at home demonstration program

Hospital readmissions reduction program

Community-Based Care Transitions Program

Extension of Gainsharing Demonstration

Medicaid Initiatives Health Homes for the Chronically Ill Medicaid Community First Choice

Option Home and Community Based

Services State Plan Option Hospital Care Integration Global Capitation Payment for Safety

Net Hospitals Pediatric ACOs

• In addition to these specific demonstration initiatives, the health reform law provided the Secretary with broad authority to test various payment incentives and patient care models in both the Medicare and Medicaid programs

• More importantly , the Secretary has the authority to expand, nationwide, those innovations which are demonstrated to be valuable because they lower costs or improve quality

• Demonstrations, based on the Rapid Learning Network model, will be the responsibility of a new Center for Medicare and Medicaid Innovation (CMI), within CMS

CMS Innovation Center’s Rapid Learning Model

The HHS Secretary is given significant new authority to expand successful innovations in the Medicare and Medicaid programs

A new center, referred to as CMI, will operate within CMS to:– encourage innovations in payment and delivery systems– increase the value of benefits covered under Medicare and/or

Medicaid The law presumes a “Rapid Learning Model” which allows the innovation to

shift from testing mode to expansion once there is an expectation that it will lower costs or improve quality

---testing a wide range of innovations

--- nationwide expansion

Value-Based Evaluation–cost reductions–quality improvementsPhase I

Phase II

of successful m

odels

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CMS Center for Innovation Project Examples

Provision Key Details

Center for Medicare & Medicaid Innovation at CMS

•Establishes Innovation Center by Jan. 1, 2011.•Research, develop, test and expand innovative payment and delivery models to improve quality and reduce cost.•Cited Examples:–Care coordination for chronically-ill patients at high risk of hospitalization through a health IT-enabled provider network that includes care coordinators, chronic disease registry, home telehealth technologies.–Improve post-acute care through continuing care hospitals that offer inpatient rehab, long-term care hospitals and home health or skilled nursing care during an inpatient stay and the 12 days immediately following discharge.–Facilitate inpatient care, including intensive care, of hospitalized applicable patients at their local hospital through the use of electronic monitoring by specialists based at integrated health systems.•Factors for consideration of a program include “whether the model uses technology, such as EHRs and patient-based remote monitoring to coordinate care over time and across settings.”

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Summary of Key Health IT and/or Health IT Enabled Provisions Under Medicare & Medicaid with Implications for State HIE


Medicare shared-savings program for Accountable Care Organizations (ACOs)

•Beginning no later than January 1, 2012, allows providers organized as accountable care organizations (“ACOs”) that voluntarily meet quality thresholds to share in the cost savings they achieve for the Medicare program. •To qualify as an ACO, organizations must agree to be accountable for the overall care of their Medicare beneficiaries, have adequate participation of primary care providers, must define processes to promote evidence-based medicine, must report on quality and costs, and must coordinate care.•The Secretary to establish quality performance standards to assess the quality of care furnished by ACOs .•May incorporate reporting requirements and incentive payments related to PQRI, EHRs, and other similar initiatives.

Medicaid Pediatric Accountable Care Organization (ACO) demonstration project

•Establishes a demonstration project that allows qualified pediatric providers to be recognized and receive payments as ACOs under Medicaid. •Pediatric ACOs that meet guidelines and provide services at a lower cost would share in those savings. •The demonstration will operate from January 1, 2012 through 2016.

Accountable Care Organizations:How They Work

ACO

Hosp

PCP

Spec

Coordinates carefor shared patients

ImprovedOutcomes

Financial bonusfrom payers

ACO Attributes• Coordinates care for shared Medicare patients with the goal of meeting

and improving on quality and cost benchmarks• Hires an administrator and establish a formal legal structure to work with

payers, monitor performance, and collect any shared savings• Receives a financial bonus that is divided among its participants

according to their agreement.

Accountable Care

Organization

Accountability, Performance

Measurement, Shared Savings

Bundled Payments

HIT

Partial Capitation

Medical Home

The ACO is the Overarching Structure Within Which Other Reforms Can Thrive

Slide Source: Engelberg Center at Brookings

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Independence at Home demonstration projects

•By January 1, 2012 – pilots for chronically ill Medicare beneficiaries to test a payment incentive and service delivery system that utilizes physician and nurse practitioner directed home-based primary care teams aimed at reducing expenditures and improving health outcomes. •Defines an “independence at home medical practice” as one that “uses electronic health information systems, remote monitoring, and mobile diagnostic technology.”

Community-based care transitions program

•Begins January 11, 2010 and lasts 5 years.•Provides funding to hospitals and community-based organizations with hospital partnerships that furnish evidence-based care transitions to Medicare patients at high risk for readmission. •Applicants must include proposals for at least one care transition intervention (such as actively engaging with patient through self-management tools or conducting comprehensive medication review and management across care transitions).

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State option to provide “health homes” for enrollees with chronic conditions

• Effective January 1, 2011.•Provides states the option of enrolling Medicaid beneficiaries with chronic conditions into a patient centered medical home.• States must also include in their state plan amendments a proposal for use of health IT in providing health home services and improving service delivery and coordination across the care continuum (including the use of wireless patient technology to improve coordination and management of care and patient adherence to recommendations made by their provider).

Grants or contracts to establish community health teams to support patient centered medical homes

•Among other requirements, to receive funding, a health team must demonstrate a capacity to implement and maintain health IT that meets the requirements of Certified EHR Technology under HITECH and, where applicable, report to the Secretary on quality measures included in HITECH.

How Health IT Supports Medical Homes

Health IT Products

Health IT Components of Medical Homes

CDMS/Registry

EHR eRxPatient Portal/PHR

PracticeMgmt.

Solution

HIEPlatform

Patient Tracking & Scheduling HIE

enables the

medical home to

more effectively coordinate and deliver

care across many

clinical settings

Registry Functions

Care Management

Electronic Prescribing

Test Tracking

Referral Tracking

Performance Reporting/Improvement

Web-based Services for Patients

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State-level demonstration project to evaluate integrated care around a hospitalization

•Establishes a demonstration project in up to eight states to study the use of bundled payments for hospital and physician services under Medicaid. •The demonstration will run from January 1, 2012 through December 31, 2016.

State-level Medicaid global payment demonstration project

•Establishes a demonstration project in up to five states that would allow participating states to adjust their current payment structure for safety net hospital systems or networks from a fee-for-service model to a global capitated payment structure. The demonstration will operate during Fiscal Years 2010-2012.

Community-based collaborative care networks

•Provides grants to develop networks of providers to deliver coordinated care to low-income populations. •Networks are to include a hospital and all Federally Qualified Health Centers (FQHCs) located in the community. •Grants may be used for assisting low income individuals to access and appropriately use health services and expand capacity, through telehealth, after-hours services or urgent care, for example. •Funds are authorized to be appropriated for Fiscal Years 2011-2015.

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Other Provisions with Implications for State HIE


Community Health Centers

•More than doubles current Federal CHC funding•Grants for capital improvement and EHR purchase will be available to CHCs

Certified EHR program for long term care

•Authorizes the Secretary to make grants to long-term care facilities to assist with costs related to purchasing, leasing, developing, and implementing Certified EHR Technology. •Authorizes $20 million for FFY 2011, $17.5 million for FFY2012 and $15 million each for FFY 2013 and 2014.•Also required two facility-based demonstration projects to test EHR and health IT deployment in long term care facilities.

Centers of Excellence for depression

•Grant awards to centers of excellence for depression.•Among several other requirements, must use EHRs and telehealth for improved care coordination and improved access to care.

Co-locating primary and specialty care in community-based mental health settings

•Grants for coordinated and integrated services through co-location or primary and specialty care in community-based mental and behavioral health settings.•Funds can be directed to facility improvements and health information technology purchase.

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Summary of Provisions Related to Health IT Standards and Protocols / Administrative Simplification


Modernizing computer and data systems at CMS

•Requires the Secretary to develop a plan to modernize the computer and data systems of CMS to support improvements in care delivery.•The plan must be posted on the CMS website no later than 9 months after enactment.

Health IT enrollment standards and protocols

•Requires the development of standards and protocols to promote the interoperability of systems for enrollment of individuals in federal and state health and human services programs. •The standards shall allow for electronic data matching, and electronic documentation. •The Secretary may require states or other entities to incorporate such standards as a condition of receiving Federal health information technology funds.

Administrative Simplification

Accelerates HHS adoption of uniform standards and operating rules for the electronic transactions that occur between providers and health plans that are governed under HIPAA (such as benefit eligibility verification, prior authorization, and electronic funds transfer payments).

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Summary of Provisions Related to Health IT Standards and Protocols / Administrative Simplification


Development of standards for financial and administrative transactions

•Requires identification of opportunities to create uniform standards for financial and administrative health care transactions, not already named under HIPAA.• Also directs the Secretary to task the International Classification of Diseases Coordination and Maintenance Committee, ICD-9-CM, to convene a meeting, no later than January 1, 2011, to receive input from appropriate stakeholders regarding the crosswalk between the 9th and 10th Revisions, ICD-9 and ICD-10 and to make revisions as appropriate.

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Summary of Provisions Related to Quality Measurement and Reporting


Development of a national strategy to improve healthcare quality

•Requires the Secretary to establish and update annually a national strategy to improve the delivery of health care services, patient health outcomes, and population health. First year’s due on Jan. 1, 2011.• Establishes, not later than January 1, 2011, a federal health care quality internet website. •It must include such items as coordination among agencies and include provisions for incorporating the quality improvement and measurement programs in the ONC strategic plan for health IT required under HITECH.

Quality Measurement Development

•Directs the Secretary, AHRQ and CMS, to identify gaps where no quality measures exist and existing quality measures need improvement, updating, or expansion. •Priority to the development of quality measures that allow for such items as health outcomes and functional status of patients, the management and coordination of health care across episodes of care, and the meaningful use of health IT. •Specifies that data on measures be submitted through the use of a qualified electronic health record. Measures will be publicly reported.

Health ReformKey Takeaways

– Health Reform is designed to encourage innovations in healthcare delivery; many, if not most, will be health IT enabled.

– Medicare Payment Reform includes a variety of incentives to encourage productivity, redesign of health care processes and a new organizational model – the Accountable Care Organization (ACO)

• ACOs will have incentives to lower per capita costs for a population of Medicare beneficiaries who are assigned to the ACO

• ACOs will share the savings with the Medicare program based on a formulary determined by the HHS Secretary

• Current IPA, PHO and group practices can qualify as an ACO to reduce costs by coordinating care and changing the average mix of healthcare services provided to Medicare beneficiaries

– Health Insurance Reform includes a variety of programs and incentives which encourage a greater focus on value and a person’s engagement in managing their health

– Quality Measures and Standards Development build off of Meaningful Use.

ehealth initiative april connecting communities call implications of health care reform on state...

Documents

health care reform legislation

health costs

medicare medicaid

payment updates medicare

medicare payment systems

medicare payment reforms

cost of care

coordination of care