1

The Changing Health Care Landscape: Affordable Care Act,

Payment Reform and EMR Adoption

HIPPA-COW Fall Conference

Friday October 15, 2010

Karen TimberlakeWisconsin 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

Wisconsin’s 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

Wisconsin’s 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 state’s 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

Don’t 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’s 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

Data Mart V2 Data Mart V3Reporting Period 10/1/06 - 9/30/08 10/1/07 - 9/30/09Members Included^ 1,507,846 2,651,947Claims 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

WHIO Data Mart V2 vs. Data Mart V3

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

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 hadn’t 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 Women’s 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

$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

Grants Wisconsin has Received

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 CareFuture 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 CareFuture 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

Office of Health Care Reform

Please visit www.healthcarereform.wi.gov

for more information

29

HIE/HIT

PROGRESS REPORT

30

31

“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?

31Protecting and promoting the health and safety of the people of Wisconsin

32

Preliminary Results: Evaluation Impact on MD Ordering

33

Preliminary Results: Impact on Efficiency Study

34

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.

Develop and sustain a trusted, secure statewide health information network and HIE services that provide value to participants.

Vision

Mission

35

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

National estimate suggests that up to 30 percent (30%) of health care is unnecessary1

Wisconsin’s 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

WIHealthcare 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

How Electronic Medical Records

Save Money

37

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

The ONC’s 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

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

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

Layer 3

Layer 2

Layer 1

41

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 statutes—Chapters 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

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

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

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 technology’s 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 technology’s 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 technology’s capacity to provide electronic syndromic surveillance data to public health agencies and follow-up submission if the test is successful

45

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.

THANK YOU