Patricia MacTaggart, MBA

5th National Medicaid CongressJune 8, 2010 11:15 – 11:45 a.m.

The Power and Potential of HIT for Medicaid Quality and Efficiency

The Power and Potential of HIT for Medicaid Quality and Efficiency Agenda

• Context

• Content

• CMS/State Roles & Responsibilities

• Course of Action for States

• Capitalizing Results through Coordinating Efforts: CHIPRA and Health Care Reform

Context: Acronyms• CCHIT: Certification Commission

for HIT

• CGD: Certification Guidance Document

• EMR: Electronic Medical Record

• EHR: Electronic Health Record

• HIE: Health Information Exchange (Statewide)

• HIO: Health Information Organizations (< statewide)

• HIT: Health Information Technology

• HITECH: HIT for Economic and Clinical Health

• MU: Meaningful Use

• NIST: National Institute of Standards and Technology

• NVLAP: National Voluntary Laboratory Accreditation

• ONC: Office of the National Coordinator for HIT

• ONC-AA: ONC-Approved Accreditor

• ONC-ACB ONC-Authorized Certification Body

• ONC-ATCB ONC-Authorized Testing and Certification Body

• SMHP: State Medicaid HIT Plan

Context: Parameters for Nationwide HIT & Utilization of EHR

• By 2014• Use of certified EHRs to improve quality and coordination of

care• Protect the privacy and promote security:

– Segmentation– Protection from disclosure of specific and sensitive

individually identifiable health information– Accounting of disclosures made by a covered entity– Allow individually identifiable information to be rendered

unusable, unreadable or indecipherable to unauthorized individuals when transmitted

• Technologies that address the needs of children and other vulnerable populations

Context: Pillars of Meaningful Use- Blumenthal

• Patient & Family Engagement• Coordination of Care• Ensuring Privacy and Security• Improve Quality, Patient Safety &

Efficiency while Decreasing Disparities• Improve Population Health and Public

Health

Medicare• Feds will implement • Fee schedule reductions begin in

2015 for providers that are not MU• Must be a MU user in Paymnet

Year 1• MU definition common • Medicare Advantage (Section

4102): for certain EHs• EP (Section 4101):

– 2014: Last year to initiate– 2016: Last payment in program – 2015: Payment adjustments begin

• Physicians in “health professional shortage areas”: 10% additional payment, for a total of $48,400

Medicaid (Section 4201)• Voluntary for States to implement• No fee schedule reductions• Adopt/Implement/Upgrade option

for 1st participation year• EPs max incentive = $63,750 • States can adopt a more rigorous

definition but not require more functionality than certified

• Medicaid MCO providers must meet regular eligibility requirements

• EP: 2016 Last year to initiate & 2021: Last payment in program

• EPs=5 types, Hospitals=3 types

6CMS

Content: “MU” Law and Regulation

Medicare• Excluded: hospital-based provider

individual provides at least 90 % of covered professional services in an inpatient/outpatient hospital setting – codes 21, 22, 23

• Eligible Providers: individual doctors of medicine or osteopathy, dental surgeons, doctors of dental medicine, podiatrists, optometrists and chiropractors.

• EHs: Section 4102 as defined under Section 1886 (d)(1)(B)

• EPs Payment Year = CY• EHs Payment Year = FY• Use of a qualified EHR, regardless

of purchase date

Medicaid• States cannot propose fewer or

less rigorous criteria & CMS must approve proposed

• EPs Payment Year = CY (same)• EHs Payment Year = FY (same) • Multistate: If a provider/hospital

serves a multistate population, the provider/hospital can participate only in the Medicaid incentive program through a single state

• EPs can participate in only one program: Medicare or Medicaid. A one-time-only switch between programs is permitted.

7CMS

Content: Medicare Vs Medicaid MU

Content: Medicaid AIU – First Year

• Adopt = Acquire and Install• Implementation = Commenced Utilization• Upgrade = Version 2.0 with Expanded Functionality

Content: Medicaid Professional Incentives

Content: StagesStage 1-2011: capturing information electronically & using it:• Electronic capture health information in a coded format, track key clinical conditions;

communicate about care needs (including provider and patient communication); facilitate disease and medication management, implement clinical decision support tools, and report key quality and public health information.

Stage 2: expand upon Stage 1 to exchange & use information to improve the care of individual patients : 2013 advance clinical process

• use of HIT for continuous QI at the point of care• exchange of information in the most structured format possible

– E.g. Electronic transmission of orders entered using CPOE– E.g. Electronic transmission of diagnostic test results

• Apply more broadly to both the inpatient and outpatient hospital settings

Stage 3: upon Stage 2 to promote systemic improvements : 2015 outcome improvements

– Promote improvements in quality, safety, and efficiency– Advance decision support for national high priority conditions– Provide patient access to self management tools– Facilitate access to comprehensive patient data– Improve population health

• MU Stage 1 Focus for Eligible Providers & Eligible Hospitals:

– electronically capturing health information in a coded format;

– using information to track key clinical conditions

– communicating that information for care coordination purposes (whether that information is structured or unstructured), but in structured format whenever feasible;

– implementing clinical decision support tools to facilitate disease and medication management;

– Reporting clinical quality measures and public health information

• State Activities Scope:– Administering incentive

payments, including tracking of meaningful use

– Conducing adequate oversight of the program, including tracking MU

– Pursuing initiatives to encourage the adoption of certified EHR technology to promote HC quality and e-HIEA. “As Is”B. “To Be”C. Roadmap

Assessment Planning Organizing Implementation Maintain MU

CMS/ State Roles/Responsibilities Maintaining Meaningful Use

CMS/States Roles/Responsibilities HIT Current

Responsibilities/Opportunities• 5010

– Convert from Health Insurance Portability and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12 version 4010A1 to ASC X12 version 5010 and National Council for Prescription Drug Programs (NCPDP) version 5.1

to NCPDP version D.0. – Submitters will be able to concurrently submit 4010A1 and 5010 HETS 270/271

transactions from January 1, 2011 until December 31, 2011.

• ICD-10– ICD-10-PCS is the new procedure coding system that is being developed as a

replacement for ICD-9-CM, Volume 3.– ICD-10-CM is the new diagnosis coding system that is being developed as a

replacement for ICD-9-CM, Volumes 1 & 2.

Course of Action for States State HIE Strategic/Operation and

Medicaid HIT Plans

• Simultaneous & Sequential• Sections in the Same Chapters in the Same

Book• Strategic Plan• Operational Plan• SMHIT Plan

Capitalizing Results through Coordinating Efforts

CHIPRA: Children & “MU” Measurement• Express Lane Eligibility and Administrative Simplification• Quality Measurement for Children Reporting (Mandatory

State – Optional Core National)– 4 Overlapping Measures: MU and Recommended Core CHIPRA Measures:

• BMI 2 - 18 year old (NCQA and nominated by CMS)• Follow-up care for children prescribed attention-deficit/hyperactivity disorder

(ADHD) medication • Annual hemoglobin A1C testing (all children and adolescents diagnosed with

diabetes) • Pharyngitis - appropriate testing

• Enhanced Funding Reporting & Tracking• Model EHR

Capitalizing Results through Coordinating Efforts Health Care Reform: HIT Provisions Only

• Quality- HHS:– Dev. requirements for use by group health plan and insurer offering group

or individual health insurance coverage to prevent hospital readmissions & reduce medical errors through use of evidence based medicine and HIT

– National strategy to improve delivery of healthcare services that incorporates QI and measurement in the ARRA HIT

– Award grants, contracts of intergovernmental agreements to dev quality measures with priority for items that address episodes of care and “MU” of HIT

– Establish quality performance standards to assess quality of care by accountable care organizations, including PQRI, use of e-prescribing & EHRs

– Strategy for public reporting aligned with expansion of HIT and interoperability of such technology

• Care Coordination: State Plan Option for individuals with chronic conditions who select a designated provider “health home” for health home services

• Community-Based Collaborative Care Networks - telehealth

16

April July September End of 2010

2010 Health Insurance Reforms Having IT Implications

• State option to expand Medicaid to adults to 133% FPL: Eligibility

System Changes

• Temporary high risk pool: CMS & Some New StatesNeed IT Systems

• Employer retiree health benefits reinsurance

• Young adults on parent’s plans: MCO/HP Systems - edits

• Small business tax credits: State Tax Systems Potentially

• No pre-existing condition exclusions for children: MCO/HP Systems - edits

• Prohibitions against lifetime benefit caps & rescissions: MCO/HP Systems - edits

• Annual review of premium increases

• Public reporting by insurers on share of premiums spent on non-medical costs

• Coverage and no cost-sharing for preventive care in Medicare and private plans: Medicare/Medicai d/MCO/HP

• $250 rebates for Medicare Part D enrollees in "donut hole"

Source: The Commonwealth Fund, Timeline for Health Care Reform Implementation: Health Insurance Provisions, (New York: The Commonwealth Fund, April 2010).

172010-2012 Payment & System Reforms Having IT Implications• Modify Medicare payment to providers to account for productivity improvements (2010): Medicare & Medicaid at State-audit, claims,

• Center for Medicare and Medicaid Payment Innovation to test payment and delivery system reforms (2011): TBD by State Medicare and Medicaid

• Eliminate Medicaid payment for hospital-acquired conditions (2011): Medicaid at State – audit, claims,

Source: The Commonwealth Fund, Timeline for Health Care Reform Implementation: System and Delivery Reform, (New York: The Commonwealth Fund, April 2010).

• 10 percent Medicare bonus payment to primary care providers for five years (2011): Medicare & Medicaid at State

• Shared savings to Accountable Care Organizations for Medicare savings relative to a cost benchmark: Medicare ??

• Reduce Medicare payment for preventable hospital readmissions: Medicare and State Medicaid

• Reward hospitals that participate in a value-based purchasing program: Medicare & Medicaid State

2010-2011 2012

182011-2013 Health Insurance Reforms Having IT Implications

• Insurer administrative simplification requirements: Medicaid/Medicare/Com mercial

• Limits on contributions to flexible spending accounts to $2500/year: Private

• Insurers must spend at least 85% of premiums (large group) or 80% (small group/individual) on medical costs or provide rebates to enrollees

• Establish national, voluntary insurance program for purchasing community living assistance services and supports (CLASS program)

• 50% discounts on brand-name drugs to Medicare part D enrollees in the donut hole: pharmacies

• Over-the-counter drug costs reimbursement restrictions in flexible spending accounts and account based health plans

• Increased tax on non-medical distributions from health savings accounts (HSAs)

Source: The Commonwealth Fund, Timeline for Health Care Reform Implementation: Health Insurance Provisions, (New York: The Commonwealth Fund, April 2010).

2011

2013

192014-2018 Health Insurance Reforms Having IT Implications• Medicaid expanded to 133% FPL: Medicaid Eligibility Systems

• Insurance market reforms including no rating on health

• State insurance exchanges: DDI Exchanges

• Essential benefit standard: Exchanges DDI

• Premium and cost sharing credits for exchange plans: DDI Exchanges

• Premium increases a criteria for carrier exchange participation:

• Increase in small business tax credit: Tax Systems

• Individual requirement to have insurance • Employer shared responsibility penalties• CHIP reauthorization 2 year extension

• Excise tax on high cost employer plans: Tax Systems

Source: The Commonwealth Fund, Timeline for Health Care Reform Implementation: Health Insurance Provisions, (New York: The Commonwealth Fund, April 2010).

20142018

202013-2016 Payment & System Reforms Having IT Implications• National voluntary pilot program on payment bundling for acute care episodes – providers to share in Medicare savings subject to quality performance: Some states TBD Medicare Carriers/Intermediaries & State Medicaid

• New Independent Payment Advisory Board to present Congress with recommendations to reduce Medicare excess cost growth and improve quality of care along with non-binding recommendations for health system cost and quality: Results TBD

Source: The Commonwealth Fund, Timeline for Health Care Reform Implementation: System and Delivery Reform, (New York: The Commonwealth Fund, April 2010).

• Bring Medicaid primary care payment up to Medicare levels: Medicaid State Systems – time limited 100% Medicare Primary Physicians

• Create physician value-based payment program to promote increased quality of care for Medicare beneficiaries (2015): Medicare & Medicaid claims in some states TBD

• Establish a pay-for- performance pilot program for Medicare providers; expand after 2018 if successful (2016): TBD Some States Medicare Carriers/Intermediaries & State Medicaid

• Reduce Medicare payments to hospitals with high rates of hospital-acquired infections (2015): Medicare Carriers/Intermediaries & State Medicaid

2013-20142015-2016

Efficient Adm & Service Delivery

Ensure Privacy &Security

Care Coordination

Coverage AccessImproved &

Patient Engagement

Clinical Quality& Patient

Safety Improved Disparities Decreased

Population Health &

Public Health

Standardized Eligibility & Enrollment

Uniform Data Elements/SourcesGet Data once –use

multiple programs

Coordinate Care-Physical & BH

Improved IndividualClinical Quality Performance

Improved PopulationHealth“Value” Validated

Eliminate PaperReduce Lab/Xray/etc

Duplication & UnnecessaryAdministrative EfficiencyDischarge Planning-Community Care Coordination

MU Pillars

Reduction in Adm CostsState and Providers

Reduction in Repetition ofData Collection from Ind.

Potential MUPerformance Metrics Success Results

Improved Results forMU Clinical Quality Measures and CHIPRARequired Measures

Reduction in Health DisparitiesIncreased Comparative Effectiveness

Improved Results for MU Access Measures

How Will You Know “Success”

Questions/ Comments /Discussion