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 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 Update: Data Mart WHIO Data Mart V2 vs. Data Mart V3 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

18. WHIO Update: Health Reform Wisconsin Payment Reform Initiative (WPRI)

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. 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 General Wellness and Prevention 20 different sections that address

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. $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

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

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? Protecting and promoting the health and safety of the people of Wisconsin 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 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 millionin annual health care costs in Wisconsin

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 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. 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 • 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) Layer 3 Layer 2 Layer 1 • 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 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:

41. Legal and Policy Legal and Policy Framework 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

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 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

46. THANK YOU