Preparing for Meaningful Use and the Transformation of our Health Care Delivery System

1. Preparing for Meaningful Use and the Transformation of our Health Care Delivery System November 18, 2009 California State Rural Health Association

2. The New Deal and The Interstate The New Deal (1933 – 36): Three ‘Rs’: Relief for unemployed Reform of business and financial practices Recovery of the economy Created institutions: SSA, FDIC, SEC, Fannie Mae 1956 Defense Highways Act: Allocated $25 Billion over 20 years, cost $144B ($425 B in 2006 dollars) Created standards: speed limits, controlled access, etc 2

3. HITECH Overview(HITECH = Health IT for Economic and Clinical Health Act) 3

4. Historical Look at Spending in Health IT • Total Federal Health IT Spending (through ONC) before HITECH: $300,000,000 • Total expected gross outlays through HITECH (up to): $45,000,000,000 • i.e., a 15,000% increase • Represents a 600% increase in the EMR market, essentially overnight 4

5. Funding Flows – Entitlements Entitlement Funds (Up to $45 billion in gross outlays) Program Distribution Agency* Use of Funds Acute Care and Children’s Hospitals Medicare Payment Incentives Incentive Payments through Carriers CMS Incentive Payments through State Agencies Medicaid Payment Incentives CMS and states Physicians and Dentists Nurse Practitioners and Midwives “Meaningful Use” FQHC Source: California HealthCare Foundation, 2009 CMS is Center for Medicare and Medicaid Services, 5

6. Medicare Incentives Medicare may provide up to $44,000 per provider for meaningful use, broken down in yearly payments as shown below. 6

7. Medi-Cal Incentives Medicaid may provide up to $65,000 per provider for meaningful use, broken down in yearly payments as shown below: 7

8. Differences between Medi-Care and Medicaid (Medi-Cal) programs • No penalties for Medi-Cal program • Medi-Cal providers can start as late as 2016 and still receive full incentive • Hospitals can apply for both (if qualified) • Medi-Cal providers can get some incentive funds “up front”: • Year 1: $21,250 • Year 2: $ 8,500 8

9. Funding Flows – Appropriations Loans Appropriated Funds ($2 billion in gross outlays) Use of Funds Program Distribution Agency* State-designedEntity HIE Planning and Development $564 million in State grants ONC States EHR AdoptionLoan Program (“may”) Loan Funds Health CareProviders ONC Health ITExtension Program $598 million - up to 70 competitive grants to non-profits ONC Indian Tribes Medical Health Informatics & EHR in Medical School Curricula, Funding amount unknown WorkforceTraining Grants HHS,NSF Nonprofits Least-advantaged Providers New Technology Research and Development Grants Health Care Information Enterprise Integration Research Centers NIST, NSF Higher Education Medical/Graduate Schools Source: California HealthCare Foundation. ONC is Office of the National Coordinator, HHS is Department of Health and Human Services, NSF in National Science Foundation, and NIST is National Institute of Standards and Technology. Federal Government Labs 9

10. Programs SupportingMeaningful Use 10

11. Health Information Exchange (HIE) Cooperative Agreement Program $564 million Federal program; $38.8 million for California To develop HIE services across California Coordination with Medi-Cal, RECs, and other programs Governance entity Priority: Support Meaningful Use for California providers 11

12. HIE Supported Meaningful Use Functions • E-prescribing and medication reconciliation • Electronic lab ordering and results reporting • Continuity of care • Administrative transactions (claims and eligibility) • Public health reporting • Quality reporting 12

13. Regional Extension Center Program • $598 million in federal funding, 70+ centers funded in three cycles • Assist providers in achieving meaningful use • Deliver technical assistance to facilitate certified EHR adoption and exchange • Integrate HIT and HIE into practice management to achieve clinical and operational efficiencies and better health outcomes DRAFT 13

14. Priority providers • Primary care providers in any of the following settings: • Individual and small group practices • Public and critical access hospitals • Community clinics and rural health centers • Other settings serving underserved populations 14

15. Scope of Services • Education and outreach • EHR vendor selection and group purchasing • Project management • Workflow redesign • Information exchange • Progress towards meaningful use • Workforce support • Privacy and security best practices 15

16. Regional Extension Center Program • Three CA organizations submitted four proposals by Nov. 3: • Cal-REC (CPCA, CMA, CAPH) – two applications • LA Care • CalOptima • Applicants drafted MOUs describing how they would collaborate and coordinate activities • Decision from ONC due: December 11 • Next round preliminary applications due December 22 16

17. Broadband and the California Telehealth Network (CTN) CTN: • $22.1 million FCC Grant • ~800 sites; private broadband network • ARRA funding could expand CTN to ~2,000 sites • Services may include: • Dedicated broadband • Health information exchange • Electronic health records • Training 17

18. EHR Loan Fund • Not “required” under HITECH • CHHS Workgroup in the summer outlined a program, two parts: • Non-profit organizations • For-profits (practices, RHCs and critical access hospitals • Workgroup will reconvene in December and design a program for California 18

19. Workforce • Required under HITECH; hasn’t been defined • Likely will focus on four areas: • Training incumbent workforce • Curriculum for new clinicians • Informatics • “Geek squad” • Anticipate announcement this calendar year 19

20. …A Foundation for Health Reform “…investments in electronic records and preventive care are just preliminary steps. They will only make a dent in the epidemic of rising costs in this country… But what accounts for the bulk of our costs is the nature of our health care system itself – a system where we spend vast amounts of money on things that aren't making our people any healthier; A system that automatically equates more expensive care with better care… Health care reform is the single most important thing we can do for America's long-term fiscal health..” - Barack Obama, Speaking to the American Medical Association, June 15, 2009 20

21. Coronary Bypass Proceduresper 100,000 Population, 2006 Data: OECD Health Data 2008 (June 2008) *2005; **2004 21

22. CABG Procedure Variation in CAper 100,000 Population, 2007 22 Data: OSHPD

23. Timely Preventative Care? Adults receive recommended care about half the time Sources: The World Factbook (ISSN 1553-8133; also known as the CIA World Factbook). Wal-Mart 2006 Annual Report. 23 23

24. Columbia Basin Health Association 24

25. 24,991 Patients 75% Hispanic or Latino 57% of Patients Best Served in a Language other than English 47% Migrant/Seasonal Agricultural Workers Demographics 25

26. Patient Income 26

27. Payer Mix 27

28. Outcomes Measurement ` 90th percentile – national HMO commercial plans EMR Go-Live 28

29. Outcome Measures, Continued EMR Go Live 29

30. “If we can measure it, we can manage it.” - Greg Brandenberg, CEO, Columbia Basin Health Association “I just found out that I.T. wasn’t ‘it’! - Gary Shannon, M.D., solo practice physician, Dinuba, California 30 30

31. How to get involved Sign up for listserv, submit comments and questions, get involved: hie@chhs.ca.gov Website: www.hie.ca.gov Wiki: https://chhsahitworkgroups.basecamphq.com/clients Bi-weekly Bulletins Monthly webinars: Thursday December 10, 2009, 1pm – 2pm Pacific https://www1.gotomeeting.com/register/522974001 NEW – Twitter: http://Twitter.com/CAeHealth 31