Medicaid, HIX, and HIE: Using Data to Manage Health. David Nelson, Senior Director. August 2012, MESC Conference Truven Health Analytics Inc.

Transcription

1 Medicaid, HIX, and HIE: Using Data to Manage Health David Nelson, Senior Director August 2012, MESC Conference

2 The Healthcare Business of Thomson Reuters is now Truven Health Analytics We are please to introduce our new name Truven Health Analytics. And we re proud that we continue to be known for: Independent, objective analytics Decision support and data warehousing Industry-best program integrity solutions Health Information Exchange (HIE) and clinical data solutions Experienced Knowledgeable staff Nearly 30 years serving Medicaid 2

3 The Evolving Landscape Meaningful Use & Health Information Exchange I need answers, not applications! I need Thought Leadership, Strategic thinking Accountable Care Organizations Health Insurance Exchange How can I add so many new eligibles and keep my costs down? Has the quality of care improved? Control Costs Expanded Coverage Payment Reform Improve Care Improve Program Integrity Why are my programs not performing as expected? How am I going to evaluate quality of care and program efficiency through the ICD-10 transition? How can I find & eliminate waste? Dual Eligibles MITA, 5010 & ICD-10 Compliance 3

4 Integrating Clinical and Claims Data Improves Numerous Areas Meaningful Use & Health Information Exchange I need answers, not applications! I need Thought Leadership, Strategic thinking Accountable Care Organizations Health Insurance Exchange How can I add so many new eligibles and keep my costs down? Has the quality of care improved? Control Costs Expanded Coverage Payment Reform Improve Care Improve Program Integrity Why are my programs not performing as expected? How am I going to evaluate quality of care and program efficiency through the ICD-10 transition? How can I find & eliminate waste? Dual Eligibles MITA, 5010 & ICD-10 Compliance 4

5 Convergence of Medicaid, HIX and HIE Information Medicaid Higher Quality Lower Costs HIX Health Insurance Exchange HIE Health Information Exchange 5

6 Integration of clinical and financial data to drive better health outcomes Integration supports stage 2 meaningful use HIE and care coordination Outcomes measurement & improvement Capture structured data 6 6

7 MITA Maturity Model Vision Medicaid Mission: To provide quality health care to members by providing access to the right services to the right people at the right time at the right cost. Level 1 Level 2 Level 3 Level 4 Level 5 Regulatory compliance to encourage providers to participate and thereby promote access to care Outcomes measurement limited to observations based on administrative data Automated application of rules meets statutory requirements for error rates Goal: Improve health care outcomes for Medicaid Members Improved health outcomes are a byproduct of creative efforts to control costs, e.g., managed care, waiver programs Widespread adoption and use of national standards for administrative data; in-state collaboration and coordination All stakeholders have access to clinical data that produces a major leap forward in analysis of health outcomes Goal: Transformation of capability to measure health care outcomes Researchers conduct evaluations of costeffectiveness that report on health care outcomes Use of national standards, shared services, collaboration across programs, and intrastate exchange Access to clinical data transforms the measurement of outcomes Goal: Ensure efficient, effective, and economical management of the Medicaid program Program evaluations show savings from managed care & waivers; decision support tools improve program analysis Consolidation of programs / processes with economies of scale through shared, re-usable services and standard data Access to and use of clinical data increases the efficiency and effectiveness of decision-making National interoperability among state and federal agencies in the most comprehensive way we can now envision The Medicaid agency realizes economies of scale and focuses on strategic goals, e.g., healthcare outcomes The Medicaid agency realizes economies of scale and focused on strategic goals, such as effective management. Source: MITA 3.0 Part 1 Business Architecture, Appendix B Maturity Model Details 7

8 Health Insurance Exchanges: a patchwork Established State Exchange 3 Planning for Partnership Exchange 16 Studying Op9ons Status of state insurance exchange ac9vity 32 9 No Significant Ac9vity 7 Decision Not to Create State Exchange Note: Status as of Aug 1, 2012; Kaiser Family Foundation for Medicaid and the Uninsured, State Health Facts, 8

9 Medicaid & Insurance Exchange Coverage Expansion and Funding Criteria Program Who s Paying # Covered $ Individual Premium and Cost Sharing Credits* To 133% FPL: 2% of income, max 6% of total costs % FPL: 3-4% of income, max 6% % FPL: 4-6.3% of income, max 13% % FPL: % of income, max 27% % FPL: % of income, max 30% % FPL: 9.5% of income, max 30% Small Businesses with <100 Employees State-Based American Health Benefit Exchanges State-Based Small Business Health Options Program (SHOP) Federal Grants to States to Establish Exchanges TBD and State On-Going Administration (can charge assessments or user fees) both apply to SHOP also. Federal Premium Tax and Cost Sharing Credits and the Individual Maximum Federal Employer Tax Credit of 35% - 50% **, Employer, and Individual +24 million 133% - 200% FPL Optional State-Based Basic Health Plan 95% Fed.***, State Admin, & Ind. To be determined To be determined Optional Non-Profit Consumer Operated & Oriented Plan (CO-OP) Multi-State Health Care Choice Compacts (min 2 per State, 1 non-profit) Federal $6B for Loans and Grants and Individual OPM Administration, Employer, and Individual < 133% FPL New Medicaid Eligibility Existing Eligibility Requirements (varies by State) Legacy Medicaid Federal: 100% , 95% 2017, 94% 2018, 93% 2019, 90% 2020 State % Starts % FMAP average Federal and State +16 million 47 million Note: The CBO expects that 8M Americans will move from their current insurance into either the Exchanges or Medicaid/CHIP. *Must be in Silver Plan (plan pays 70% of costs) to be eligible for Cost Sharing subsidies (Bronze 60%, Gold 80%, Platinum 90%). **Max Tax Credit of 35% to 2013 and 50% 2014 and later <25 employees. ***95% of the funds that would have been paid as federal premium and cost-sharing to eligible individuals to establish the plan. Current FPL is $10,830 for 1 person with $3,740 for each additional individual for the 48 Contiguous States and the District of Columbia (Alaska and Hawaii have separate FPLs). 9

10 An estimated 28,000,000 people will move between Medicaid and Health Insurance Exchanges Medicaid Insurance Exchange Within six months, more than 35 percent of all adults with family incomes below 200 percent of the federal poverty level will experience a shift in eligibility from Medicaid to an insurance exchange, or the reverse; within a year, 50 percent, or 28 million, will. Source: Sommers B D, Rosenbaum S Health Aff 2011;30:

11 Income Changes Over Time Among Adults Ages With Incomes Initially Under 133 Percent Of The Federal Poverty Level. Source: Sommers B D, Rosenbaum S Health Aff 2011;30:

12 Income Changes Over Time Among Adults Ages With Incomes Initially Between 133 Percent And 200 Percent Of The Federal Poverty Level. Source: Sommers B D, Rosenbaum S Health Aff 2011;30:

13 A continuous view of claims needed for better healthcare and administration Insurance Exchange 28M Medicaid 13

14 Health Insurance Exchange data required for risk adjustment ACA Sec Risk adjustment. Requires a permanent state program for risk adjustment Gives HHS in consultation with states, significant discretion on its design and implementation. Typically each enrollee s specific risk score is determined based on clinical conditions, typically captured through claims data. A health plan s score is typically an aggregation of each enrollee s score. A standard risk adjustment program across all insured populations provides greater, population-based predictability of health costs supporting a more refined approach to rate setting in the Medicaid/CHIP programs, and evaluation of premium rates in the private market. Risk adjustment data set can be examined for additional purposes Sources: Medicaid s Role in the Health Benefits Exchange, Bachrach, Boozang, Dutton, National Academy for State Health Policy and Robert Wood Johnson Foundation, March 2011; Rong Y and D Laurent. "What Kind of Risk Adjustment Systems Are Necessary for Health Insurance Exchanges, National Healthcare Reform Magazine, November 4, 2010; 14

15 Value of Merging Exchange and Medicaid Data Sample Outcomes Outcomes Effective and efficient risk adjustment Medicaid Target the right people for intervention Intervene with the right services HIX Health Insurance Exchange Better assess quality Evaluate programs for the entire population Improve program integrity by identifying fraud, waste, abuse and overpayment more effectively 15

16 Integrating Clinical and Claims Data The result -- powerful new insights into performance measurement 16

17 More effective population health management 17

18 More effective population health management 18

19 Value of Merging Clinical and Administrative Data: Sample Business Uses Example Clinical test results identify individuals whose disease is not controlled Reconciling medication orders with prescriptions finds individuals not taking needed drugs Business Use Target the right people for intervention in a timely way Intervene with the right services in a timely way Clinical data support more refined patient stratifications and outcomes Better assess treatment effectiveness Birth records add detail on neonatal complications Clinical data produces real outcome measures that can be examined along with cost of care Identify the right quality of care improvement strategies Purchase at the right cost based on value 19

20 LINKING CLINICAL WITH ADMINISTRATIVE DATA: MOST COMMON USE CASES Measure Results Monitor Health Identify Candidates Determine Impact Problem: A major defense contractor wanted to regularly monitor the status of their disease management population in order to make sure the program was having the intended consequence of improving health and reducing absenteeism Solution: Our consultants produce quarterly reports that include metrics around diabetes and hypertension lab results Result: The customer is able to hold the disease management vendor accountable for results Problem: A paper manufacturer wanted to better understand how well it s employees were managing their diabetes as they evaluated whether or not any interventions were needed. Solution: Our consultants produced a diabetes dashboard that provided year over year trends for a variety of measures, including blood glucose lab results. Result: The customer has a better understanding of the health status of their diabetic population and has the information it needs to make decisions around future interventions.. Problem: A health plan needed to identify members with specific conditions for inclusion in disease/care management programs. Solution: Our consultants produced a series of reports that used HDL cholesterol, LDL cholesterol, Creatine Serum, BUN, and HbA1c results to identify patients with poor results who could be targeted for intervention. Result: The customer was able to identify the right people for the right programs. Problem: A large pharmaceutical company needed to evaluate their pilot disease management program in order to determine whether or not to expand or discontinue it Solution: Our consultants reported on pre and post intervention measures of blood pressure, fasting blood glucose, cholesterol levels and body weight Result: Members of the program showed clinically meaningful improvements and as a result the program was expanded 20

21 POTENTIALS OF SECONDARY RESEARCH Required Lab Data egfr HbA1c HER2NEU Hepatitis B (HBV) Hepatitis C (HCV) HPV PsA Rheumatoid Factor Triglycerides Most Common Use Cases To stratify patients by severity/subtype of disease. For example, in a study of chronic kidney disease they often want to verify the level of kidney function, measured as the glomerular filtration rate (GFR). Or in a breast cancer study they would want to know the HER2NEU genomic status of each patient. To measure outcomes of treatment. In diabetes the near-term clinical outcome measure is the glycated hemoglobin (HbA1c) level. In the treatment of viral infections (hepatitis, HIV, etc.) the outcome of interest is the viral load. 21

22 Contact David Nelson Senior Director Truven Health (734)