Measuring the Impact of the ACA in Rhode Island Developing an Evaluation Framework for the ACA SHADAC and State Network Small Group Consultation Minneapolis, MN May 1, 2012 Tricia Leddy, RI Executive Office of Health and Human Services
Today s Presentation Building on RI s Past Experience: What Works? Measuring the Impact of Health Reform in RI Measuring the Impact of RI s Exchange Lessons Learned Potential impact of measurement 2
Building on Past Experience: What Works? RIte Care: Medicaid managed care development, implementation and monitoring Goals Established and Communicated Improve access to care Improve quality of care Reduce cost trends Objectives Established and Communicated: Measures / Indicators of Success Reduce uninsurance among children and families Increase primary/ preventive care visits Improve prenatal care Increase intervals between births Decrease childhood lead poisoning Improve access to children s dental services 3
Building on Past Experience: What Works? RIte Care: Medicaid managed care development and implementation and monitoring Measuring Indicators : Criteria for Data Sets Data available for RI Population Collected at least annually, so changes over time can be measured Benchmark available, so comparisons can be made: Health insurance coverage status available: Medicaid/RIte Care, Privately Insured and Uninsured Or Other states benchmark data available Five Available Data Sets met the criteria: 1. Current Population Survey (CPS), Annual Social and Economic Supplement (ASES), Census, 2. Behavioral Risk Factor Surveillance System (BRFSS), RI Department of Health 3. Hospital Discharge Data Set (HD, RI Department of Health 4. RI Vital Statistics Birth & Death Files (VS) RI Department of Health 5. Pregnancy Risk Assessment Monitoring System (PRAMS), RI Department of Health 4
Building on Past Experience: What Works? RIte Care: Measuring Performance Measure, communicate, and give credit to policy-makers / funders: National Data set example: 5
Building on Past Experience: What Works? RIte Care: Measuring Performance State Data Set example Vital Stats 6
Building on Past Experience: What Works? Measuring and Communicating Progress / Success: Set Policy Goals Establish Measurable Objectives Focus on person-centered measures Develop evaluation plan before the intervention begins Find existing data sets that can provide a context through a benchmark and provide trend data Create additional data sets only if needed to measure key objectives Measure: Keep it graphic, simple, and limit number of measures Repeat familiar measures each year; add more gradually Give credit to Policy Makers 7
Today s Presentation Building on RI s Past Experience: What Works? Measuring the Impact of Health Reform in RI Measuring the Impact of RI s Exchange Lessons Learned Potential impact of measurement 8
Measuring the Impact of Health Reform in RI The process for evaluating the impact of health reform in RI will be approached in two ways. Top Down Goals will drive measures of success Need specific measures matched to each overall goal Bottom Up Where s the data? Leverage preexisting data sources Look for opportunities to create new data sources: new administrative data systems Create new data sources when necessary, as the last choice 9
Top Down: Measuring the Impact of Health Reform in RI RI Healthcare Reform Commission In January 2011 the Governor signed Executive Order 11-04 establishing the R.I. Healthcare Reform Commission and its Executive Committee, and appointing the Lt. Governor as Chair: State government must provide clear leadership and accountability to ensure successful implementation of both ongoing state level healthcare reform initiatives and successful implementation of national health reform, which will cut across traditional lines of agency and department responsibility.. To assure on-going coordination, the R.I. Healthcare Reform Commission and its Executive Committee are hereby created. The R.I. Healthcare Reform Commission and its Executive Committee are tasked with coordinating health reform efforts in Rhode Island. 10
Top Down: Measuring the Impact of Health Reform in RI RI Healthcare Reform Commission Priorities Broad stakeholder involvement in establishing Priority Goals and Objectives, and defining success: Defining Health Reform Commission Goals and Objectives High level participation executive committee approved final goals/objectives Visible, public, iterative process Disseminate Information - A new website Healthcare.ri.gov has been established as a clearinghouse for public access to RI Healthcare Reform 11
Top Down: Measuring the Impact of Health Reform in RI 2011 RI Healthcare Reform Commission Priorities The RI Healthcare Reform Commission is tasked with coordinating health reform efforts in Rhode Island. Its 2011 priorities created community workgroups, reports, and demand for measures of current status How is RI doing? Expand access to high quality, affordable healthcare including Medicaid expansion and the Health Benefits Exchange Payment and delivery system reform Build the primary care workforce and the home and community-based care workforce Build the infrastructure to measure the impact of healthcare reform Develop and publish agreed upon outcome measures and metrics for tracking the efficacy of healthcare reform efforts in RI Facilitate effective implementation of the All Payer Claims Database Advance the successful implementation of Health Information Technology (HIT) including both EMR and the Health Information Exchange (HIE) (data collection and data sharing) Place all state related health data online for research and public health 12
Top Down: Measuring the Impact of Health Reform in RI 2012 RI Healthcare Reform Commission Priorities PROPOSED CONTINUING AND ADDITIONAL PRIORITIES: Facilitate RI s movement toward a more coordinated, effective health care delivery system. Continue to support coordinated health planning, system improvement and measurement. Support and coordinate expanding payment and delivery system reform. Support and coordinate expanding system performance measurement efforts. Facilitate successful implementation and integration of Exchange with other coverage efforts Add Strategic Communication focused on adequately communicating health reform to the general public 13
Bottom Up: Process for selecting success measures The process for selecting metrics needs to start with the end goals. Exchange Goals Start with definition of success Require broad stakeholder involvement Metrics Selection Determine metric for each success factor Include metrics in systems design Data Required Existing federal data most cost effective Availability of benchmarks and trends key State or administrative Data Identify gaps in available data 14
Bottom Up: Measuring the Impact of Health Reform in RI Defining Key Indicators of Health System Performance Measurement workgroup established to select and define harmonized measures to evaluate the performance of RI s health care delivery system Participants include RI Medicaid, OHIC, Quality Partners (the Medicare QIO), RI s all-payor medical home project, Brown s School of Public Health, the Dept. of Health, health plans, hospitals, etc. Uses existing databases Process identified the need for an APCD 15
Bottom Up: Measuring the Impact of Health Reform in RI Defining Key Indicators of Health System Performance Aggregate Indicators Priority Indicators Supplemental Indicators 1. Inpatient Admissions 3. Preventable Inpatient Admissions ED Visits, 30-Day Post-Inpatient Hospital Discharge 2. ED visits 4. All Cause Inpatient Readmissions 7. Observation Stays, 30-Day Post- Inpatient Hospital Discharge 5. Preventable/Avoidable ED visits 16
Bottom Up: Measuring the Impact of Health Reform in RI Defining Key Indicators of Health System Performance Next steps: Develop Indicator Dashboard Public Process, led by SHADAC Can include existing national and state databases Can include new databases under development: APCD Population Survey 17
Bottom Up: Measuring the Impact of Health Reform in RI New Database: Purpose and Major Uses of the APCD, currently under development: Provide OHIC with the information required to conduct ACA required riskadjustment in the small group and individual markets as well as inform health plan rate review, and measurement of OHIC s affordability standards Assure transparency of information about access, quality, utilization, efficiency, payments and cost of RI s health care delivery system. Provide public information about health care utilization and payment. Identify the major health care cost drivers in RI. Compare the performance and efficiency of Rhode Island s health care delivery system to other states. Provide information that will improve health care value (best product for the best price). Enable the evaluation of new initiatives, such as Patient-Centered Medical Home, Rhode Island Chronic Care Sustainability Initiative, the Beacon Community Program, and Medicaid s medical home programs 18
Today s Presentation Building on RI s Past Experience: What Works? Measuring the Impact of Health Reform in RI Measuring the Impact of RI s Exchange Lessons Learned Potential impact of measurement 19
Measuring the Impact of RI s Exchange RI Health Benefits Exchange Mission and Goals Developed using a Broad Public Process: State Leadership and Staff Community Stakeholder meeting Exchange Board of Directors / Public Meeting 20
Top Down: Measuring the Impact of RI s Exchange RI Health Benefits Exchange (HBE) Mission and Goals RI Health Benefits Exchange Mission: The Rhode Island Health Benefits Exchange will serve as a robust resource for Rhode Islanders and Rhode Island businesses to learn about and easily compare the quality and affordability of their health insurance options, enroll in coverage and, if eligible, access subsidies for coverage. RI Health Benefits Exchange Goals Improve the health of Rhode Islanders Achieve near universal coverage Favorably impact health insurance cost trends Favorably impact health care delivery system effectiveness and efficiency Add value to employer health insurance purchasing 21
Bottom Up: Measuring the Impact of RI s Exchange HBE Evaluation Metrics Potential metrics for each of the Exchange goals. HBE Goal Potential Metrics Data Source Improve the health of Rhode Islanders Health status BRFSS Other survey data? Achieve near universal coverage # uninsured in state ACS/CPS Favorably impact health insurance cost trends Favorably impact health care delivery system effectiveness and efficiency Add value to employer health insurance purchasing Average cost of insurance plans Average cost of insurance after subsidies Hospital readmissions Preventable hospitalizations Avoidable ED visits # employers in SHOP Exchange % of employers offering insurance % of employees with insurance Cost of small business insurance MEPS Exchange data Medicare data Other state sources? MEPS Exchange data Other survey data? 22
Bottom Up: Choosing HBE success measures Use the best data available while working on finding better data. Leverage existing federal data Nationwide benchmarks are key to defining success Trend data available Most cost-effective to use existing data Define data needed from Exchange systems Ensure that key data will be available by including measures in the systems design process UHIP (United Health Infrastructure Project) will include Exchange, Medicaid and SHOP data Identify other potential sources of data DOH, OHIC, other state departments APCD under development 23
Bottom Up: Choosing HBE success measures Metrics need to measure impact of the Exchange and health reform efforts on ALL Rhode Islanders, not just those who enroll through the Exchange. Rhode Islanders seeking Health Insurance Medicaid eligible individuals Subsidy eligible individuals Individuals (self pay no subsidy) Employees of Small Employers Employees of Large Employers (1) Web Portal: a robust marketplace for all Rhode Islanders to identify health insurance options and purchase coverage (2) Determine Eligibility Determine eligibility for Medicaid, exchange based tax credits, other human services program support (3) Enroll Enroll in coverage, & facilitate subsidy 24
Bottom Up: Choosing HBE success measures Building measurement infrastructure Many of these measures are available already or will be available with the implementation of planned new data sources. Existing federal /state data sources APCD UHIP eligibility and enrollment system New RI Health Information Survey ACS Community Survey CPS MEPS BRFSS Medicare data Under development Claims data Enrollment data Utilization Payments Exchange enrollment Medicaid enrollment SHOP enrollment User experience data from web portal Health status Access to affordable insurance Similar to other state s surveys so benchmark data may be available 25
Bottom Up: Measuring the Impact RI s Exchange New Database: UHIP: Unified Health Infrastructure Project UHIP is the integrated eligibility and enrollment system to be used by the Exchange, Medicaid and (in the future) all other human services programs. UHIP will contain enrollment, subsidy, and premium payment information for the Exchange and Medicaid UHIP includes a web portal for Rhode Islanders to determine eligibility for subsidies, compare pricing information, and enroll in insurance. Metrics for the measurement of user experience are being considered now and will be included in the final specifications for the design of UHIP. 26
Bottom Up: Measuring the Impact of RI s Exchange New Database: RI Health Information Survey Rhode Island is working with SHADAC to design and conduct a health information survey during 2012 Information from the survey will be used for a microsimulation analysis of potential Exchange enrollment and other insurance status changes as a result of ACA implementation Survey info will also give us a baseline for measurement of changes in health status and insurance status in the future RI s survey is based on the Coordinated State Coverage Survey (CSCS) in order to facilitate comparisons to other states 27
Today s Presentation Building on RI s Past Experience: What Works? Measuring the Impact of Health Reform in RI Measuring the Impact of RI s Exchange Lessons Learned Potential impact of measurement 28
Lessons Learned Know what your end goal is when you start Create consensus around a vision early Identify which objectives are important to your stakeholders so can align measures with those objectives to demonstrate success Leverage existing data sources Cost effective Reliable, known data sources more readily accepted Transparency: measures must be derived from publicly available data using clear and simple methods Benchmarks are key to making a measurement meaningful Is 5% hospital readmission good or bad? Need a comparison. 29
Today s Presentation Building on RI s Past Experience: What Works? Measuring the Impact of Health Reform in RI Measuring the Impact of RI s Exchange Lessons Learned Positive impact of measurement 30
Positive impact of measurement Demonstrate success to ensure continued political support Demonstrate success Identify areas for improvement Make midcourse corrections Evaluate progress against nationwide benchmarks 31