Healthcare Transformation Learning Session August 22, 2014 Improving Healthcare Transparency in Greater Columbus …exploring the opportunities and challenges for consumers, providers, and purchasers Medical claims …Commercial, Medicare, Medicaid
Clinical data
…electronic medical records
Upcoming Learning Sessions 9/24/14 Webinar 1:00 - 2:00p Topic: Better Health Care Changes to Learn About 10/22/14 Webinar 1:00-2:00p Topic: Pharmacists expanded roles in value-based healthcare 12/5/14 In-Person, 8:30-11:30a Topic: Annual showcase of best practices and lessons learned featuring our pubic-private partners
Patient surveys
www.hcgc.org
…experiences
Improved healthcare transparency
Register today! www.hcgc.org/registration
AGENDA Objectives
• AWARENESS on All-Payer Claims Database (APCD) – transparency area with the most activity and learning available • EXPLORE opportunities and challenges for consumers, providers, purchasers • LEARN from diverse perspectives of participants
8:30-8:50a
Welcome & Briefing • Krista Stock & Jeff Biehl, Healthcare Collaborative of Greater Columbus
8:50-10:50a
APCD Overview • APCD -- What and Why • Usage Examples – How are APCDs being used? Featured Speaker • Jo Porter, MPH, Deputy Director for the Institute for Health Policy and Practice at the University of New Hampshire and the co-chair of the national All-Payer Claims Database (APCD) Council. Discussion Panel • Tom Hadley, Senior Vice President, Wells Fargo Insurance Services • Kevin Hinkle, Regional Vice President, Anthem Blue Cross and Blue Shield • Isi Ikharebha, MPH, Executive Director, Physicians Care Connection • Bill Wulf, MD, CEO, Central Ohio Primary Care
10:50-11:00a Next Steps
All-Payer Claims Database (APCD) Overview Does Ohio Need an All Payer Claims Database? Discussions regarding healthcare payment reform in Ohio are gaining momentum, with initiatives such as the State Innovation Model grant, Comprehensive Primary Care initiative, and local and payer initiatives. If Ohio will be successful with payment reform, a credible measure of value is needed. An All Payer Claims Database could serve as a tool for measuring value. What is an APCD? An All-Payer Claims Database (APCD) is a statewide database that is used to systematically collect and aggregate health care cost and quality data from all health care payers in order promote cost containment and quality improvement efforts. Data could include medical claims, dental claims, pharmacy claims, patient eligibility files, and provider files. APCDs may be driven by state law or voluntary data collection efforts. APCDs combine data from all payers, providing statewide information to answer questions related to costs, quality, utilization patterns, and access to care. When the data are made publically available, consumers and purchasers have the tools they need to compare prices and quality, in order to make informed health care decisions. According to the All-Payer Claims Database Council, eleven states currently have mandated APCDs (i.e., Maine, New Hampshire, Vermont, Massachusetts, Maryland, Tennessee, Minnesota, Kansas, Colorado, Utah, and Oregon). An additional three states have voluntary APCDs in existence (i.e., Washington, California, and Wisconsin). Six states are in the process of implementing an APCD (i.e., Rhode Island, Connecticut, New York, Virginia, West Virginia, and Nebraska). Why is an APCD a good idea for Ohio? Numerous stakeholders in Ohio are working to achieve the Triple Aim of improving the patient experience of care, improving the health of populations, and reducing the per capita cost of care for all Ohioans. In order to be truly successful with payment reform efforts, a tool such as an APCD could be crucial in providing a credible source of measuring value. An APCD could assist with these efforts in numerous ways, including: • Serve as a tool for health equity work • Serve as a tool for patient safety work • Aid in payment reform work, including enabling strategies to pay for value (e.g., shared savings) • Enable price transparency for health care consumers • Answer important questions about cost and quality of care • Enable data-driven policymaking (e.g., population health) and legislative efforts • Enable measurement of impacts of treatments and policy interventions • Encourage consumer engagement and informed decision-making Who may benefit from an APCD? Many stakeholders in Ohio would benefit from an APCD, including consumers, employers, insurers, health professionals, health care facilities, researchers, and government (e.g., Medicaid, public health). Consumers, for example, could benefit if an APCD is used to improve patient safety, address health disparities, and increase price transparency. Healthcare providers may be interested in an APCD for the purposes of quality improvement and payment reform efforts. Employers may benefit by obtaining information about employee utilization of preventative health services, quality of care, and cost of care.
Source: Ohio Patient-Centered Primary Care Collaborative (OPCPCC), August 2014
Glossary of Key Cost and Transparency Terms
Source: Aligning Forces for Quality (AF4Q), Defining the Problem Allowed (or Allowable) Amount: The most amount of money that a health plan will pay for a covered good or service. The allowed amount is negotiated between the plan and the provider, reflecting any discount the plan is able to achieve for its members. The allowed amount reflects the “true price” of health care, but allowed amounts usually are considered proprietary information and rarely are released to the public. Often used interchangeably with cost. Charge: The amount of money a provider would seek across the board. This amount often is charged to patients who do not have health insurance; health plans typically negotiate the charge down to the allowable amount on behalf of their members. Claim: A request for payment by a provider; a bill the provider sends to the health plan. Claims Database: A database, sometimes created by state mandate, that includes claims data derived from medical, eligibility, provider, pharmacy and or dental files. Many claims databases rely exclusively on administrative claims from commercial insurers (e.g., a private health plan such as BlueCross BlueShield) to create their performance measures. Some cost reporting efforts are based upon all-payer claims databases, which include Medicare, Medicaid, and self-pay patients. Cost: The amount of money actually paid to a health care provider. As a performance measure, cost is a measure of the total health care spending, including total resource use and unit price(s), by payer or consumer, for a health care service or group of health care services associated with a specified patient population, time period, and unit(s) of clinical accountability. This term often can be used interchangeably with allowed amount. Efficiency: The relationship between a specific product (output) of the health care system and the resources (inputs) used to create the product. Episode of Care: A grouping of a series of care which quantifies the services (resources used) across multiple settings and providers involved in the diagnosis, management and treatment of specific clinical conditions. Episode-of-care measures can be developed for the full range of acute and chronic conditions, including diabetes, congestive heart failure, acute myocardial infarction, asthma, low back pain and many others. Because episodes of care can be defined more tightly and specifically around aspects of a given clinical condition, it may be easier to determine accountability based on per-episode than on per-capita measurement efforts. Pay-for-Performance (P4P): The general strategy of promoting quality improvement by rewarding providers (meaning individual clinicians or, more commonly, clinics or hospitals) who meet certain performance expectations with respect to health care quality or efficiency. Price: The amount paid for a service or product, typically determined via market mechanisms that take into account the supply of and demand for the service or product. AF4Q defines price as the amount a consumer would pay for a service. Relative Resource Use: A general term for utilization of health care services. The term resource use measures broadly captures indicators of the cost and efficiency of providing health care. Health care resource use measures reflect the amount or cost of resources used to create a specific product of the health care system. The specific product could be a visit or procedure, all services related to a health condition, all services during a period of time, or a health outcome. Value: Often loosely defined as quality divided by price. Simply defined, value is the health outcome per dollar of cost expended. The National Quality Forum (NQF) has defined value of care as “a measure of a specified stakeholder’s (such as an individual patient’s, consumer organization’s, payer’s, provider’s, government’s, or society’s) preference-weighted assessment of a particular combination of quality and cost of care performance.”
Glossary of Key Health Care Quality Terms
Source: National Committee for Quality Assurance (NCQA),The Essential Guide to Health Care Quality Accreditation: A “seal of approval” presented to a hospital, health plan or other organization for meeting a specific set of criteria or standards. Accreditation is viewed as a symbol of quality. The Joint Commission on the Accreditation of Health Care Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA) are the most well-known health care accreditation organizations. Benchmark: In health care, a way for hospitals and doctors to analyze quality data, both internally and against data from other hospitals and doctors, to identify best practices of care and improve quality. Chronic Disease: A disease that is long-lasting or recurrent and which can become a non-life threatening condition with proper disease management. Examples include diabetes, asthma, heart disease, kidney disease and chronic lung disease. Computerized Prescription Order Entry (CPOE): A software system that allows doctors to transmit their directions for patient care electronically to other medical staff. Done properly, CPOE speeds treatment and reduces human error related to handwriting or transcription. Consumer-Directed Care: A form of health insurance that combines a high-deductible health plan with a tax-favored health savings account to cover out-of-pocket expenses. Disease Management: An approach designed to improve the health and quality of life for people with chronic illnesses by keeping their conditions from getting worse. Disparities: Most often used to describe differences in the delivery of health care, access to health care services and medical outcomes based on ethnicity, geography, gender and other factors that do not include socioeconomic status or insurance coverage. Understanding and eliminating the causes of health disparities is an ongoing effort of many groups and organizations. Electronic Health Record (EHR): A computerized medical file that contains the history of a patient’s medical care. Evidence-Based Care or Evidence-Based Medicine: Patient care that combines the expertise of health practitioners with the best available research evidence to ensure quality, effectiveness and safety. Health Information Exchange (HIE): A computer based network that allows sharing of patient information across hospitals, doctors and other health care institutions in a city, state or region. More than 100 state and regional HIE projects are under way across the country. Health Information Technology: The use of computers, software programs, electronic devices and the Internet to store, retrieve, update and transmit information about patients’ health. Health Plan Employer Data and Information Set (HEDIS): A set of health care quality measures designed to help purchasers and consumers determine how well health plans follow accepted care standards for prevention and treatment. Formerly known as the Health Plan Employer Data Information Set. Medical Error: A mistake that harms a patient. Adverse drug events, hospital-acquired infections and wrong-site surgeries are examples of preventable medical errors. Medical Record: A paper or electronic history of a patient’s medical care that includes information about past illnesses, injuries, allergies, medications, vaccinations and treatment.
Glossary of Key Health Care Quality Terms (continued) “Near Miss”: A mistake that almost happens but is avoided. Many patient-safety advocates urge hospitals and doctors to track their near misses so that they can identify and implement processes that will make care safer. Patient Registry: A patient database maintained by a hospital, doctors’ practice or health plan that allows providers to identify their patients according to disease, demographic characteristics and other factors. Patient registries can help providers better coordinate care for their patients, monitor treatment and progress and improve overall quality of care. Patient-Centered Care: Care that considers patients’ cultural traditions, their personal preferences and values, their family situations and their lifestyles. Responsibility for important aspects of self-care and monitoring is put in patients’ hands—along with the tools and support they need. Patient centered care also ensures that transitions between different health care providers and care settings are coordinated and efficient. When care is patient centered, unneeded and unwanted services can be reduced. Performance Measures: Sets of established standards against which health care performance is measured. Performance measures are now widely accepted as a method for guiding informed decision making as a strong impetus for improvement. Practice Guideline: A specific set of care recommendations designed to help health care professionals and patients make decisions about screening for preventing or treating a health condition. Practice guidelines generally are developed by reviewing the best available medical evidence, or, where such evidence is lacking, through an expert consensus process. Sometimes the two methods are combined. Sentinel Event: Any unexpected event in a health care setting that causes death or serious injury to a patient and is not related to the natural course of the patient’s illness. Telemedicine: Remote medical care provided by doctors, nurses and other health care professionals for a patient who is in an isolated area or is unable to travel. Value Purchasing: A broad strategy used by some large employers to get more value for their health care dollars by demanding that health care providers meet certain quality objectives or supply data documenting their use of best practices and quality treatment outcomes.
Collaborative Transformational Activities
Coordinated by:
(updated: 8/18/2014)
The Healthcare Collaborative of Greater Columbus is a non-profit, public-private partnership. We serve as a catalyst, convener, and coordinator of healthcare transformation & learning in Greater Columbus. Strategic Areas of Focus Shared Responsibility …exploring and catalyzing best practices to improve engagement between consumers, providers, and purchasers
Collaborative Activity
Activity Purpose
Choosing Wisely
CONSUMERS, PROVIDERS, PURCHASERS engaging in meaningful discussion about healthcare procedures that may be unnecessary, and in some instances can cause harm
Patient Engagement Education & Training
CONSUMERS engaging in their healthcare by using the right questions
Open Notes
CONSUMERS, PROVIDERS engaging in the use of online access to visit notes
Patient-Centered Medical Home
PROVIDERS achieving national recognition as a patient-centered medical home (PCMH)
Medical Neighborhood Pilot
PROVIDERS implementing a shared client referral infrastructure
Physical-Behavioral Integration Pilot
PROVIDERS measuring the value and sustainability of integrating physical and behavioral healthcare
Healthcare Transparency …exploring and catalyzing best practices to improve access to price and quality information
Primary Care Quality Reporting Pilot
PROVIDERS sharing comparative quality data and demonstrating the meaningful use of health information technology
Apply Collaborative Learning …exploring and catalyzing best practices to improve the application of learning in Greater Columbus
• •
CONSUMERS, PROVIDERS, PURCHASERS exploring best practices and sharing lessons learned from national, state, and regional activities
Healthcare Delivery …exploring and catalyzing best practices to improve the value of healthcare
• • • • • •
Public-Private Board of Directors National, State, and Regional Healthcare Improvement Collaboratives Healthcare Transformation Learning Sessions Speaking Engagements Behavioral Health Learning Group FQHC Senior Leadership Group Navigator & Certified Application Counselor Learning Group Purchaser Learning Group www.hcgc.org
Our Public-Private Funding Partners Lead Supporter
Major Supporters
Additional Supporters 100% of our Board of Directors & Staff www.hcgc.org
Individual & Corporate Donations