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All Payer Claims Database and Health Information Exchange ARRA Opportunities and Challenges Anthony Rodgers, Director Arizona Health Care Cost Containment.

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Presentation on theme: "All Payer Claims Database and Health Information Exchange ARRA Opportunities and Challenges Anthony Rodgers, Director Arizona Health Care Cost Containment."— Presentation transcript:

1 All Payer Claims Database and Health Information Exchange ARRA Opportunities and Challenges Anthony Rodgers, Director Arizona Health Care Cost Containment System

2 Challenges of Linking Health Information Exchanges with All Payer Administrative and Clinical Data Bases

3 The Connected Healthcare System Remote Patient Self Monitoring Hospital Care Coordination Order Entry Lab Result Reporting EHR/HIE Specialist Referral E-Prescribing MCO Medical Medical Mgmt. & Administrative Data Primary Care Medical Home Provider Research & Comparative Effectiveness Diagnostics

4 Rational for Building a Clinical & Administrative Data Repository Facilitates Cost and Quality Transparency Essential for Continuity of Care Records Facilitates Population Health Management Improves Medical Management Improve Program Evaluation and Decision Making Facilitates Comparative Effectiveness Research Enhances Health Policy Formulation Simulation

5 Focus Building the State Level HIT Infrastructure Labs Rxs Othe r EHR1 EHR2 EHR3 EHR4 PHR5 PHRn EHR1 EHR2 EHR3 EHRn HI E Aggregated Clinical Database Repository Couple with HIE

6 Basic Health Information Exchange with Data Repository Web Browser Provider EHR Health Plan Adm.. Sys Laboratories Pharmacies Web Portal Server Clinician Data Repository Master Patient Index Basic Patient Health Summary HIE Record and Results Delivery Interfaces HIE Utility Applications Clinical Data Repository

7 Federated Model for Data Exchange Distributed Data Marts

8 Health Information Exchange Platform Architecture Radiology Health Data Publication Layer Clinical Lab Data Sources Health Data Management Layer Health Data Integration and Translation Layer Data Analysis Applications Web Services Application Collaborative Knowledge Management Platform Services Value Added Web Services Security and Consent Policy AdministrativeEHRRx History

9 HIT Infrastructure Platform Design


11 Mapping Data Partners and Data Utilities

12 Administrative Data Sets

13 Methodology for Reconciling Encounter Data Completeness Number Claims Converted to encounters New day encounters Adjudicated new day encounter Pended encounter Resolved pended encounter Total adjudicated and percent adjudicated Paid member months Claims per member per month Adjudicated encounter per member month

14 Methods of Aggregating Data There are four different form types of claims/encounters types: HCFA 1500 Encounters (Form A) - Used primarily for professional services, including: physician visits, nursing visits, surgical services, anesthesia services, laboratory tests, radiology services, home and community based services, therapy services, Durable Medical Equipment (DME), medical supplies and transportation services. Services must be reported using appropriate HCPCS procedure codes. UB-92 Encounters (Form B) - For facility medical services, such as inpatient or outpatient hospital services, dialysis centers, hospice, nursing facility services, and other institutional services. Services must be reported through the use of revenue codes and bill types. Universal Drug Encounters (Form C) - For prescription medicines and medically necessary over the counter items. Dental Encounters (Form D) - For dental services.

15 UB92 Encounter Types Beneficiary member ID Service provider ID Bill type Total bill amount (from the last encounter detail line containing revenue code ‘001’) Service begin date Service end date

16 Breakdown of Key Data Elements: HCFA 1500, Universal Drug Encounters, Dental Encounters Key Encounter Fields Beneficiary member ID Service provider ID Procedure code National Drug Code (Form Drug only) Procedure modifier (HCFA 1500 only) Diagnosis code (Form HCFA 1500 only) Service begin date Service end date Tooth number (Form Dental only) Tooth surface number (Form Dental only)

17 Common Claims Data Fields Coding definitions are provided for the following data fields : Admission Types Admission Source Bill Type Codes Category of Service County Codes Diagnosis Codes EPSDT Type Codes Patient Status Pharmacy Codes (NDC) Place of Service Codes Procedure Codes Procedure Modifier Codes Revenue Codes Sub-capitation Codes Units of Service

18 Provider Data Sets For each provider, the following information is included: Provider Demographic data Provider status Categories of service type Service rates Licenses/certifications Specialties Medicare coverage Restrictions Service/billing addresses

19 Provider Types 01 Hospitals 02BPharmacy 03CLaboratory 04AClinic 05AEmergency Transportation 06ADentist 07DPhysician 08ANurse-Midwife 09APodiatrist 10APsychologist 11ACertified Registered Nurse Anesthetist 12AOccupational Therapist 13APhysical Therapist 14ASpeech/Hearing Therapist 15AChiropractor 16ANaturopath 17APhysicians Assistant 19ARespiratory Therapist 20ANursing Home 22BHome Health Agency 23APersonal Care Attendant 24AGroup Home (Developmentally Disabled) 25AAdult Day Health 27ANon-Emergency Transportation Providers 28ACommunity/Rural Health Center 29ADME Supplier 30AOsteopath 31ARehabilitation Center 33AHospice 35BAdult Care Home 36AHomemaker 37ADevelopmentally Disabled Day Care

20 Categories of Services 01Medicine 02Surgery 03Respiratory Therapy 05Occupational Therapy 06Physical Therapy 07Speech/Hearing Therapy 08EPSDT 09Pharmacy 10Inpatient Hospital (Room & Board and ancillary) 11Dental 12Pathology & Laboratory 13Radiology 14Emergency Transportation 15DME and Appliances 16Out-Patient Facility Fees 17ICF 18SNF 19ICF/MR 20Hospice Inpatient Care 21Hospice Home Care 22Home Delivered Meals 23Homemaker Service 24Adult Day Health Service 26Respite Care Services 27IHS Outpatient Services 28Attendant Care29Home Health Aid Service 30Home Health Nurse Service 31Non-Emergency Transportation 32Habilitation 37Chiropractic Services 39Personal Care Services 40Medical Supplies 42DD Programs (DD Day Care Programs) 44Home & Community Based Services (Other) 45Rehabilitation46Environmental 47Mental Health Services 48Licensed Midwife 98Case Manager

21 Methodology Aggregating Data for Categories of Service Report By creating a two-digit coding definition called a Category Of Service (COS) can perform cost and utilization comparisons. The COS is determined based on an encounter’s procedure code, bill type, revenue code, or pharmacy NDC code. This is not part of the encounter but is determined by the business user. For HCFA-1500 and Dental encounters, the COS assignment is determined by the range or description of each HCPCS procedure code. –For example, AHCCCSA assigns COS 12 (pathology & laboratory) to HCPCS procedure code G0001 (Routine venipuncture of finger/heel/ear for collection of specimen/s). – For UB-92 encounters, the COS assignment is based on the bill type and revenue codes used on the individual encounter. –For Universal drug form encounters, the COS is based on the NDC code. A current list of the AHCCCSA assigned COS is summarized in the following table.

22 Cost Performance Score by MCO Hypothetical Illustration: * Performance Index equals the Expected Paid divided by the Actual Paid and is controlled by ETG Case mix. Expected Cost Performance Low PI Means Higher than Expected Cost per EPC Significant Lower Cost per EPC

23 Cost and Quality Value Performance (hypothetical illustration) Low Cost But Low Quality Outcome High Quality but High Cost Value Performance Target Cost Target



26 Enterprise Level Data Repository and Decision Support Infrastructure Public Health Claims/Encounter Clinical Data Sets Demographic Data Prescription Drug EHR Data Evidence-Based Medicine Comparative Data Sets Beneficiary Data Sources External Data / Profiles Program Data Methods/Analytics Episodes of Care Performance Measures Disease Staging Data Management Process Security Protection Integration Translation Standardization Data Validation Profile and Screens Data Architecture And Data Cubes Data Architecture And Data Cubes Medical Management Fraud Detection Cost and Quality Analysis Performance Analysis Eligibility Analysis Chronic Illness Sub-databases Registries Chronic Illness Sub-databases Registries Decision Support Reporting Applications Eligibility Data Data Warehouse Health Plan & Provider Decision Support Health Plan & Provider Decision Support

27 Creating Key Performance Transparency Inpatient Cost and Utilization Pharmacy PMPM cost Diagnostic PMPM cost Percent LTC members in home and community based settings Bed days and admissions per 1000 ER Cost and Utilization Per 1000 Overall for long term care PMPM cost Member satisfaction level Provider satisfaction level Enrollee healthcare access Quality of care rates against HEDIS targets MCO program cost effectiveness level Health plan administrative performance and efficiency levels: claims and business process cycle times and per transaction cost for administrative activities (e.g. claims, eligibility screening, etc.)

28 Cost Containment Quality Improvement Administrative Efficiency Public Health & Research Meaningful Use of EHR to better coordinate care and Quality Performance Meaningful use of EHR to Reduce Admin. Process Cycle Times Meaningful Use of EHR to build Population Health Mgmt. & Research Meaningful Use of EHR to reduce Duplication, Errors and improve Admin Efficiency Strategic HIT Focus Areas Reduced Unnecessary Cost/Utilization = Reduced PMPM & Lower % Admin Cost HIT Strategic Performance Metrics Performance Outcomes Higher Provider Satisfaction & Reduction in Admin. Cost Public Health Responsiveness Reduction in Health Disparities Improved Quality Against HEDIS and Other Benchmarks Meaningful USE Barrier PERFORMANCE Management Barrier Strategic Planning Logic Map Map of Strategic Outcomes for EHR Adoption Efforts

29 Clinical Data Repository

30 Strategies and Approaches Big Bang: building the mother of all clinical and administrative data repositories interface via HIE. Incremental: Start with well defined electronic clinical data sets from a common EHR for example: – Build around the Medicaid or other payer claims database –Build a clinical data repository from linked EHRs, –Build a data mart with public health database, –Build around an integrated hospital system with EHR) Data Mart to Data Mart: Start with a smaller distributed data mart approach linking each data mart and pull data to run data analysis or other applications. Centralized Data Warehouse: Use clinical data repository and administrative data repository under the management of a trusted authority.

31 New State Level Roles and Responsibilities Governor’s role: Decide who will lead state level development of HIE ( State Designate Entity (SDE)) Appoint a HIT Coordinator for the state (agency level position) Assign and accountable party to develop and implement Strategic HIT plan for the state –Ensure effective governance of HIE in the state –Develop state level directories and enable technical services for HIE –Remove barriers and create enablers for HIE (Lab, hospitals, clinicians, health plans, and other information data partners) –Convene stakeholders Assure the participation and integration of public health programs, Medicaid, and private delivery systems in health information exchange Assure the development of effective privacy and security requirements for HIE State’s will be awarded grants in the range of $4.0 to $40.0 million. (

32 New CMS Roles and Responsibilities CMSO –Set expectations for public accountability and transparency, –Develop a Medicaid Roadmap and Strategic Framework for wide-spread adoption of EHR technology in Medicaid and integrating planning with other federal agencies, –Set overall state Medicaid performance standards, –Establish the policy and HIT standards for Medicaid, –Provide evaluation and dissemination of best practices, –Participate in national policy and consensus standard making bodies, –Leverage successful HIT Medicaid Transformation grantee initiatives and provide continued support, –Support the work of the Multi-Collaborative for Medicaid Transformation and other –Provide adequate technical support for Medicaid programs and Medicaid providers

33 New Medicaid Roles and Responsibilities State Medicaid Agency Role: –Participation in development of a specific State roadmap for HIT adoption and use as it relates to Medicaid as well as the state’s plan of HIE, –Set Medicaid-specific performance goals related to EHR technology adoption, use, and expected outcome, –Establish leadership accountability for assuring return on investment and provider public reporting on clinical quality, –Arrange or provide technical assistance and training of Medicaid providers in planning, adoption, and use of EHR, –Provide forums and opportunities for input from stakeholders, –Collaborate and coordinate with other HIT initiatives in the public and private sector, –Continue to bring successful Medicaid Transformation Grant initiatives to scale, –Initiate, where appropriate, State legislation to create legal and regulatory authorities for HIT, –Ensure existing quality reporting processes are aligned

34 Questions?

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