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  Governors Task Force on Health Care Access and
Reimbursement MHCCs efforts to Expand Health
Information Technology Adoption

• Rural Health Roundtable
• October 2, 2008
• Ben Steffen
• Center Director
• Maryland Health Care Commission

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Organization of Presentation

• Task Force on Health Care Access and
  Reimbursement
• Possible Recommendations
• Impact on Rural Communities and Rural Providers
• State Health Information Technology Initiatives
• Opportunities for Rural Providers

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HCAR Mission Develop Recommendations on

1. Options to increase physician reimbursements
   given limitations in Federal law.
2. Options available to increase the ability of
   physicians to negotiate reimbursement rates with
   health insurance carriers
3. The sufficiency of present statutory formulas for
   the reimbursement of noncontracting providers.
4. Do state agencies have sufficient authority to
   regulate rate-setting and marketrelated
   practices of insurance carriers ( that
   unreasonably reducing reimbursements)?

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HCAR Mission Develop Recommendations on

• Need to establish a ratesetting system for
  physicians and other health care providers.
• Advisability of the use of payment method linked
  to quality of care or outcomes,
• Need to prohibit a health insurance carrier from
  requiring health care providers to participate in
  another carriers network.
• Should carriers provide incentives for physicians
  to provide care on evenings and on weekends.
• The ability of primary care physicians to be
  reimbursed for mental health services performed
  within their scope of practice.

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What are the some of the problems?

1. Geographic and income-driven access problems,
   concerns that problems are worsening.
2. Federal law limits state policymakers ability to
   act.
3. Highly concentrated health insurance market
   little prospect for new entrants.
4. High costs per user has fueled purchaser and
   consumer resistance to fee increases.
5. Reimbursement systems poorly linked to desired
   outputs.
6. Uneven quality and cost efficiency systems to
   measure quality and effectiveness are in their
   infancy.

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Process

• October 2007 August 2008 gathered information
  on
• Insurance market concentration
• Physician workforce and future needs
• Challenges of rural areas and existing programs
  to address shortages
• Variations in reimbursement rates across
  specialties
• Alternatives for spawning growth in primary care
• Factors affecting practice formation
• October December 2008
• Task Force develops recommendations
• Public Comment
• Submission of the recommendations to Governor and
  General Assembly

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Options that affect rural communities

• Establish a practice development loan program
• Many communities struggle to attract providers
• Practices are economic resource
• Modify incentives for reimbursing
  non-participating providers (19-710.1)
• Raise reimbursement levels for non-participating
  providers that treat HMO patients
• Set payment floors for PPO payment to
  non-participating providers in hospital-setting
  (where patient cant choose provider).
• Require the carrier or provider to absorb cost of
  non-participation
• Limit carriers ability to designate a hospital as
  a participating provider ,if physicians are
  non-participating.
• Allow further experimentation with reimbursement
  alternatives
• Develop a demonstration to test the feasibility
  of a hospital-based physician payment system.
• Require pay-for-performance systems to be linked
  to factors in addition to cost efficiency
• Promote greater transparency in design

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Options that affect rural communities (continued)

• Further primary care practice development.
• Leverage Marylands leadership in
  patient-centered medical home development by
  participating in demonstrations .
• Encourage rural hospital residency program
  development .
• Establish a loan program to finance residency
  program development.
• Require commercial carriers and Medicaid to pay
  10 percent bonus in rural geographic HPSAs as
  required under Medicare.
• Expand incentives to provide cost effective care.
• Require commercial payers to incentivize
  providers for after hours care, phone and eVisit
  communications delivered at any time of the day
  or night.
• Establish parity in payments for primary care
  physicians that provide mental health services
  within scope of practice.
• Improve ability to plan for future needs by
  improving data collection on physician practices
  through the Maryland Board of Physicians and MHCC.

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The promises of Health IT

• Fewer adverse drug events, medical errors, and
  redundant tests and procedures because EHRs can
  ensure physicians have access to an accurate and
  complete health history.
• Faster diagnoses and treatment of serious
  illnesses with comprehensive information
  available at the touch of a screen.
• Timely provision of preventative care and
  services, such as health screenings, which can
  help reduce health care costs.
• Better communication between patients and
  physicians, giving patients enhanced access to
  timely information.
• Shorter wait times for patients and lower
  operating costs for physicians through improved
  office efficiency.

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Why the Slow Pace?

• Health IT adoption in integrated systems VA, DOD,
  Kaiser Permanente, Geisinger, Mayo Clinic.
• Significant internal savings and quality
  improvements accrue to organization bearing the
  expense.
• Non-integrated providers have a more difficult
  time capturing the benefits of IT.
• External savings accrue to the system , not the
  investor .
• Current financial incentives may penalize
  providers for use.
• Providers and payers feel competitive pressures
  -- sharing information may allow competitors to
  pursue patients.
• Inability to internalize investment is a major
  factor in slow adoption.

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Marylands Health Information Technology Strategy

• Determine roadblocks and identify possible
  solutions.
• Plan a Consumer-Centered Information Exchange.
• Collaborate with other states and federal govt
  in joint initiatives and demonstrations.
• Use the planning process and shared knowledge
  gained through collaboration to launch health
  information exchange.
• Need for experimentation is great and other
  parallel innovations in care delivery and
  reimbursement must also occur.

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Consumer-Centered Health Information Exchange
Planning Phase(Building the Backbone)

• Two multi-stakeholder groups were chosen the
  Chesapeake Regional Information System for our
  Patients and the Montgomery County Health
  Information Exchange Collaborative.
• Both groups received approximately 250,000 to
  take part in the planning phase funded through
  the all-payer rate system
• A final report is due in early 2009 that will
  address governance, privacy and security, access
  policies, strategies to ensure appropriate
  patient engagement, general architecture,
  proposed technology, estimated costs, and a
  possible sustainable business model.
• Development phase to follow for an exchange
  based on principles proven in the planning
  period. Development phase will be funded at
  significantly higher level through all-payer
  system.

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Collaborate with other states and the federal
govt

• Centers for Medicare Medicaid Services
  Electronic Health Record Demonstration Project
• A five-year project designed to show that
  widespread adoption and use of EHRs will reduce
  medical errors and improve quality of care.
• 200 Family Practices, General Practices,
  Geriatrics and Internal Medicine practices with
  20 or less physicians are eligible to
  participate.
• 100 practices will be assigned to the
  demonstration and 100 to the control group.
• Practices can receive an incentive payment
  ranging from 58,000 (per physician) to 290,000
  (per physician practice) over five-year period.
• To participate, practices must have a minimum of
  50 fee for service Medicare beneficiaries for
  which they provide the greatest number of primary
  care visits. (Primary source of Care).
• MHCC estimates that approximately 1,200 practices
  eligible to participate.

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Time Frame

• September 2, 2008 Recruitment begins
• November 26, 2008 Last day for applications
• March 2009 Notification to practices of their
  participation
• May 2009 Local kick off meetings
• June 1, 2009 Demonstration begins
• May 31, 2014 Demonstration ends

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Where we need to go

• Better information
• Access to information when it is needed
• Comparative effectiveness research
• Greater transparency
• Improved financial incentives
• Better care, not more care
• Coverage patients vs. differentiated payments for
  each treatment
• Focus on Health behavior
• Evidence-based behavior and social norms among
  medical professionals
• Manage chronic disease
• Emphasize prevention
• Make it easy for people to lead healthy lives

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For More Information

• Task Force on Health Care Access and
  Reimbursement
• http//www.dhmh.state.md.us/hcar/index.html
• Ben Steffen bsteffen_at_mhcc.state.md.us
• Electronic Health Record Demonstration Project
• http//mhcc.maryland.gov/electronichealth/cmsdemo/
  index.html
• CMSEHRDEMO_at_mhcc.state.md.us or by phone to Kathy
  Francis at [phone].