Report from WashingtonmHealth Initiative

J. Michael Fitzmaurice, Ph.D.

Agency for Healthcare Research and Quality

June 4, 2009

2

Agenda

Health Reform

AHRQ

ARRA-Comparative Effectiveness

ARRA-HITECH

3

Health Reform Issues

Medicare Trust Fund

Medicaid and State Budgets

Employer financing of employee health benefits

– International competition on price and quality

Piecework payments for health care

Patient Safety/Medical Errors

17 % of GDP20, 25, 30 % in my lifetime

Are we getting value for our dollar?

4

Patient Involvement Campaign

AHRQ‟s campaign with The Advertising Council uses a

series of TV, radio, and print public service announcements

Web site features a “Question Builder” for patients to

enhance their medical appointments

– www.ahrq.gov/questionsaretheanswer

5

Agency for Healthcare Research and Quality (AHRQ)

Mission

Improve the quality, safety, efficiency and effectiveness

of health care for all Americans

6

Research At HHS

What is AHRQ’s “Space?”

NIH

Biomedical

research to prevent,

diagnose, and treat

diseases

CDC

Population health

and the role of

community-based

interventions to

improve health

AHRQ

Long-term and

system-wide

improvement of

health care quality

and effectiveness

8

AHRQ FY 2009 Funding

$372 million

– $37 million more than FY 2008

– $46 million more than the president‟s request

FY 2009 appropriation includes:

– $50 million for comparative effectiveness

research, $20 million more than FY 2008

– $49 million for patient safety activities

– $45 million for health IT

9

AHRQ Priorities

Effective Health

Care Program

Medical Expenditure

Panel Surveys

Ambulatory

Patient Safety

Patient Safety

Health IT

Patient Safety

Organizations

New Patient

Safety Grants Comparative

Effectiveness Reviews

Comparative Effectiveness Research

Clear Findings for

Multiple Audiences

Quality & Cost-Effectiveness, e.g.

Prevention and Pharmaceutical

Outcomes

U.S. Preventive Services

Task Force

MRSA/HAIs

Visit-Level Information on

Medical Expenditures

Annual Quality &

Disparities Reports

Safety & Quality Measures,

Drug Management and

Patient-Centered Care

Patient Safety Improvement

Corps

Other Research &

Dissemination Activities

10

Comparative Effectiveness and ARRA

The American Recovery and Reinvestment Act of

2009 includes $1.1 billion for comparative

effectiveness research:

– AHRQ: $300 million

– NIH: $400 million (appropriated to AHRQ and

transferred to NIH)

– Office of the Secretary: $400 million (allocated at the

Secretary‟s discretion)

Compare alternative treatments for common

health conditions and make the findings public

11

Recovery Act Timeline: AHRQ

2009

March 19: Due date

for establishment of

Federal Coordinating

Council for

Comparative

Effectiveness

Research

February 17: The

American

Recovery and

Reinvestment Act

of 2009 is signed

into law

January April July

June 30: Due date

for IOM submission

of a list of national

priority conditions*

May 1: Due date

for Agency wide

and program-

specific Recovery

Act plans

October

November 1:

AHRQ FY

„10 operations

plan due

July 30:

AHRQ to

submit FY

‟09

Operations

Plan

2010

December 31,

2010: All

Recovery Act

funding to be

obligated

* Stakeholder input required

12

Questions for Setting Clinical Policy:A Systematic Process

1. What is the outcome I care most about?

2. How good is the evidence that the interventions can

improve those outcomes?

3. How sure am I that it will work in “real world”?

4. How do the potential benefits compare to possible

harms and costs?

5. What constitutes “good enough” evidence?

6. What other considerations are relevant?

13

ARRA

American Recovery

and Reinvestment Act

of 2009 (Public Law

111-5, February 17,

2009)

“Economic Stimulus

Package”

– Health Information

Technology for

Economic and Clinical

Health (HITECH) Act

14

ARRA Purposes

(1) To preserve and create jobs and promote economic recovery.

(2) To assist those most impacted by the recession.

(3) To provide investments needed to increase economic efficiency by spurring technological advances in science and health.

(4) To invest in transportation, environmental protection, and other infrastructure that will provide long-term economic benefits.

(5) To stabilize State and local government budgets, in order to minimize and avoid reductions in essential services and counterproductive state and local tax increases.

15

Goals of ARRA

Improve Health Care

– Quality

– Safety

– Efficiency

16

ARRA of 2009

American Reinvestment and Recovery Act of 2009

HITECH portion

– Codifies ONC

– Creates 2 Federal Advisory Committee Act committees

– Provides for incentive payments to health providers for

meaningful use of EHRs

– Provides for $2B of HIT investment funds for ONC

– Adds to privacy protections, such as found in HIPAA

– Mandates publication of designated standards by 12-31-09

17

ARRA Creates Two HIT FACA’s

To advise the National

Coordinator for HIT

HIT Policy Committee

HIT Standards

Committee

18

HIT Policy Committee

Formed: May 11, 2009

Charge: Make recommendations on– A policy framework for the development and adoption of a nationwide

health information infrastructure, including standards for the exchange of patient medical information

– Standards, implementation specifications, and certifications criteria in eight specific areas.

Chair: David Blumenthal, MD, National Coordinator for HIT

Working Groups– Meaningful use of EHRs

– Certification and adoption of electronic records

– Information exchange

19

8 Areas of Policy Focus

1. Technologies that protect the privacy of health information

2. A nationwide health information technology infrastructure

3. The utilization of a certified electronic record for each person in the US by 2014

4. Technologies that support accounting of disclosures made by a covered entity

5. The use of electronic records to improve quality

6. Technologies that enable identifiable health information to be rendered unusable/unreadable

7. Demographic data collection including race, ethnicity, primary language, and gender

8. Technologies that address the needs of children and other vulnerable populations

20

Other Areas to Consider: HIT &

– Self-service -- Diverse populations

– Telemedicine -- Patient‟s own access to PHI

– Public health -- Quality and Efficiency of HC

– Home health care

21

HIT Policy Committee

David Bates, Brigham and Women‟s Hospital

Christine Bechtel, National Partnership for Women & Families

Neil Calman, The Institute for Family Health

Richard Chapman, Kindred Healthcare

Adam Clark, Lance Armstrong Foundation

Arthur Davidson, Denver Public Health Department

Connie White Delaney, University of Minnesota/School of Nursing

Paul Egerman, Businessman/Entrepreneur

Judith Faulkner, Epic Systems Corporation

Gayle Harrell, Former Florida State Legislator

Charles Kennedy, WellPoint, Inc.

Michael Klag, Johns Hopkins University, Bloomberg School of Public Health

David Lansky, Pacific Business Group on Health

Deven McGraw, Center for Democracy & Technology

Frank Nemec, Gastroenterology Associates, Inc.

Marc Probst, Intermountain Healthcare

Latanya Sweeney, Carnegie Mellon University

Paul Tang, Palo Alto Medical Foundation

Scott White, 1199 SEIU Training and Employment Fund

22

HIT Standards Committee

Formed: May 15, 2009

Charge: Make recommendations on – Standards, implementation specifications, and certification criteria for

the electronic exchange and use of health information

– Focus on areas developed by the HIT Policy Committee

– Provide for testing standards and IS‟s by NIST

Chair: Jonathon Perlin, MD– Vice Chair: John Halamka, MD

Working Groups– Clinical quality

– Clinical operations

– Privacy and security

23

HIT Standards Committee

Dixie Baker, Science Applications International Corporation

Anne Castro, BlueCross BlueShield of South Carolina

Christopher Chute, Mayo Clinic College of Medicine

Janet Corrigan, National Quality Forum

John Derr, Golden Living, LLC

Linda Dillman, Wal-Mart Stores, Inc.

James Ferguson, Kaiser Permanente

Steven Findlay, Consumers Union

Douglas Fridsma, Arizona State University

C. Martin Harris, Cleveland Clinic Foundation

Stanley M. Huff, Intermountain Healthcare

Kevin Hutchinson, Prematics, Inc.

Elizabeth O. Johnson, Tenet Healthcare Corporation

John Klimek, National Council for Prescription Drug Programs

David McCallie, Jr., Cerner Corporation

Judy Murphy, Aurora Health Care

J. Marc Overhage, Regenstrief Institute

Gina Perez, Delaware Health Information Network

Wes Rishel, Gartner, Inc.

Sharon Terry, Genetic Alliance

James Walker, Geisinger Health System

24

Incentive Payments

Beginning 2011-2014 to providers who

meaningfully use EHRs

– A total of $29B [12B in savings expected]

Disincentives from 2015 onward

Under development are

– The definition of meaningful use

– The structure of these incentive payments, and

– Any reporting measures (Quality, Use, other)

25

HIT Investments

$2B appropriated to Office of the National Coordinator for HIT– No-year funds (FACAs, workforce training, HIT extension

centers, grant programs, other)

– $20M for NIST

– Investment areas are guided by many sections of ARRA Studies, technology implementation assistance, state grants,

facilitate loan programs, demonstration projects

Privacy Officer for ONC

HIPAA Privacy Rule applies to business associates of CE‟s

26

Publication of Standards

Standards, interoperability specifications,

certification criteria--Annually

Publish the initial set as an Interim Final Rule

by 12-31-09, in the Federal Register

– As opposed to a Notice of Proposed Rule Making

(NPRM)

– May use standards previously

accepted/recognized by the HHS Secretary in

this initial set

27

The Path to Incentive Payments

Define meaningful use for 2011

Find the standards that support meaningful uses of

EHRs

Specify the certification criteria for EHRs to enable

meaningful uses by providers

Reward providers who meaningfully use EHRS with

increases in their Medicare and Medicaid payments

Continue for 2013 and 2015

Then the beatings begin

– We know where we are going

28

According to Yogi Berra

“If you don't know

where you are going,

you might wind up

someplace else.”

Report from WashingtonmHealth Initiative

J. Michael Fitzmaurice, Ph.D.

Agency for Healthcare Research and Quality

June 4, 2009