An Introduction to FAIR Health · 2016-01-15 · Example: “80th percentile” means that based on...

© FAIR Health, Inc. 2016

An Introductionto FAIR HealthJanuary 2016

www.fairhealth.orgwww.fairhealthconsumer.orgwww.consumidor.fairhealth.orgFH® Cost Lookup / FH® CCSalud

Copyright 2016 FAIR Health, Inc. All rights reserved.CPT® Copyright 2015 American Medical Association. All rights reserved.


Agenda

FAIR Health Mission and Origins FAIR Health Data Assets/Products/ Analytics Applications of FAIR Health Data Role of FAIR Health Data at State Level Episodes of Care FAIR Health As Model APCD Consumer Engagement Platform Data in Action

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The FAIR Health Mission & Origin

• MISSION: bring clarity to healthcare costs and health insurance information

• ORIGINS: established as conflict-free, independent, national not-for-profit

• ACTION: fulfills mission with robust dataproducts, award-winning consumer tools and research platform

• IMPACT: recognized as valued, authoritative resource by diverse stakeholders

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FAIR Health Board of Directors

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Stephen Warnke (Chair)Ropes & Gray, LLP

NancyMarie BergmanBells Nurses Registry

Charles BellConsumers Union

Sherry GliedNew York University

Christopher F. KollerMilbank Memorial Fund

Peter MillockNixon & Peabody, LLP

Nancy NielsenState University of New York at Buffalo

Sara RosenbaumGeorge Washington University

John W. RoweColumbia University

Michael StockerNew York City Health and Hospitals Corporation


FAIR Health Value Proposition

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Conflict-free Uncompensated, premiere governing body Robust network of independent advisory boards Independent, unaffiliated with any insurer Largest private claims collection in the country Physical custody of the claims Data access to all stakeholders Codified in statutes; included in regulations; referenced in official

memoranda All work performed in-house


Data received

continually from payors

Undergo rigorous auditing and

validation

Create a highly secure, robust claims

database

Organize by procedure

code and “geozip”

Capturing approximately

75% of the privately insured

population

19B Medical & Dental

Procedures Performed Since 2002 Nationwide

151MCovered Lives from

Contributors

493 Geozips

Reflecting Local Billing Patterns

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2BCMS Claims Records

FAIR Health Data Assets



FAIR Health By the Numbers: Florida

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More Than 1B Procedures~4B Procedures in the Southeast

83% Medical

29 Medical Contributors*

28 Dental Contributors*

17% Dental

23 Geozips

* 15 Contributors Submit Both Medical and Dental


FAIR Health Data Contribution

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Claims data are contributed by payors:• Over 60 separate contributors

• Data must include a number of key data fields for the submission period

• Data cannot be manipulated, supplemented or pre-edited• Data must use specific medical/dental procedure(s) or

service(s)

• Zip codes must reflect where the actual service was performed

• Business Associate Agreements define data use and HIPAA compliance


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Data Security/Privacy Protections Data Contributions

• Secure transition method for data contributions(SFTP or HTTPS) • Encrypted files using PGP software with public and private keys prior to sending

BAAs• BAAs govern use and protection of PHI pursuant to HIPAA

Data Storage • Data housed in secure data center with limited, controlled access• Requirements include valid card key, biometric scan and entry of pin code • Data encrypted in storage

IT Security • Intrusion detection and prevention systems • Anti-virus and vulnerability scanning

Data Use • Access to PHI restricted to limited set of users • Encrypted hardware • HIPAA training required for all users with access to PHI



Data Security Infrastructure

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Stakeholders We Serve

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Government Researchers Payors Employers Healthcare Systems/Facilities Healthcare Professionals Bill Review Companies Consumers Unions

TPAs Consultants Pharma Actuaries Brokers DME Companies Think Tanks Investment Analysts Litigation Support Medical Societies Trade Associations



FAIR Health Data Products

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FH NPIC® Database

Medical/SurgicalAllowed Medical

DentalInpatient Facility

Outpatient FacilityAnesthesia

HCPCS Healthcare Common Procedure Coding System

Ambulatory Surgery CenterMedicare GapFill PLUSCustom Data Analytics

Interactive Data DashboardsData Visualizations


FAIR Health Benchmark Products

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Standard FAIR Health data modules report benchmarks for medical and dental professional, facility, equipment and other charges

Modules updated 2X/year based on 12-months of claims data, e.g., May 2015 releases include 3/1/14 thru 2/2/15 dates of service

Modules report benchmark values for charges arrayed from 50th through 95th

percentiles: 50th, 60th, 70th, 75th, 80th, 85th, 90th, 95th

• Additional percentiles available upon request

Example: “80th percentile” means that based on FAIR Health’s methodology and data, 80% of all charges are equal to or lower than the given amount

Granular view: Benchmarks reported for all codes for every “geozip” – i.e., geographic area defined by first 3 digits of zip code

• Zip code level data available upon request subject to applicable laws and regulations

Customized datasets available (e.g., data showing trending over time, rural/urban configurations of data, etc.)


Usual, Customary and Reasonable Charges

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FAIR Health does not set UCR

Commonly called: UCR, UCC, R&C, U&C, U&P, C&P and R&N

In the past, these terms were applied to identify any data used to process claims

UCR currently determined by:‒ Insurance policy language‒ Payor guidelines‒ State laws and regulations‒ Federal agencies and laws


Broad Acceptance in the IndustryFAIR Health is a neutral, unbiased source of data

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How FAIR Health Data Are Used

Management and Operational Support• Plan, Benefit and

Provider Network Design

• HR/Benefits Administration

• Premium Rate Review

• ACO/Bundled Payment Modeling

• Support Public/Private Exchanges

• Management of CDHPs/HSAs

• Value “Add-ons” for Plan Members

• Strategic Planning

• Fraud Detection

Provider Fee Schedules and Reimbursement

• In-Network Fee Schedules

• Out-of-Network Fee Schedules

• Episodes of Care

• Balance Billing Negotiations

• Reference Pricing

• Medicare Gap Fill

• ASC Fee Schedule

Public Health and Consumer Engagement

• Consumer Transparency Tools: Bilingual Website & Mobile Apps

• Educational Materials

• Public Health/Education Campaigns

Policy and Research • Health Economics and

Policy Research

• Analyze Legislative and Regulatory Action

• Identify Health Status, Treatment & Cost Disparities

• Statutory Benchmark for State Programs

• Market Research

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How FAIR Health Data Support States

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State Fee Schedules and Health Programs• Workers’ Compensation• Consumer Cost Transparency • Dispute Resolution• Litigation Settlements• State Exchange Consumer Platform• UCR Reference Point• Balance Billing Laws• Auto Liability• Medicaid Reform• Medical Indemnity Fund• State Government Health Plans • Dental Reimbursement


Sampling of States Utilizing FAIR Health Data

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• Alaska• Arizona• California• Georgia• Indiana• Kentucky• Louisiana• Minnesota• Mississippi• New Jersey • New York• North Dakota• Oklahoma• Pennsylvania• Virginia• Wisconsin


NY Statute: Role of FAIR Health

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Issues addressed:• Lack of transparency regarding out-of-network services• Changing reimbursement models • Adequacy of provider networks• Surprise bills• Reimbursement for emergency services• Fair, practical dispute resolution process


Codified Definition: NY Usual and Customary Cost (“UCC”) 80th percentile of charges for a particular service in a particular

geographic area

As reported in a benchmarking database maintained by a conflict-free not-for-profit organization

Plans are not required to reimburse at 80th percentile level but must articulate how they reimburse in comparison to UCC

Supports “apples to apples comparisons”

Advances amicable reimbursement decisions

Supports dispute resolution

FAIR Health is only data source officially recognized as UCC

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NY Law: A Model for the Nation

From The New York Times – September 24, 2014

“More states need to follow New York’s pioneering law, which consumer advocates have praised as the toughest in the nation. Patients everywhere need similar protection from unexpectedly high bills.”

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Continuing Recognition for NY Law as Model

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Official Transparency Source—Exchange Plans

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FAIR Health Data: Choice of Both Sides for Settlements

FAIR Health data facilitated settlement of suit involving disputed claim reimbursements in 38 States & DC

FAIR Health 80th percentile benchmark agreed upon as a standard for “usual and customary” charge for five years

Lebanon Chiropractic Clinic v. Liberty Mutual Insurance Company, Case No. 14-L-521 in the Circuit Court of St. Clair County, Illinois. Court approved February 23, 2015. www.lebanonpipsettlement.com

Other cases settled in Oregon, Washington

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Federal Role Model for APCD

FAIR Health created against the backdrop of the Affordable Care Act

Statutory APCD attributes purposely mirror FAIR Health• Served as the model for Medical

Reimbursement Data Center/CMS Data Center

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Serving as National Multi-Payor Database

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Day-to-day operations of FH involve operating a multi-payor claims database based on plans with more than 151 million covered lives…

Develop fair, accurate fee

schedules and tools that reflect

geographic differences for

healthcare services

Use sophisticated

methodologies and

technologies to develop fee

schedules/tools

Regularly refresh and update data

Make data available to

consumers via website

Support policy-making and

research


Advancing Goals of Medicaid Reform Programs

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Improve

• Process of discovering actionable insight from claims to reward provider quality• Clinical outcomes and cost reductions

Expertise

• Robust tools• Exceptional Talent• Unparalleled Analytics• Proprietary advanced and secure technology infrastructure

HCI3• Trusted methodology• Separate episode results based on risk and severity adjustment

Delivery

• Transformation of raw claims data into actionable deliverables by bridging the divide between data and knowledge

• Delivery of timely analytics using payors’ and Managed Care Organization (MCO) claims and enrollment data


TargetsIsolate Where Reform is Best Focused to Improve Care and Reduce Costs

Trends

Changes in Cost and Care Patterns Over Time

Episode VariabilityUnderstand Episode Cost Variability

• Causes• Possible Clinical Effects

Provider ScorecardsIdentify Most Efficient and Highest Quality Providers who:

• Avoided Complications• Avoided Unnecessary Spend

Actionable Insights

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Targets

Trends

Episode Variability

Provider ScorecardsReward Provider Excellence

Improve Policy

Learn & Educate

Improve Quality

Actionable Insights: Multiple Uses

InsightAction

Outcome

Reduce Cost

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Episodes Constructed

Expected Episode Costs• Expected Typical Costs• Expected Complications Costs

Member Historical Risk Factors &

Co-Morbidities

Episode Severity

Analysis Compares Adjusted Expected Costs Compared to

Actual Costs

Methodology: Comparing “Apples to Apples”

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Ease of Engagement

Claims

RX

Member / Enrollment

Provider

Extract Files

Send to FAIR

Health

Reports & Interactive Dashboards

Data Files

Analytics

Expert Context

Receive

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Risk Factors for the Selected Episode


Value Proposition Beyond Episodes of Care

Anticipate Clinical/Health System Trends

Data Auditing and Validationo Assess Data Qualityo Evaluate Coding

Improprieties

Comparative Reportso Compare Proprietary Data to

Aggregated Dataseto Uncover Utilization/Case Mix

Disparities

Market Researcho Inform Provider Network

Designo Technology Investmento Segment Market by Sector

o DMEo Place of Serviceo Emergency Careo Specialty Drugs, etc.

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Data Use in Research

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Inform Public Conversations

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Advance Academic Curricula

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Thought Leader in Consumer Engagement and Cost Transparency

.



New Era of Reform

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Confluence of Many Factors

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Consumers Are Being Asked to

Make More Decisions

Economic Climate

High Deductible

Health Plans Narrow and Tiered

Networks

Low Healthcare

Literacy

Changing Benefit Designs

Shifting Reimburse-ment Models

Public/Private Exchanges

Affordable Care Act

Transparency Initiatives

Hospital-based

Practices

Cultural Barriers


Consumer Previously in Chorus Line

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Consumer Now Center Stage

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Consumers are in effect now becoming the lead actor in their “insurance” play

With increased decision-making responsibility comes the need for a “script” or data/resources to help consumers navigate through the healthcare system


Window Into Consumer Behaviors/Attitudes

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Where Patients are Seeking Non-Emergent Care

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55%

21%

15%

5%

4%

Doctor Office

Emergency Room

Urgent Care Center

Walk In Clinic (Pharmacy/Retail)

Other

• Responses of “Don’t Know” or “Refused to Answer” are included in the “Other” category.


Where Consumers Sought Dental Care (Past 5 yrs.)

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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

DENTIST OFFICE

COMMUNITY CLINIC

HOSPITAL EMERGENCY ROOM

OTHER

91%

10%

6%

1%

• Respondents had the option to choose more than one answer, thus numbers reflect more than 100%.• Responses of “Don’t Know” or “Refused to Answer” are not included in the above results.


How Patients Describe Their Out-of-Pocket Costs

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More Than ExpectedWhat Was Expected

Less Than Expected

Not Applicable

• Responses of “Don’t Know” or “Refused to Answer” are not included in the above results.


FAIR Health Consumer ToolsFAIRHEALTHCONSUMER.ORG MOBILE APP

FH ®Cost Lookup/ FH®CCSalud

CONSUMIDOR.FAIRHEALTH.ORG

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“Crown-Jewel” Consumer Engagement Platform

• Estimates costs for medical procedures/equipment• Bundles related procedures• Compares reimbursement methods• Flexible “sliders” to customize results

FH® Medical Cost Lookup

• Estimates costs for dental procedures• Bundles related procedures• Reflects particulars of dental insurance design

FH® Dental Cost Lookup

• FH Health Insurance 101 original series • Videos and articles on various health insurance topics• Over 25 distinct “chapters”• Glossaries of health insurance terms, medical and dental

procedures• Consumer-oriented healthcare resources• FAQs

Educational Content

All Content in English and Spanish


Robust Educational Platform

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How Consumers Use the FH Website

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Should I stay in-network or

go out-of-network?

How much will I likely pay if I go out-of-network?

How much will I pay for a service that is not covered by insurance?

What amount should I negotiate with my provider?

Should I appeal?

How will insurance impact my costs?


www.FAIRHealthConsumer.org

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Step 1. Select a Procedure

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Step 2. Select Codes for a Procedure

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Step 3. Generate Estimated Costs

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Results with Related Procedures

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UCR-Based Reimbursement

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Medicare-Based Reimbursement

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Compare Reimbursement Methods

UCR Information Medicare-Based Information

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Honored for Innovation and UtilityWhite House Summit on Smart DisclosureFAIR Health Consumer Website Recognized as example of Smart Disclosure for consumers by White House. FAIR Health invited to present at National Archives before 75 federal agencies.

Agency for Healthcare Research and Quality (AHRQ)FAIR Health Cost Lookup listed as “Quality Tool” on AHRQ Health Care Innovations Exchange.

Utilization Review Accreditation Commission (URAC)FAIR Health received the award for Best Practices in Health Care Consumer Engagement and Protection at the 2013 Quality Summit.

Strategic Health Care CommunicationsFAIR Health awarded the eHealthcare Leadership Awards for four consecutive years, since 2012.

appPickerFAIR Health mobile app selected as one of best healthcare apps in 2014.

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Data in Action



Assess Provider Access

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Average Cost of ER Dental Visits Year over Year

ER Visits for Dental Diagnoses

$0

$100

$200

$300

$400

$500

$600

$700

$800

$900

$1,000

99281 99282 99283 99284 99285

99281: Emergency Room visit for E&M of a patient presenting problems that are self limited or minor. 99282 : Emergency Room visit for E&M of a patient presenting problems that are low to moderate severity. 99283 : Emergency Room visit for E&M of a patient presenting problems that are of moderate severity. 99284 : Emergency Room visit for E&M of a patient presenting problems that are high severity but not life threatening. 99285 : Emergency Room visit for E&M of a patient presenting problems that are high severity and is life threatening.

CPT Codes


Compare Rural and Urban Areas

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0.000%

0.500%

1.000%

1.500%

2.000%

2.500%

3.000%

3.500%

4.000%

4.500%

2008 2009 2010 2011 2012 2013 2014

Percent of All Extractions Compared to All Dental Visits

Rural % of Extractions Urban % of Extractions


Evaluate Impact of ACA

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This graph shows that mammography utilization in CT decreased in 2011, but then steadily increased from 2011 to 2012 and from 2012 to 2013. This may be explained by:• Change in employment rates and potential impact of COBRA coverage• Impact of Affordable Care Act preventative care

CPT Codes HCPCS Codes


Emergency Room Services

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• 99282 – Low to moderate complexity and severity.• 99283 – Moderate complexity and severity.• 99284 – High to urgent complexity and severity.• 99285 – High severity with significant threat to life.

0%

5%

10%

15%

20%

25%

2008 2009 2010 2011 2012 2013

ER Visits Trending

99282 99283 99284 99285CPT Codes


Analyze Variation Based on Place of Service

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$0.00

$50.00

$100.00

$150.00

$200.00

$250.00

$300.00

ER OutpatientHospital

Urgent CareFacility

Office Other Public HealthClinic

IntermediateCare Facility

Average Charge by Place of Service for CPT Code 99214 in Connecticut in 2013

Average Charges

• CPT Code 99214 – Office visit – 25 minutes


Evaluate Impact of Public Health Laws

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Evaluate Impact of Public Health Laws, cont.

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8,436

1,196

11,763

1,704

‐

2,000

4,000

6,000

8,000

10,000

12,000

Massachusetts Michigan

2010 2012

Frequency Measured through Concussion-Related ICD-9 Codes


Assess Impact of Public Education Campaigns

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0

2000

4000

6000

8000

10000

12000

2006 2007 2008 2009 2010 2011 2012

Claims for HPV Vaccines

Washington DC Charlotte Jacksonville


Multiple Ways to Access Data

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State Data Cuts Direct Data Licenses Standard data modules

• Organized by geozip and claim type

Custom data modules• Custom geographic aggregation

(e.g., urban/rural. east coast/west coast)

Private label consumer website Data dashboards & visual analytics

• Policymaking• Advocacy

Claims level data• Research

Provider cuts by clinical specialty and geozip

Data files by claim type• Health systems• Payors• Large provider practices• Dispute resolution

Online access• Unlimited access• Subscriptions


Questions

70


Thank You!

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For more information:855-301-FAIR (3247)

www.fairhealthconsumer.orgwww.fairhealth.org

www.consumidor.fairhealth.orgMobile App: FH® Cost Lookup / FH® CCSalud

An Introduction to FAIR Health · 2016-01-15 · Example: “80th percentile” means that based on...

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