Michael Lundberg, Executive Director

3

VHI’s MissionVHI’s Mission

To create and disseminate health care information

To promote informed decision making by Virginia consumers and purchasers, and

To enhance the quality of health care delivery

VHI Represents VHI Represents all Health Care Stakeholdersall Health Care Stakeholders

4

VHI is an independent, nonprofit,

501(c)(3) health information

organization established in 1993

Formed to administer Virginia

Health Care Data Reporting

Initiatives to benefit Virginians

5

VHI Publishes Business and Consumer Guides, Reports and VHI Publishes Business and Consumer Guides, Reports and Information at Information at www.vhi.orgwww.vhi.org

Information VHI Collects & PublishesInformation VHI Collects & Publishes

6

7

APCD Implementation ProcessAPCD Implementation Process

Source Data to Milliman for Initial

Review

Send Threshold Results to Data Submitters

Complete Data Mapping and Data

Audit

Data Roll-Up and Validation Complete

Data Available To Customer

Membership (Patient, Group,

Provider)

Medical Claims Data

Pharmacy Data

MEDINSIGHT DATA

WAREHOUSE

Other Data

We are Here

Slide 8

APCD Quality AuditsAPCD Quality Audits

Exemption Summary May 2015Exemption Summary May 2015

9

Field Level Exemptions

Provider DEA Number 27

Provider State License Number 25

Provider Specialty 23

Provider Office Zip 19

Provider Office State 19

Categories of Exemption

Accommodation for historical data 29

Improvement plan in place 49

Not applicable for Medicare/Medicaid 42

Not collected 82

Submitted when collected 216

10

MedInsight® Analytic PlatformMedInsight® Analytic Platform

Population and benefit driven including:

Age Gender Geography Benefit design

Benchmark detail: DRG Procedures Drugs Episodes Chronic conditions

Based on Milliman Health Research Database of 45M members

Methodologies Benchmarks

*Courtesy of Milliman MedInsight

• Health Cost Guidelines• Evidence Based Measures• Milliman Advanced Risk Adjustors• Chronic Conditions Hierarchical Groups

(Disease Identification)• Global RVUs (Standardized Proxy

Reimbursement)• Member and Provider Crosswalking• Provider Attribution• Provider Affiliation into Group Practices • NYU Avoidable Emergency Dept. visits• Episode Grouping - Truven MEGs

11

12

Milliman, Top-ranked for H.C. Industry AnalyticsMilliman, Top-ranked for H.C. Industry Analytics

Section 4.3 – Scope – Data Submission: Section 4.3 – Scope – Data Submission:

13

Amendment to Data Submission and Use Agreement. Each of the plans that participates in the APCD executed a Data Submission and Use Agreement (“DSUA”) with VHI effective as of January 1, 2013. The enclosed draft Amendment to the DSUA is intended to amend the original DSUA as follows:

1. The DSUA currently provides that Data Suppliers are not required to submit Data Claims files related to Medicare Advantage or FEHBP. However some of the plans have submitted claims data related to both Medicare Advantage and FEHBP. VHI suggests that the parties remove the exclusion of Medicare Advantage data and change the language surrounding FEHBP data to include such data unless the US OPM otherwise prohibits its inclusion.

2. Section 4.3 requires each participating plan to submit to VHI an updated Health Plan Adoption Form in the form of Schedule A to the Amendment. As you will recall, each plan submitted a similar form at the time the DSUA was executed.

The new form provides more examples of categories of types of business in response to questions to Data Suppliers. See next slide

Revised form for determining % of population covered by APCDRevised form for determining % of population covered by APCD

14

Could be revised to indicate covered Virginia resident lives to clarify differences between this and reporting to SCC.

15

Section 5.1 (e) – Uses and Disclosures; Section 5.1 (e) – Uses and Disclosures; Review Period and CorrectionsReview Period and Corrections

Adds the phrase “to the general public”

to clarify that Reports can be released to

the Data Suppliers and Data Subscribers

prior to the expiration of the 60 day

review period provided their use of the

data is otherwise in compliance with the

DSUA or DSA, as applicable.

16

Section 7.1 – Term. Section 7.1 – Term.

Extends the term of the Agreement from July

1, 2015 through June 30, 2018 to match the

updated APCD Expense Budget.

Exhibit 2 (2015) – Business Associate

Agreement. The form of Business Associate

Agreement executed between VHI and each

of the Data Suppliers has been updated to

incorporate certain changes from the HIPAA

Omnibus Rule.

17

Exhibit 3 (2015) – Data Subscriber AgreementExhibit 3 (2015) – Data Subscriber Agreement

The form of Data Subscriber Agreement (“DSA”) attached to the original DSUA as

Exhibit 3 has been revised as follows:

Section 2.C. - Rights on Termination of License: Adds more specific requirements and processes for return or destruction of De-Identified Data or reports when a DSA is terminated.

Section 3.B. – Disclosure of De-Identified Data: Adds language to ensure that subcontractors or independent contractors of Data Subscribers are bound to a Confidentiality Agreement restricting their use and disclosure of data and further confirms that written permission from VHI is necessary for disclosures to third parties.

Section 3.E – Responsibility for Data Subscriber’s Users and Unauthorized Users. Adds language to specifically prohibit any attempt by Data Subscribers or their Users or agents to identify individuals whose data resides in the APCD.

18

Exhibits to Data Subscriber AgreementExhibits to Data Subscriber Agreement

Exhibit A to DSA - Data Subscribers Authorized Users to APCD: Exhibit A was

revised to allow for more detailed User and contact person information.

Exhibit B to DSA – Vendor Confidentiality Agreement: This new Exhibit is

the form of Confidentiality Agreement that Data Subscribers are required to

enter into with “vendors” – their subcontractors and independent

contractors (accompanies changes to language in Section 3.B.).

Exhibit C to the DSA - Equipment Specifications: Additions to this Exhibit

detail minimum computer equipment specifications for access to online

system.

Exhibits to Data Subscriber Agreement - Exhibits to Data Subscriber Agreement - ContinuedContinued

19

Exhibit 4 (2015) – Permitted Uses of Actual Reimbursement Data: This

revised Exhibit retains the prohibition on disclosure of provider-specific,

facility-specific or payer-specific reimbursement information or any

information capable of being reverse-engineered, combined, or otherwise

used to calculate or derive such reimbursement information.

However to assist in measuring the impact of VDH population health improvement efforts, reports may currently be generated by VHI for VDH on the cost burden of a disease, chronic disease, injury or health condition across the state and by Health Planning Region.

The revision, requested by VDH expands the geographic areas to also include as appropriate Health Planning District, City, County or Zip Code as long as the prohibitions described above are adhered to.

Section 6.1 – FundingSection 6.1 – Funding

20

Section 6.1 - Funding: this section has been updated since initially provided to Data Suppliers and reflects a reduction in the subcontract with Milliman.

As now modified, this section will be revised to updates the Data Supplier’s individual APCD expense funding obligation for the 36 month period commencing July 1, 2015. New Section 6.1 provides that the Data Supplier’s aggregate funding obligation for the 36 month period is $ 189,976. As you may know, pursuant to the Participation Agreement, the plans that chose to participate in the APCD were responsible, as a group, to fund 40% of the APCD expense budget for the initial 30 months of the APCD.

At the time that the DSUA’s were prepared, it was believed that 10 plans would participate; however only 9 plans ended up participating. As a result, the funding provided by the participating plans for the initial 30 months of the APCD was short of the plans’ aggregate 40% obligation.

The $189,976 includes a one-time, catch-up payment of $14,591 and 12 quarterly payments of $14,615 (assuming only 9 plans participate). In the event 10 plans participated each plans allocable portion of the expense would be reduced to $170,978 ($13,153 per quarter).

1st Contract vs Renewal Contract Costs by Stakeholder Group 1st Contract vs Renewal Contract Costs by Stakeholder Group

21

VAHP VHI VHHA

Individual Member Payment

(Quarterly)*

Individual Member

Payment (Total)

Total for all Members Quarterly Total Quarterly Total

1st Contract- 30 months (1/1/2013-

6/30/2015) $ 14,584.44 $ 145,844.44 $ 1,312,600.00 $ 65,630.00 $ 656,300.00 $ 131,260.00 $ 1,312,600.00

Renewal- 36 months (7/1/15-6/30/18) $ 14,615.42 $ 175,385.07 $ 1,578,465.60 $ 65,769.00 $ 789,232.80 $ 131,538.00 $ 1,578,465.60

% Difference 0.2% 20.3% 20.3% 0.2% 20.3% 0.2% 20.3%

*1st Contract number includes 1 time catch up as 10 health insurance companies were budgeted but 9 plans actually participated

Category

FY 2016 Ongoing Development,

Submission of Data, Operation and

Reporting

FY 2017 Ongoing Development,

Submission of Data, Operation and

Reporting

FY 2018 Ongoing

Development, Submission of

Data, Operation and Reporting

Totals

Legal $29,000 $25,000 $25,000 $79,000

VHI Staff-Existing 2.5 FTEs: Analyst, Program Manager, Sr. Management/Indirect

389,241 327,615 343,995 $1,060,851

Data Processing and Analytics – negotiated amount

906,000 $906,000 $906,000 $2,718,000

Travel $3,500 $3,500 $3,500 $10,500

Insurance- based on current amounts $25,000 $25,250 $27,563 $77,813

Totals $1,352,741 $1,287,365 $1,306,058 $3,946,164

REVISED APCD Budget for FY 2016 – 2018 (July 1, 2015-June 30, REVISED APCD Budget for FY 2016 – 2018 (July 1, 2015-June 30, 2018)  2018) 

Category Total 30 Month Budget

(Jul 11-Jun 15) Actual Direct Expenses as of

May 19, 2015 with projections and indirect

$ Difference

Budget vs Actual

% Difference Actual to Budget

*Data Processing – subject to vendor contract negotiations $ 1,600,000 $ 764,250 $ 835,750 -52%

Consultants- RFP development & evaluation for data processing, hosting & analytics $ 70,000 $ 46,450 $ 23,550 -34%

Analytics – reports, access to data, data extracts – subject to vendor contract negotiations $ 1,000,000 $ 764,250 $ 235,750 -24%

Travel $ 4,500 $ 4,698 $ (198) 4%

*VHI Staff-Existing 1st 6 months Up to 2 FTEs + .35 for second and third twelve month periods $ 562,000 $ 812,160 $ (250,160) 45%

Legal- for Data Submission and Use Agreements $ 45,000 $ 150,878 $ (105,878) 235%

Accounting (indirect of non-restricted) unbudgeted $ 3,749 $ 3,749 unbudgeted

Depreciation (indirect of non-restricted) unbudgeted $ 14,164 $ (14,164) unbudgeted

Insurance (direct for E&O, indirect of non-restricted) unbudgeted $ 62,727 $ (62,727) unbudgeted

Marketing (indirect of non-restricted) unbudgeted $ 3,004 $ (3,004) unbudgeted

Office Expenses (indirect of ie copier, graphic design & printing, network, postage, building, supplies, website) unbudgeted $ 2,068 $ (2,068) unbudgeted

Consultants (indirect of database mgr & govt relations) unbudgeted $ 27,209 $ (27,209) unbudgeted

Total $ 3,281,500 $ 2,655,607 $ 633,392 -19%

Minus Health Plan Unbilled $ (131,260)

Adjusted Total $ 3,150,240 $ 2,655,607 $ 494,633 -16%

Budget for Thirty Month APCD Expenses Comparison to Actual Budget for Thirty Month APCD Expenses Comparison to Actual Amount SpentAmount Spent

24

Next StepsNext Steps

VHI will incorporate any revisions to the documents and send them to representatives.

Please review each of the referenced documents in their entirety. Upon acceptance, please:Execute the Amendment to the Data Submission and Use Agreement;

Complete the Health Plan Adoption Form attached to the Amendment as Schedule A;

Execute the Business Associate Agreement attached to the Amendment as Exhibit 2 (2015); and

Return the foregoing documents to Wyatt Beazley at wbeazley@williamsmullen.com

Closing RemarksClosing Remarks

25

26

Budget for Thirty Month APCD Expenses Budget for Thirty Month APCD Expenses Comparison to Actual Amount SpentComparison to Actual Amount Spent

27

Category

1st Six months After Signing of Data Submission and

Use Agreements*

(Jul 13-Jun 14) Next 12 months

Development , Submission of Data,

Operation and Report Design

(Jul 14-Jun 15) Next 12 months of

Operation and Report

Development

Total 30 Month Budget

(Jul 11-Jun 15) Actual Direct

Expenses as of May 19, 2015 with

projections and indirect

% Difference Actual to Budget$ Difference Budget

vs Actual

*Data Processing – subject to vendor contract negotiations N/A $ 800,000 $ 800,000 $ 1,600,000 $ 764,250 $ 835,750 -52%

Analytics – reports, access to data, data extracts – subject to vendor contract negotiations N/A $ 500,000 $ 500,000 $ 1,000,000 $ 764,250 $ 235,750 -24%

Consultants- RFP development & evaluation for data processing, hosting & analytics $ 30,000 $ 25,000 $ 15,000 $ 70,000 $ 46,450 $ 23,550 -34%

Travel $ 1,500 $ 1,500 $ 1,500 $ 4,500 $ 4,698 $ (198) 4%

*VHI Staff-Existing 1st 6 months Up to 2 FTEs + .35 for second and third twelve month periods $ 62,000 $ 250,000 $ 250,000 $ 562,000 $ 812,160 $ (250,160) 45%

Legal- for Data Submission and Use Agreements $ 25,000 $ 10,000 $ 10,000 $ 45,000 $ 150,878 $ (105,878) 235%

Accounting (indirect of non-restricted) $ 703 $ 1,479 $ 1,567 unbudgeted $ 3,749 $ 3,749 unbudgeted

Depreciation (indirect of non-restricted) $ 3,373 $ 5,327 $ 5,465 unbudgeted $ 14,164 $ (14,164) unbudgeted

Insurance (direct for E&O, indirect of non-restricted) $ 1,300 $ 31,747 $ 29,680 unbudgeted $ 62,727 $ (62,727) unbudgeted

Marketing (indirect of non-restricted) $ 538 $ 1,296 $ 1,170 unbudgeted $ 3,004 $ (3,004) unbudgeted

Office Expenses (indirect of ie copier, graphic design & printing, network, postage, building, supplies, website) $ 18,545 $ 36,043 $ 32,088 unbudgeted $ 2,068 $ (2,068) unbudgeted

Consultants (indirect of database mgr & govt relations) $ 4,258 $ 10,842 $ 12,108 unbudgeted $ 27,209 $ (27,209) unbudgeted

Total $ 147,216 $ 1,673,234 $ 1,658,579 $ 3,281,500 $ 2,655,607 $ 633,392 -19%

Minus Health Plan Unbilled $ (131,260)

Adjusted Total $ 147,216 $ 1,673,234 $ 1,658,579 $ 3,150,240 $ 2,655,607 $ 494,633 -16%

28

APCD Heath Plan FundingAPCD Heath Plan Funding

9 plans 10 plans

VAHP Total 1,578,465.60 1,578,465.60

Per plan 175,385.07 157,846.56

Plus 1 time payment 189,976.07 170,978.46

APCD Budget FY16-18 36 Months VHHA (40%) VAHP (40%) VHI (20%)

FY16 1,352,741.00 541,096.40 541,096.40 270,548.20

FY17 1,287,365.00 514,946.00 514,946.00 257,473.00

FY18 1,306,058.00 522,423.20 522,423.20 261,211.60

Total 3,946,164.00 1,578,465.60 1,578,465.60 789,232.80

# of Plans # of Payments 1x Payment 12x Total 12x-1x Total Total

(36 months)

9 12 14,591.00 14,615.42 175,385.07 189,976.07 1,709,784.60

10 12 13,131.90 13,153.88 157,846.56 170,978.46 1,709,784.60

Total 131,320.00

Plus One Time $131,319.00

Total 1,709,784.60