Organizational and Legal Issues-- Developing organization and

governance models for HIE

Day 2 -Track 5 – FIRST SESSION – RHIO GOVERNANCECONNECTING COMMUNITIES for BETTER HEALTH

2nd Annual Learning Forum and Exhibition

WALTER SUAREZ, MD, MPHPRESIDENT, PUBLIC HEALTH DATA

STANDARDS CONSORTIUM

Governance Issues

Most models call for involvement of all stakeholders, including:

• Providers (through their local professional associations)– Individuals (MDs, RNs, RPh, Others)– Institutional (Hospitals, Nursing Homes, others)

• Plans (individually and/or through their local trade association)– Private (HMOs, others)– Public (Medicaid, Medicare)

• Purchasers– Private employers/employer coalitions– Public employers (state, local)

• Public Health• Quality Improvement Organizations (QIOs)

And then also….

• Patients (consumers/unions)• Researchers/academia• Vendors

Governance Issues

There are unique issues across states

• Relative strength of key components (public health; purchasers; health plans; providers)

• Market consolidation/fragmentation

• State regulatory constrains

• Geography

The significance (and challenge) of getting all members at the table:

• RHIO Organization must have a defined role/goal that is addresses each member’s needs:

• Providers – connectivity to support clinical care, quality improvement, patient safety

• Plans – improve business processes to support plan administration

• Purchasers – quality measurement, accountability, value-based purchasing and P4P

• Public Health – improving health of population; enhancing monitoring and surveillance; providing population-based reference data for clinical decision making

• QIOs – New business role under Medicare/CMS Scope of Work

• What about patients? Researchers? Vendors?

Why RHIOs Need to Discover/Invent Themselves

• No cookie-cutter approach. When you’ve seen one…. You’ve seen one

• Internal market dynamics drive process for establishing a regional initiative

• While at the end regional organizations might look somewhat similar

(“independent multi-stakeholder non-profit”), each community needs to go

through the organizing process from start to end:

– Process validates the need/value of regional effort

– Process allows establishment of trust

– Process ensures buy-in by participating organizations

– Process ensures ongoing commitment from organizations

• There are state laws that will affect the formation of regional organizations

– Privacy

– Health plan regulations

– Provider regulations

– Public health laws

Building a “Sustainable Business Model”

Governance need to be established first• Will decide the mission and purpose of RHIO

The Governance will then need to determine WHAT is the RHIO going to DO and HOW is the RHIO going to do it?

• Convener/Facilitator/Educator on Standards• Pilot tester/Prototype developer• Buyer vs Builder of infrastructure (vs leveraging existing private

infrastructure and Internet)• Buyer vs Builder of value-added services

– Aggregator of data (repository)– Transaction switcher/router– Administrator of cross-system patient linkage system– Clinical support systems

• Role in establishing privacy and security• Role in disseminating information• Role/product/service for consumers/patients?

Building a “Sustainable Business Model”

The Governance will need to create a business plan including timeline of implementation, start-up/maintenance costs, and methods for paying for these costs (upfront contributions from participants, grants, ongoing fees, state funding, etc)

Differences between existing vs new organizations

• Existing organizations will need to ‘re-purpose’ their mission to adopt/adapt to new role; business plan would then follow

• New organization will need to establish governance, determine purpose and scope of activities, develop funding

The TRUST Factor

Three levels of Trust:

• Within competing constituencies (i.e. among hospitals or among health plans in the region)

• Between represented constituencies (i.e. between providers and payers or payers and purchasers/employers)

• With the public (in the community)– Organized patient/consumer advocates– Consumers/patients at large

Significance of trust with public will depend on the ROLES of the organization

• What is the interaction with the public?

• Does the public know (care?) what the regional organization is about?

Public Representation, Non-Profit Status and Trust

Representation of “The Public” is one of the hardest issues to deal with

• “We all represent The Public” (providers, plans, employers, public health)

• “Employers represent The Public” (their employees)

• “Government represents the Public” (public health, public programs)

• Consumers REALLY represent The Public– Who to select? (individuals; advocates; unions)

Non-profit Status Does Not Ensure Public Trust

• In many states most/all hospitals and health plans are non-profit!

Public Health CAN serve as a neutral, trusted convener party

• Transition out of role as convener after ‘founding’ organizations establish mission/goals/priorities for group and define organizational approach (independent non-profit)

Statewide vs Community-based Organizations

Are the roles and responsibilities different?

• Depending on their inter-dependencies and relationship, one might become an ‘overseer’ and the other be responsible for operationalizing the core components of the RHIO in a smaller region/area.

Is there a need for both levels?

• It all depends on the market/region

• In some states, a statewide organization can suffice

• In other states, there might not be a statewide organization, and community-based organization might need to be formed

• Yet in other states, a statewide organization (RHIO?) might be formed to ‘oversee’ activities, and community-based organizations in areas within the state might exist to ‘operationalize’ components of the RHIO.

• There might be also areas where a regional community-based organization is formed to covered various states, and within each state there are either statewide organizations or smaller community-based organizations that operationalize the components of the RHIO

Statewide vs Community-based Organizations

Need for further federal action

• Federal guidelines can be provided to explain the possible scenarios and reinforce the co-existance of multiple models for RHIO development

• Federal guidelines should not define a single approach to RHIO formations and models.

Financial Models and Financial Incentives

Financial Models will depend on WHAT regional organization is doing:

• Convener/Educator/Standards facilitator– Financial Approach: Membership-based

• Innovator/Pilot Developer– Financial Approach: Grants

• Products and services– Financial Approach: User fees

Financial Incentives

• RHIOs might facilitate/promote the use of financial incentives to support the adoption of HIT/Standards in the market

• RHIOs should stay away from ‘standardizing’ the contractual relationships between payers and providers related to financial incentives and pay for performance

– Might constitute restriction of trade– Could result in stiffening innovation in quality management– Creates conflicting dual roles as convener/facilitator/promoter of the

adoption of standards, and at the same time, measuring and having a financial impact on those organizations that are members