Health reform, ECLIPSE and data management in the private sector

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1 Health reform, and data management in the private sector Nicolle Predl Abstract The Australian Health Service Alliance (AHSA) is a company that provides services to more than twenty private health insurers, including hospital contracting, medical agreements and data management and statutory reporting. AHSA is well represented in a wide range of industry forums to promote the best interests of member health insurers and the private sector in general. There have been a number of initiatives over many years to achieve consistency in Electronic Data Interchange. In more recent times, there has been the emergence of the Electronic Claim Lodgement and Information Processing Service Environment, or as it is known to the industry. There has been considerable success in the uptake of by numerous stakeholders, including medical providers, health insurers and both public and private hospitals. Hospital Casemix Protocol (HCP) and Private Hospitals Data Bureau (PHDB) are two of the reporting requirements of private hospitals. Until recently, and HCP reporting have existed completely independently of one another, despite the clear majority of HCP fields being in common with fields. The Health Reform Agenda, with its single provision, multiple use in respect to data collections, has played a significant part in the successful alignment of and HCP. How far this principle will be taken remains to be seen. This paper considers other duplications in the reporting of private hospital activity. Keywords (MeSH): Health Information Systems; Data Collection; Funding; Private Hospitals; Health Insurance; Australia Introduction Hospitals are required to routinely report data under various acts of legislations. More specifically, private hospitals have a greater reporting burden to various organisations and departments of what are essentially the same data. The degree of commonality between these datasets is high and the same information is reported multiple times. There are some instances where hospitals are required to report the same data, defined in slightly different ways, to different organisations. Private hospitals are also required to report an additional dataset directly to the Department of Health (DH) known as the Private Hospitals Data Bureau (PHDB). This paper looks at where the commonality lies between the Hospital Casemix Protocol (HCP) and the Private Hospitals Data Bureau (PHDB). It also specifically notes the level of duplication of data for private hospitals provided to the NMDS via the states, and how developments in electronic fund claiming could reduce this burden. Health reform quite clearly focuses on the public sector. However, there is a flow-on effect to the private sector in many facets, including funding models, classification development, streamlining, enabling comparability between public and private hospitals, and data management (Health Information Management Association of Australia). This paper focuses on the single provision, multiple use principles, as outlined in the National Health Reform Agreement (Australian Government Department of Health & Ageing 2011), and how as an industry this could be achieved. Overview of HCP Reporting of HCP data from private hospitals to private health insurers is a mandatory requirement under Commonwealth legislation 1 (see also Australian Government Department of Health & Ageing 2011). These data are similar to the state health collections, but with some differences, including: reporting on privately insured patients only, whether they be in a private or public hospital, or a day facility; and containing financial information (charges levied by providers and benefits paid by health insurers). Hospitals are required to provide a monthly data submission to each insurer (or AHSA on behalf of its member insurers) within six weeks after the end of the month of separation. For example, October 2013 separations need to be submitted in mid-december Those hospitals that provide rehabilitation are also required to report Australian National Sub-Acute and Non-Acute Patient (AN-SNAP) data as part of the HCP. Health insurers match these data to each member hospitalised and amalgamate all elements of the hospital stay and claim details (Table 1): Overview of PHDB PHDB data are sent directly from private hospitals to DH, and describe all their patient activity such as non-insured and third party payers, not just those who have used their health insurance. The structure of the dataset is identical to the HCP, and privately insured patients in private hospitals are reported in both datasets to DH (PHDB data directly, and HCP data via the insurer or its agent (AHSA). 1 Private Health Insurance Act Private Health Insurance (Health Insurance Business) Rules HIM-INTERCHANGE Vol 4 No ISSN (PRINT) ISSN (ONLINE) 19

2 REPORT Overview of is owned by the Department of Human Services (Medicare), and has evolved after significant industry-wide input from hospitals, health insurers, practice managers, software vendors and other key stakeholders. The solution covers a wide range of data interchanges, including Online Eligibility Checking, Inpatient Hospital Claiming (IHC), Online Patient Verification and Inpatient Medical Claiming between health facilities and insurers. The IHC is of interest in this discussion, which has involved significant software development for hospital (or facility) and insurers alike, as well as a strong commitment from the industry (Australian Government Department of Human Services Medicare 2013). IHC comprises a standard format for the transmission and receipt of hospital claim data. Until recently contained most, but not all HCP information, including several data elements that could be successfully derived from the claim message through. The most significant advantages of are the removal of the requirement for paper claims, the level of standardisation it provides, and the infrastructure through the HUB to act as a data repository to a potential that is significantly greater than which currently exists. Burden of reporting In addition to the reporting of HCP and PHDB data, as well as claims information by either electronic or manual means, private hospitals have the burden of reporting their activity to their state health department. The flow of data from private hospitals is described in Figure 1. It has been estimated that as much as 90% of data reported to the NMDS (via the states), HCP and PHDB data are virtually the same at the data element level. Examples of duplication across all three datasets include: Table 1: Hospital stay and claim details Hospital episodes Medical Prosthesis AN-SNAP Sourced from the hospital, including: demographics admission and separation dates diagnosis and procedure information charge/benefit information. Sourced from the doctor s inpatient invoices/claims to the insurer, including: Medicare Benefits Schedule (MBS) item number(s) charges and benefits includes consultations and theatre charges can have multiple lines of data for each episode Sourced from the hospital claim, including: charges and benefits for prosthesis, by item code, which includes the identification of the prosthesis supplier. Sourced from the hospital for rehabilitation episodes, including: functional impairment (describing the reason for rehabilitation) Functional Independence Measure scores to indicate the level of independence of each patient at admission and discharge.(australasian Rehabilitation Outcomes Centre 2012). Manual Claim Private Hospital Hub Health Fund HCP Data Hospital to Fund PHDB Data Hospital to DH State Health Authority NMDS Figure 1: Private hospital data flows 20 HIM-INTERCHANGE Vol 4 No ISSN (PRINT) ISSN (ONLINE)

3 admission and separation dates patient demographics diagnosis information, as classified by the ICD-10-AM procedures, as classified by the ACHI DRG other, including care type, source of referral and mode of separation (Australian Institute of Health and Welfare n.d.). There are some exceptions, for example HCP and PHDB data contain: financial information membership information (such as membership number) for HCP. To complicate the reporting burden, there are some fields that have the same intent but have slightly different definitions between states or DH, such as Hours of Mechanical Ventilation. These differences are subtle (e.g. rounding rules), but nevertheless provide an avoidable complexity to reporting requirements. Comparison: PHDB, HCP and The structure of the PHDB dataset is identical to the hospital reporting component of the HCP. This means that the format specifications have the same number of fields and they are the same size. There are some non-structural differences between the two datasets, which essentially means that some fields are blank filled, and one has different values within the same sized field. The comparison of these fields is described in Table 2. When was first developed in 2005, there was a strong correlation between the HCP formats and the message structure, as HCP data were initially considered in the message. However, had not been maintained as HCP has changed, which has caused a several discrepancies, including: missing mandatory fields, such as qualified newborn days field definition changes, such as admission weight field size changes impending HCP changes not catered, such as condition onset flag some AN-SNAP fields. was therefore deemed to be incomplete in terms of its usability for HCP in its current form. Climate in recent years Before the health reforms of the then Rudd Government in 2008, key HCP and industry groups operated in isolation. There was no common representative on either committee; therefore communication was very much retrospective, if at all. There was no funding available, nor any incentive, to change the message structure to reflect HCP changes, nor agreement regarding who should bear the cost of such changes. Furthermore, future changes, timeframes and requirements were not known to either group, which meant that should any changes have been agreed to for to accommodate HCP, there was a high risk that it would soon become out of date. Private Hospital Data Collection Review In early 2011, the then Department of Health and Ageing (DoHA, now DH) engaged KPMG to review the private hospital data collection process, which involved extensive stakeholder consultation. Their briefing clearly stated that it was the health reforms that were driving the review, Table 2: Comparison of HCP and PHDB datasets HCP Requires Insurer Membership Identifier to assist with matching the data to the correct member of the health fund. Insurer identifier is collected to identify the individual health fund. Requires family and given names, for the purposes of the health insurer matching the data to the correct member. Collection for insured patients only. AN-SNAP data is specified in a separate file, to be reported by all hospitals with designated rehabilitation programs and rehab facilities. PHDB Insurer Membership Identifier is not required. This field is blank filled. Insurer/Payer Identifier provides detail of the funder of the episode, such as Self Insured, Workers Compensation, Motor Vehicle or Department of Veteran s Affairs. Health insurers are not separately identified. Does not require names. This field is blank filled. Family Name Blank filled. Not required for reporting to DH. Contains all activity of the hospital by episode, including those outlined above. PHDB contains the episode specification only. It does not contain the AN-SNAP additional file. Table 3. Findings of the KPMG review of private hospital data collection process Streamlining Investigate a common file format for data fields common to PHDB, HCP and NMDS. Apply generic specification for all fields common to the NMDS. Investigate the feasibility of data linking between states and insurers for improved HCP. The record specification should be updated to permit transmission of current format HCP data. The record specification should be maintained to ensure its ongoing capability to transmit HCP. HIM-INTERCHANGE Vol 4 No ISSN (PRINT) ISSN (ONLINE) 21

4 REPORT particularly in relation to the single provision, multiple use, comparability and transparency principles (Australian Government Department of Health 2012). The objectives of the review, in brief were to: increase the collection, management, and handling efficiency of private hospital data; and support increased comparability between public and private sectors. The findings of the review relevant to this paper are shown in Table 3: A full copy of the report can be found at health.gov.au/internet/main/publishing.nsf/content/phdcreview Recent developments In 2012, the then DoHA commissioned an additional project from KPMG referred to as the Private Hospital Data Collection Harmonisation project to address duplication issues for private hospitals. Although this involved wide stakeholder consultation, the report is yet to be released. HCP is now fully aligned with, in terms of the hospital HCP format specifications. Although the structure is present, it is not yet replacing the need for private hospitals to submit HCP data via separate means; however, it is the necessary first step to doing so. There is now significant industry cross-representation between HCP, PHDB and key working groups, to ensure that the issues, needs and developments of all stakeholders are well known and catered for. Future developments With the recent change to a Coalition government in September 2013, the full extent of how and when any future plans to further reduce the reporting burden on private hospitals remains to be seen. However, development work must continue to keep the HCP and aligned. This will require continued close consultation between all key stakeholders and industry groups, as well as funding to maintain consistency of collections. There remain significant issues to be considered, such as ensuring that any claims that are not transmitted through can be reported to HCP at either the hospital or episode level. Not all hospitals use or other compatible electronic claiming solutions. Considerable discussion has occurred around the possibility of sending PHDB information through the (without a claim), so that all private hospital activity (e.g. non-insured, insured, third party) can be transmitted once. This would facilitate reconciliation of data, as all episodes are transmitted by the same means for each facility (irrespective of whether a claim was required), with the relevant authorised recipients accessing the data they are entitled to in line with reporting obligations. This would mean that by reporting all private hospital activity via, there would be one less reporting requirement placed upon private hospitals, as this would encompass both the PHDB and the HCP. The technology exists to further reduce duplication of reporting for private hospitals by extending this principle to the NMDS, where private hospital data could be accessed directly from the hub. It is stressed that the report is looking at what is possible, not what has been agreed, as described in Figure 2. Advantages There are a number of advantages in continuing to strive for single provision, multiple use of data (Table 4). Private Hospital Hub Health Fund STATE COLLECTION NMDS HCP PHDB State Health Authority Figure 2: Possible options for single provision, multiple use of data Table 4: Advantages in single provision, multiple use of data Cost containment Data Quality Efficiency Streamlining/simplification Less burden in system changes and human resources, as data is reported centrally, and only the necessary reporting requirements for each organisation/department can be downloaded. Reduced margin for error given once source for correction. Removal of paper claim and replacement with electronic claim and reporting requirements in the one message. Data used for multiple purposes, but compiled only once. 22 HIM-INTERCHANGE Vol 4 No ISSN (PRINT) ISSN (ONLINE)

5 Summary Health information management remains an exciting profession as we await the Coalition s directive of how it will progress the single provision, multiple use principle, and health reform generally. has provided the standardisation, structure and technology to be used far beyond its current capacity, and the bringing together of key industry groups to work on such projects and align to HCP, and potentially other data reporting obligations in the future. References Health Information Management Association of Australia (2012). and health reform: a heath insurer s view. Available at: org.au/2012/presentations/wed%2031%20oct/%20-%20 N%20Predl/predl.pdf (accessed 25 September 2013). Australian Government Department of Health (2011). National Health Reform Agreement. Available at: internet/yourhealth/publishing.nsf/content/nhra-agreementtoc~preliminaries#.ulyuniscphw (accessed 25 September 2013). Australian Government Department of Health (2013). Reporting requirements for Hospital Casemix Protocol (HCP) and Private Hospitals Data Bureau (PHDB). Available at: main/publishing.nsf/content/health-casemix-data-collectionsabout-hcp (accessed 27 September 2013). Australasian Rehabilitation Outcomes Centre (2012).. The FIM TM Instrument. Available at: html (accessed 27 September 2013). Australian Government Department of Human Services Medicare (2013).. Available at: business/online/eclipse/ (accessed 15 Oct 2013). Australian Institute of Health and Welfare (n.d.). Metadata Online Registry National Minimum Dataset specifications. Available at: aihw.gov.au/content/index.phtml/itemid/ (accessed 27 September 2013). Australian Government Department of Health 2012). Private Hospital Data Collection Review. Available at: publishing.nsf/content/phdc-review (accessed 27 September 2013). Nicolle Predl, BAppSc(MRA) Senior Health Information Manager Australian Health Service Alliance Camberwell VIC HIM-INTERCHANGE Vol 4 No ISSN (PRINT) ISSN (ONLINE) 23

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