Advanced Imaging Management Workgroup Report

Transcription

1 Advanced Imaging Management Workgroup Report FINAL REPORT As Required by Engrossed Substitute House Bill 2105 Chapter 258, Laws of 2009 August 2010

2 Table of Contents Advanced Imaging Management Workgroup Members and Staff...3 Purpose... 4 Background... 6 Executive Summary... 4 Phase Two Process... 6 Next Steps... 8

3 Advanced Imaging Management Workgroup Members: Steve Hill, Health Care Authority Administrator Workgroup Chair Craig Blackmore, MD, Health Technology Clinical Committee Workgroup Vice Chair Robert Bree, MD, Washington State Radiology Society Susie Dade, Puget Sound Health Alliance Nancy Fisher, MD, Health Care Authority Gary Franklin, MD, Department of Labor and Industries Robert Karl, MD, Washington Health Care Forum Fred Mann, MD, Washington State Hospital Association Andrew Oliveira, MD, Multi-State Health Carrier Lisa Plymate, MD, Primary Care Provider Jeff Thompson, MD, Department of Social and Health Services Mark Whitaker, MD, Association of Washington Health Plans Brian Wicks, MD, Washington State Medical Society Expanded Participants: Stu Freed, MD Wenatchee Valley Med. Center Norm Beauchamp, MD UW Radiology; Mika Sinanan, UW Medicine Judy Glenn VMMC; Bob Mecklenberg, VMMC; Al Fisk, Everett Clinic; John Vassal, MD Swedish; Wendy Wilkins-Russell, WMI; Cliff Roberston, MD Franciscan Health System; Larry Schecter, MD, Providence Staff: Leah Hole-Curry Nate Rozeboom Denise Santoyo

4 Executive Summary AIM participants represent WA s major health plans, large providers, provider associations, and quality organizations. Through a collaborative process over the past year, the participants defined and agreed to a unanimous conceptual framework for a state wide solution to manage advanced imaging in a common and evidence based way. Further, at the last AIM workgroup meeting in June 2010, a core group of providers and payers have agreed to participate and fund a six month intensive planning phase to define the statewide solution and business case. The agreed six core components are listed below, and next steps are detailed later in the report: Decision support based: Electronic system with transparent, evidence based criteria for imaging ordering that is capable of being added to a provider s electronic medical record or accessed via the web Institutional gold card: Providers that can clearly demonstrate current evidence based management of advanced imaging(across all categories) qualify for a by pass of system with benchmark and outcome reporting No conflict with WA Health Technology Assessment (HTA): Criteria in electronic system do not conflict with decisions of WA HTA program Include hard stops : Imaging that does not meet agreed criteria is not reimbursed by payers Implement at point of order: provider ordering test accesses criteria before proceeding to enhance decision support Accreditation and HIPAA compliance: electronic transactions and processes will meet appropriate legal and quality standard (e.g. HIPAA, URAC, etc) AIM workgroup recommendations and the findings and outcomes are outlined in this report. Additional information about the workgroup, meetings, and full materials are available at:

5 Purpose Washington State is leading efforts to use evidence based medicine to make sound health policy and coverage decisions. This report is submitted in compliance with Engrossed Substitute House Bill (ESHB) 2105 which was signed by the Governor and enacted as chapter 258, Laws of The act directs the Health Care Authority (HCA) to convene a workgroup to: Identify evidence based best practice guidelines or protocols applicable and decision support tools applicable to advanced diagnostic imaging services to be implemented by state purchased health care programs. Section 2(1). Report its findings and recommendations to the Governor and the appropriate committees of the Legislature no later than July 1, Section 2(5). Explore the feasibility of using the guidelines or protocols for state purchased health care services that are purchased from or through health carriers and all payors in the state (to be completed no later than July 1, The HCA appointed the Advanced Imaging Management (AIM) workgroup immediately following enactment of the legislation. The 13 member workgroup representing health care provider, payor, and quality organizations and completed its initial task of identifying evidence based best practice guidelines and protocols prior to the July 1 deadline. The work product of the workgroup to date is electronically available on the HCA website at This report addresses the second legislative task that directs the workgroup to explore the feasibility of using the guidelines or protocols for state purchased health care services that are purchased from or through health carriers and all payors in the state by January 1, 2011, for the reimbursement of advanced diagnostic imaging services. Authorizing Legislation - ESHB 2105 / chapter 258, Laws of 2009 Section 1 Definitions Section 2 Workgroup membership and tasks Section 3 Requires state agencies to implement in direct purchased care Section 4 All Medicare accreditation requirements apply to all state providers

6 Background Nationally and within Washington state; there is documented overuse and increased cost of medical imaging (MRI, CT, PET, Cardiac Nuc) without corresponding health improvement. See, e.g. Health Affairs, Nov. 10, 2008, Study Charts Dramatic Rise In Medical Imaging The governor and legislature convened a WA State workgroup (AIM) to address rising state agency costs ($108m/yr) by identifying evidence based management program(s) to control cost, increase safety and reduce variability. AIM is also required to investigate the feasibility of apply recommendations to all payers. AIM REPORT: pdf Advanced Imaging Management Workgroup Phase Two Process From September 2009 through June 2010, the workgroup invited representation from larger provider groups to discuss feasibility of a state wide solution. Four stakeholder meetings were held, approximately quarterly, which resulted in discussion of the following topics and definition of some agreed core principals. 1. Overview of legislation and phase one workgroup research and recommendations and agency implementation. 2. Review of Minnesota s ICSI who completed a demonstration of a multi payer and multi provider, centralized advanced imaging project. 3. Discussion of all invitee s current status and potential interest and feasibility of a state wide project to address advanced imaging. 4. Agreement on interest and core principles. Appointment of a subgroup to define a workplan proposal. Why a statewide effort? Provider perspective: Acknowledgement that there is variation and overuse in the use of advanced imaging and would like to have better criteria to support decision making and respond to patient and competitor challenges; want consistency and a voice in criteria, preservation of clinical judgment, and reduction in administrative burden imposed by current variation in payer solutions. Payer perspective: Frustrated by high variation and rising costs w/o benefits; want valid evidence based criteria and (state or multi player) source for standards, all provider participation, ability to enforce criteria and monitor outcomes, and lower cost through collaboration.

7 Agreed Core Principles o Decision support based o Institutional gold card o No conflict with WA HTA o Include hard stops o Implement at point of order o Accreditation and HIPAA compliance Gauge of expanded Group support for concepts: 1. Agree on principles (Yes by all, strong support) 2. Single state solution (Yes by all, strong by almost all) 3. Enthusiasm for working on plan to define (Yes by all, strong support)

8 Next Steps At the last AIM Workgroup on June 21, 2010, a core group of providers and payers has agreed to participate in, and fund, a six month intensive planning phase to define the business case and solution concept for a statewide solution. The following roles and outcomes are expected. Undertaking a collaborative effort to develop a statewide process(es) for advanced image management that satisfy the 6 core principles. Organizations commit to a six month planning phase of semi monthly meetings. PSHA will develop a budget for ½ time fte and can act as hiring authority, cost will be shared by organizations Meeting facilitator could remain with HCA if available The planning group will address the requirements for a statewide process, which includes agreement on: 1. Governance 2. Resources 3. Solution Description 4. Data 5. State Role and Legislative needs Specific roles are: a. Executive buy in (from participating organizations) for: i. upfront tentative commitment to participating in the statewide process identified by the planning group (based on core) ii. Identification of an organizational representative to participate in the planning phase iii. Data to produce benchmarking information on utilization as requested iv. Estimate of current organizational radiology management costs v. Funding support (shared among participants) for ½ time six month project manager as detailed in budget proposal from PSHA b. Organizational representative from each organization to consistently participate in semi monthly planning meetings i. Governance: Contribute to discussion on state wide entity requirements; ii. Data: provide benchmark and other data; iii. Solution Detail: participate in developing implementation requirements; iv. update executive and gain organizational support for moving forward c. Project manager to lead: i. Governance: Organizational requirements of entity that will manage statewide solution and investigation of current organizations that may fill this role or recommend establishment of new organization ii. Data: Summarize current utilization baseline of participant organizations and identify highest needs for intervention based on data iii. Potential solution descriptions: high level core functions, roles iv. Identification of any legislative requirements needed and state role (e.g. anti trust) v. Resources: Identify costs (entity and solution costs) and timeline for implementation