Governor s Healthcare Transformation Office Hawaii All-Payer Claims Database Request for Information

Transcription

1 Governor s Healthcare Transformation Office Hawaii All-Payer Claims Database Request for Information A. Introduction The Governor s Office of the State of Hawaii (hereafter referred to as the Agency ) is considering contracting with a vendor to collect, analyze, and publish health care cost and utilization information. This Request for Information (RFI) requests information and suggestions from vendors and other experienced informants and stakeholders such as health plans, providers, advocates, consumers/ patients and other technical experts as the Agency plans the All Payer Claims Database (APCD) project. A draft statement of work is not included, and will be developed based on information received from this request. B. Overview The State of Hawaii s Department of Commerce and Consumer Affairs (DCCA), Insurance Division received funding from the US Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), Center for Consumer Information and Insurance Oversight (CCIIO). DCCA was awarded a Cycle III grant as part of the Health Insurance Rate Review Grant Program-Grants to States to Support Health Insurance Rate Review and Increase Transparency in Health Care Pricing. The State and CMS are currently working together to transfer the grant to the Governor s Office, where it will also serve to establish baseline and trend data related to health care costs and utilization in support of healthcare transformation goals. This grant will be overseen by the Governor s Office, with support relevant to programmatic and technical expertise by the DCCA and Office of the State CIO. Establishing APCD: Vendor Requirements The Cycle III grant (referred to above) will be used to establish an All-Payer Claims Database in the State of Hawaii. The State may issue a Request for Proposals in January 2014 for that purpose. Institutional requirements: The Cycle III grant funder mandates that the Data Center to be established for the APCD must be located at an academic or other non-profit institution. Accordingly, applicants responding to our subsequent RFP must be academic or non-profit institutions, and the primary vendor for these services must adopt by-laws consistent with conflict of interest requirements in the grant, established under Public Health Service Act Section Collection of Health Claims Data: The primary vendor will collect claims-related data from a variety of healthcare payers, in order to develop utilization and cost models, for specified episodes of care and medical procedures, for research and analysis. This data collection may incorporate claims, diagnoses, and quality from payers. Analysis of Health Pricing, Utilization, and Reporting: The vendor will develop and continually update health care cost, utilization, and quality information for an agreed set of diseases, episodes of care, and medical procedures. 1

2 Transparency: The vendor shall make predetermined products of analytics available to the public, in the form of reports and research findings, inclusive of associated statistical methodologies. These elements must at minimum be presented on a consumer-oriented website to enable transparency on disease prevalence and aggregate disease costs across regions of the state. Additional reports specifically targeted for the consumption of distinct payers, providers, and most notably state agencies may be developed. The vendors are expected to maintain availability of information in transparency reports in compliance with performance targets, by means of Service Level Agreements (SLA). Minimum Requirements for Selected Vendor(s) I. Advance identified strategies for multipayer participation, with appropriate data safeguards. II. Build trust through Health Data Governance Board, security and privacy frameworks. III. Collaborate on standards for data submission, mandatory and voluntary approaches. IV. Design and deliver analytics, associated reports, of value to participating organizations. V. Educate healthcare consumers and stakeholders through publicly available reports and website. VI. Fulfill grant requirements and build community value proposition for reports and analytical products, while meeting or exceeding privacy & security expectations. Key activities related to the healthcare transformation agenda that require data support via the APCD include: Improvement in quality, health, and cost-effectiveness associated with patient-centered medical homes including reductions in ER and hospital utilization Improvement in quality, health, and cost-effectiveness associated with health homes, more extensive care coordination and management, and super-utilizer initiatives including reductions in ER and hospital utilization Improvement in health status and outcomes for Native Hawaiians and other Pacific Islanders, and for communities with noted health disparities. C. Additional Interests/Opportunities In addition to meeting minimum requirements, the State believes the development of an APCD can also contribute to the following goals: Identifying Cost Drivers and Population Health Policy Priorities Over the mid-term, the APCD would play a key role in identifying structural cost drivers and emerging population health policy issues. Even with above-average population-level health status, the annual growth rate of health care costs in Hawaii continues to outstrip the annual growth rate of inflation. The ability to identify key aggregate cost drivers at the population-level is imperative to bend the health care cost curve and identify best practices for utilization and expenditures in the health care system. Additional targeted data will inform State efforts to identify chronic disease spending patterns, including cost and utilization variances across the system for medical procedures and visits. This is particularly important for Hawaii s diverse geographic and population profile: A majority of Hawaii s 2

3 population lives in urban areas; however, a substantial portion of the state s population lives in rural areas where access to care is limited and access, utilization, and costs may differ significantly from urban areas. Ethnically/racially, the majority of Hawaii s population is Asian and Native Hawaiian and other Pacific Islanders. The APCD would also play a key role in driving population health policy initiatives based on clinically derived data. Although Hawaii has substantive data resources in both the population health and clinical health spheres, there is limited (current) ability for clinically generated data to be directly exchanged with public health entities and vice versa. This exchange would strengthen current and future public health policy efforts to deal with chronic diseases further upstream, where interventions are more numerous and the total costs of treatment is lower. For example, youth obesity in Hawaii has significantly increased in the state over the past 10 years; diabetes and cardiovascular rates are also increasing in the elderly population. The APCD s clinically relevant data would allow for a more comprehensive snapshot of the state s health that could drive public policy health policies at the state level. This is also particularly the case for identifying trends for health disparities in disparate populations. Increased Transparency for Consumers Over the long-term, the APCD will be leveraged to increase aggregate healthcare cost and usage trend transparency efforts in the state. Although current information is limited, over time reports from a functional APCD would be a key to activating consumers regarding their care options and cost information. While these planning efforts are still in developmental stages, Hawaii plans to ultimately make information from these reports on cost and quality across hospitals and providers available on an easy-to-access web site for consumers. Smarter State Purchasing Over the long-term, centralized access to clinical encounter, quality and cost data will allow the State to become a more effective purchaser of health care services. Currently, although the State has access to basic data (cost and limited quality metrics) for Medicaid beneficiaries, there is little knowledge of cost and utilization drivers for current and retired state employees. In alignment with the Healthcare Transformation goal of increasing understanding of State spending on healthcare, the APCD seeks to develop reporting capability on disease trends, healthcare services, and costs to taxpayers of chronic conditions. The APCD would provide the optimal platform to aggregate utilization, cost, and quality data in one place for state-funded beneficiaries, with the ability to analyze healthcare spending across programs. Once initial data is collected and analyzed, the resulting reports would serve as the main evidence for State efforts to implement and coordinate innovative delivery model and payment reform; indeed, Hawaii is currently collaboratively contemplating a range of potential options to cut costs and improve quality for State-funded beneficiaries. An APCD would not only help to inform the discussion of which payment reform(s) would be most successful, but would also provide for a positive feedback loop whereby the State could evaluate the impact of reforms on cost and quality, and bolster efforts to improve outcomes. The immediate impact of this solution is anticipated identification of information of 3

4 value to the healthcare system as a whole, for comprehending overall trends. Over the longer term, the State envisions exploring community interest towards directing appropriate actionable information to providers, for direct patient care comparisons or improving practice operations. The solutions offered under the APCD must deliver data collection (on utilization, costs, & quality), analysis, and reporting capabilities, and may additionally enable mechanisms for expediting communication of appropriate quality, utilization, and comparative outcome information with providers. Public Health Data collected in the APCD would support and inform programs to improve public health: Bolster public health programs and population health initiatives with increased information on costs and benefits. Allow for mapping of data related to diagnoses, aggregate cost, quality, utilization, access, and health outcomes for public health purposes. In the future, the database may be used to: Support interventions related to chronic diseases, support generation of aligned quality measures, support interventions in the area of prescription drug utilization and abuse, and be a tool to identify and solve newly identified health concerns. Continue to target priority health conditions; support evaluation and improvements in public health programs. Support continued innovation in Medicaid program waivers, support alignment of quality objectives among multiple State-paid healthcare programs, and enable value-based purchasing designs among other innovations. It is important to note that identifying business (use) cases, data governance, structures, and public reporting targets for transparency will be an on-going process in which the private sector insurers, providers, payers, and consumers are part of the development and decision-making process. Data Sets of Interest The solution is expected to target efforts primarily around controlling chronic diseases, such that a limited set of data may be collected in phase 1 with increasing sets added to the database over time, according to an established multiyear plan. The data sets that may contribute most to the goals of healthcare transformation at this stage would include the following in some form: All hospitalizations & ER utilization All urgent care utilization All long-term care utilization All home & community-based services All children s dental utilization All MQD utilization All EUTF utilization All DOH utilization All commercial utilization Conditions/diagnoses Mental health conditions Chemical dependency/ substance abuse COPD CVD/CHF (Heart disease) CKD (Kidney disease) DM (Diabetes) Obesity Communicable diseases Infections Dementia/Alzheimer s Melanoma Asthma 4

5 As part of the APCD solution development, a prioritization and multiphase plan for collecting and disseminating reports generated from analysis on these datasets is to be developed. RFI responses may describe methodologies for prioritizing or determining the relative value of certain encounter or claims information sets for this project. In addition, responses may identify preferential approaches to phasing reports and information of value to the public, payers, providers, and the healthcare system as a whole. D. Information Requested The Agency is seeking information related to strategies that would be applicable to the design, governance, development, implementation, operations, and sustainability of an APCD. Information should include best practices and innovations in business models and service delivery. We are also interested in vendors experience with comparable programs in other states, whether with public or private enterprises. The information provided should include the following APCD project planning and strategies: Data sets 1. Comment on whether the data sets identified above appear to be those most likely to support transformation goals. Suggest other non-claim data, such as lab values, if appropriate. Recommend an approach to standardized quality metrics as a means of evaluating total population health. Payer and Provider Participation 2. Identify recommended strategies for payer and/or provider participation and education. Describe possible provider concerns. Include any barriers to payer and/or provider reporting capabilities, and/or experience in executing potential strategies or roadmaps for sustainability through demonstrating community value to agencies, payers, and/or providers. Specify experience in highly integrated health care provider data. 3. Discuss whether there might be different tiers and phases for participation by certain commercial payers. If tiers/phases are recommended describe the points at which participation would be required. This may include adjusted approaches or modifications to mandatory data set contributions. Present recommended modifications on a basis of accurate and meaningful comparisons to other payers and providers, for information not maintained on costs at a given organization or data contributor. This strategy may include waivers for particular requirements, and recommendations on the means to improve compliance over time. 4. Identify opportunities and special considerations for including DOH data for FQHC uninsured/other visits, behavioral health, family planning, and other directly provided or contracted programs. Identify special considerations and opportunities around gathering uniform ethnicity information, and information on special populations, including COFA migrants and non-hawaii resident groups. 5. Discuss how Medicare, VA, and other federal health benefit program data might be incorporated into the database. Include CMS Qualified Entity Program discussion. 5

6 6. Address problems and possible solutions that may arise with regard to uncompensated and/or uninsured care, long-term care, self-funded, or self-insured programs, workers compensation, and auto accident claims. Identify solutions to potential special program data sharing issues. Security & Privacy Concerns 7. Describe requirements for vendor HIPAA compliant security and privacy measures, for protection of source data. Recommend standards, procedures to verify privacy protections, and methods for ensuring data collection, analysis, and reporting maintain appropriate safeguards. Data Governance, Collection, Analysis, Reporting 8. Discuss policies and procedures to be included in developing data submission rules with input from key stakeholders. Present challenges and potential solutions for building APCD data sharing policies and consensus through a Health Data Governance Board. Recommend policy and procedural approaches for developing community agreement on reports for the public and stakeholder institutions. 9. Discuss approach and best practices for data governance, data release, and report release, including due process for any entities that might be identified in public reports. 10. Data definitions and data integration procedures to ensure comparability of data that may be claims based to data that may be encounter-based (e.g., data from most commercial insurers vs. data from Kaiser Permanente). 11. Methods for data collection, consolidation and validation, including database structure and specifications. 12. Uses, methodologies, and recommendations for data analytics; including methodologies for analysis and reports for: internal State use, and general publication. 13. Experience and best practices for validating claims/encounter/utilization data from multiple sources. 14. Identify privacy and security issues that the Agency and its vendors must be alert to with respect to de-identified and aggregated data. Discuss whether these concerns differ depending on whether the APCD is managed by a non-profit/academic institution vs. direct Agency management. 15. Recommend which data sets should be prioritized in phases 1 3 (or more) and why, citing comparative ease of obtaining and analyzing data sets. Additionally include considerations on relative value of data sets, for purposes of moderating healthcare and premium costs, stakeholder programmatic requirements, and for healthcare transformation. 16. Describe how the data center could potentially operate technically in conjunction with existing Hawaii entities for data sharing, stakeholders data repositories, health insurance exchange, and the health information exchange. Discuss how the technical architecture for APCD could provide components of the foundation for alignment of clinical and claims data, towards the goal of providing utilization and cost references or resources. 17. Describe how data and quality metrics may be aligned with the Health Insurance Exchange. 18. Discuss preferred approaches to master patient and master physician indices in relationship to the APCD; explanation of previous experiences and best practices is highly valued. Identify methodologies for unique master patient index and master physician index, and explain approaches to integration of said unique indexes with a health information exchange. 6

7 APCD Management and Stakeholder Input 19. Recommendations on the benefits and/or challenges of having the Agency directly interface with the APCD stakeholders, operational and technical teams, or, alternatively, contracting with a non-profit or academic institution that manages the governance process and operations of the APCD at the direction of the Agency. 20. Recommendations on the most effective model for the development and governance of an APCD, including reasoning, national, and local examples supporting the recommendations. Describe recommendations on structure for a Health Data Governance Board or similar consensus vehicle for determining data inputs, analytics priorities, reporting targets, and data governance. 21. Discuss which stakeholders would need to be involved in the processes and how to include them in that process. Please include consumers, payers, and providers. 22. Recommendations for the long-term management of the APCD, potential approaches to continuing placement in a non-profit or academic setting or to have the Agency manage the APCD repository and/or analytics services directly (with or without contracting for professional services to ensure data integrity and analysis). 23. Present potential approaches to long-term solution stewardship, and identify a preferred agency as the eventual home for this solution. After the term of the federal grant, formal programmatic oversight of the APCD will transition from the Governor s Office to a healthrelated agency. Discuss where this solution might reside. 24. Describe the ideal recommended experience, competencies, and structures for vendor(s) developing the APCD. Present competencies anticipated for: data collection, analytics, report generation, and public transparency. Technical Infrastructure 25. Provide a suggested implementation schedule for proposed development of an APCD: a. Describe the benefits and challenges of how phasing in the project might work and what steps would be included in each phase; b. Provide a project timeline and discrete cost analysis for each phase, along with a detailed description of the technology solutions and services that deliver the requirements of each phase including technology infrastructure, software components, user interfaces and overall functionality; c. Detail the recommended staffing levels and capabilities needed to operate an APCD at each implementation phase. The description should include, at a minimum, recommendations on the estimated number/type/level of expertise of staff that would be assigned to each phase of this initiative; 26. Describe the features and estimated costs of developing the system, including all technical hardware, software and any other technical specifications necessary to develop, implement, manage, and maintain an APCD as described in this RFI. 27. Provide approximate estimates regarding the cost to implement the technology solutions and ongoing expenditures on an annual basis for sustainability to deliver each component of the services defined, including data analytics. 7

8 E. RFI Response Requirements Failure to respond to this RFI will not preclude a qualified vendor from submitting a proposal when the subsequent RFP is issued, nor will response to this RFI in any way influence vendor selection in the procurement process. We understand that each respondent may not have relevant knowledge of or experience associated with each requirement that is contained in this RFI. Therefore, each response should contain only information with which the respondent has direct experience and/or expertise. A non-response may be signified by stating not applicable. Please be thorough but concise in comments. Responses should be clearly labeled and referenced to the item to which they are addressed. Proprietary Information If an informant believes that portions of his/her RFI response should remain confidential, the informant shall clearly identify that portion of the response that he/she wishes to maintain as confidential and include a statement detailing the reason(s) that the information should not be disclosed. Labeling the entire response as proprietary or confidential will result in none of the document being considered proprietary or confidential. Detailed explanation for classifying certain information as confidential shall include the specific harm or perceived prejudice that may arise from public disclosure. The Agency will determine whether the identified information will remain confidential. A prior notice shall be provided to the informant if it is determined that any information which was requested to be confidential becomes part of public distribution. After receiving notification, the informant requesting confidentiality can choose whether or not to withdraw his/her submission. Cost of Response Informants are responsible for all costs associated with preparing responses to this RFI. The Agency will not be responsible for any costs associated with preparing responses to this RFI. Questions Questions concerning this RFI should be submitted in writing via to [email protected]. If time permits, responses to questions received will be made by return to the sender. Response Submission Informants responding to this RFI shall submit two (2) hard copies and an electronic copy of their responses. The electronic copy may be submitted as an attachment. If the informant deems portions of his/her response to be confidential, the informant shall also submit an electronic redacted copy of the response suitable for release to the public. The redacted copy of the response must be clearly labeled as such in the document title. Please respond in ten pages or less in total length. The response must include the following information: 8

9 a) Informant s name; place of business (address); and contact information, including telephone number(s) and address(es). b) A statement of interest in the services outlined in this RFI, including an outline of a specific product, concept, technology, expertise, or approach that would meet the goals and requirements described in this RFI. c) A description of the informant s business and its experience as it relates to the services outlined in this RFI. This description should include a narrative explaining past experiences in which the informant has engaged with health care payers, health care providers or government agencies in the area of data collection and dissemination. The informant shall indicate any experience it has for services similar in nature to those described in this RFI. Please respond to this RFI by 5:00 p.m. HST, Friday, January 17, Responses shall be submitted to: Beth Giesting, Healthcare Transformation Coordinator, Office of the Governor State Capitol, 415 S. Beretania St., Room 415, Honolulu, HI [email protected] 9