Onpoint News – June 2016
1. Academy Health Features Onpoint’s Presentation on Data Linkage among “Best of ARM”
2. Public Use Files Released by MN Solicit Innovative APCD Use Cases
3. Stakeholders Come Together to Address Impact of Gobeille Decision
4. Vermont’s “Hub & Spoke” Program Evaluation Published in Journal of Substance Abuse Treatment
5. Onpoint & Partners Join in a Discussion of Alternative Payment Models at LAN Summit 2016
6. Onpoint REVO Cycles, Supports American Lung Association at the Trek Across Maine!
Academy Health, based in Washington, DC, is a leading national organization that brings together key stakeholders from the health services and policy research disciplines to address the current and future needs of the nation’s evolving healthcare system. One of their fundamental and guiding objectives: translating evidence into action.
Each year at their Annual Research Meeting (ARM), the organization provides a platform for researchers to deliver compelling and innovative presentations on critical and emerging discoveries as well as efforts focused on improving and transforming healthcare delivery and payment systems.
At this year’s ARM conference, held earlier this month in Boston, MA, Onpoint’s health services researcher, Amy Kinner, MS, participated on a panel exploring the challenges and successes of linking data sources. Moderated by Bobbie Kite, PhD, MHS, of the Ohio State University Wexner Medical Center, the session also included three other speakers: Julia Adler Milstein, PhD, University of Michigan; Jennifer Gaudet Hefele, PhD, University of Massachusetts-Boston; and S. Raquel Ramos, PhD, MSN, MBA, FNP-BC, Yale University.
Using the Vermont Blueprint for Health’s patient-centered medical home (PCMH) program as a case study, Kinner explored the complex process used to link data from the state’s all-payer claims database (APCD) with clinical data from its statewide practice registry in an effort to provide actionable information to decision makers and providers across the state. Kinner reported that 83% of patients participating in the Blueprint’s PCMH program were successfully linked between the two statewide databases using a series of complex algorithms. Combined, the claims and clinical data offer a powerful analytic resource that provides a much clearer and broader view of the quality and cost of healthcare across Vermont.
After patients have been linked between the two databases, a variety of quality measures, such as hemoglobin A1c (HbA1c) control among diabetes patients and blood pressure control among hypertension patients, are generated by Onpoint’s analysts. These outcomes measures are aggregated for each of Vermont’s health service areas and enriched with an assortment of cost, utilization, and quality measures, along with Behavioral Risk Factor Surveillance System data, to provide insight to the practices and communities delivering primary care services across the state. The data has also been used to conduct an in-depth study on the impact of controlling HbA1c among diabetes patients on hospital use and total cost.
Kinner noted that the rich data source created by linking claims and clinical data should be further explored for healthcare research and evaluation purposes and for effectively informing policymaking.
Her presentation, “Linking Clinical Registries with the All-Payer Claims Database: A Powerful Source of Data to Reform Healthcare,” was also one of only eight abstracts selected by Academy Health (among more than 2,500 total submissions) to be highlighted in the conference’s “Best of ARM” session. This session spotlighted some of the most intriguing abstracts presented throughout the meeting, offering a glimpse of changes in the data and methods expected to transform health services research in the years to come.
According to a recent press release from the Minnesota Department of Health (MDH), Minnesota has become the first state in the Midwest – and only the sixth in the entire nation – to publish summary-level health insurance claims files using data compiled from their all-payer claims database (MN APCD). These files, available to the public free of charge and generated by Onpoint, will enable members of the healthcare community – from researchers and health improvement leaders to providers and payers – to learn more about the types of healthcare services provided in Minnesota, including their outcomes and associated costs. The release of these summary files is MDH’s most recent legislative milestone in expanding the use of the MN APCD in an effort to foster insight regarding variations and disparities in healthcare use and quality and to support price transparency.
The State of Minnesota is a pioneer when it comes to turning data into actionable analysis. Leveraging the data from its statewide APCD, developed and operated by Onpoint since 2009, Minnesota is able to help drive the state’s achievement of the Triple Aim by drilling into and investigating the state’s healthcare system to identify areas for improvement. This expanded functionality coming after the state’s APCD Workgroup’s January 2015 report, in which it called for the Legislature to expand the use of the MN APCD, initially by creating public use files and summary tables.
This first round of public data from the MN APCD summarizes the health conditions, healthcare costs, healthcare services, and places of service listed by the first three digits of the ZIP codes reported on medical claims, addressing small cell-size constraints to protect the identities of individual patients, providers, and claim providers. The first set of data files and summary tables were prepared by Onpoint earlier this spring and can be obtained by completing and sending a public use file data request form to MDH. According to MDH, additional aggregation of data based on input from data users may follow.
To date, the Minnesota Legislature has restricted the use of the MN APCD to MDH staff and its contractors to perform analyses on variation in cost, quality, utilization, and disease burden, as well as for certain evaluation activities. To explore additional interest areas and health improvement opportunities using the MN APCD, these new summary files will serve as a way for researchers and the public to join in the exploration, demonstrating the ongoing value of the MN APCD through the development of new and innovative use cases and analyses. According to MDH, “broader engagement with the data will also help inform MDH’s continuing efforts to improve the quality and effectiveness of the data and may help prioritize research at the agency.”
“We look forward to engaging with potential data users,” says Stefan Gildemeister, director of the MDH Health Economics Program. “This will help us create an evolving set of data over time and inform our own research.”
In a 6-2 decision released earlier this March, the U.S. Supreme Court (SCOTUS) ruled against the state of Vermont in the case Gobeille v. Liberty Mutual, putting at risk the breadth of all-payer claims databases (APCDs) and the expansive advantages they yield. SCOTUS’s decision effectively denies states the ability to mandate claims submission from self-funded employer groups covered under the federal Employee Retirement Income Security Act (ERISA), which was passed in 1974 primarily to safeguard pension funds and retirement benefits from corrupt practices. The Court’s ruling means that the comprehensive view of claims data that is critical to the many state and regional healthcare transformation initiatives across the country may soon become less comprehensive, impairing the ability of analysts and policymakers to perform cross-payer measurement, monitoring, and evaluation.
APCD solutions are designed specifically to fill critical information gaps, offering a reliable, population-wide data set to help understand what is happening in healthcare within a specific patient population, practice, community, state, or region. For researchers, policymakers, purchasers, and providers alike, APCDs serve as the most credible single source of truth for population- and provider-based analytics.
This is why proponents of APCDs, including Trish Riley, Executive Director of the National Academy for State Health Policy (NASHP), warn that SCOTUS’s decision is “a slippery slope that could limit states’ broader health reform activities.” For health improvement initiatives to successfully fulfill their obligations to “protect public health, regulate health delivery, and address healthcare costs and quality,” they ultimately need the kind of robust data unified exclusively by an APCD in the pre-Gobeille world.
In the new post-Gobeille world, Riley cautions that the Court’s ruling could impoverish the data critical to improving the delivery and quality of healthcare: “Can APCDs be effective without all claims, particularly since self-funded plans cover the majority of employees who have employer-sponsored insurance?”
In trying to understand what is at stake for APCDs across the nation, NASHP, the APCD Council, and the National Association of Health Data Organizations (NAHDO) have begun hosting working sessions to help navigate the path down the post-Gobeille rabbit hole and find solutions to safeguard the valuable APCD resource. Issues discussed in their workgroup’s recently published documentation include the enforcement of APCD statutes, definition of ERISA-exempt plans, and voluntary data submission of self-funded claims data among others.
This same group is also working on a possible strategy with the U.S. Department of Labor (DOL) to provide a regulatory solution that would enable continued access to ERISA-plan data by state APCD programs. (The SCOTUS ruling pointed to the DOL as the appropriate federal agency to address the issues brought forward in the case.)
Additionally, the APCD Council and NAHDO have published a brief highlighting the ways in which APCD data are used to support the most paramount needs of employers, specifically those with self-funded plans impacted by the Court’s decision. This value equation for employers – supplying data to APCDs enables them to identify inefficiencies in the care and cost for their own employees – is a powerful argument that may help dissuade employers and their reporting plans from seeking exemption under Gobeille – a win/win proposition for all.
- NASHP article, "Are States Losing Key Tools for Health Reform?" by Trish Riley (April 5th, 2016)
- NASHP resource page on the Gobeille ruling
- APCD Council
- APCD Council publication, "Key Regulatory Issues Facing APCD States Post Gobeille v. Liberty Mutual"
- APCD Council publication, "The Value of All-Payer Claims Databases for Employers"
Addiction to opioid substances such as heroin, morphine, and prescription pain medication continues to grow as a national public health crisis, demonstrating widespread economic, personal, political, and social consequences. In 2013, 1.9 million Americans were dependent on pain medication and 517,000 on heroin, with the former’s use remaining nearly consistent or declining since 2002 and the latter’s increasing. Mortality rates have mirrored these trends: In 2013, overdose deaths from opioid pain relievers declined slightly to 16,235 (from 16,651 in 2010) while heroin overdose deaths nearly tripled to 8,257 (from 3,036 in 2010).
According to a recently published article in the Journal of Substance Abuse Treatment(JSAT), the state of Vermont’s experience follows this same pattern: “From 2011 to 2013, the number of Vermonters receiving treatment for prescription opiates and heroin increased from 2,864 (654 for heroin and 2,210 for prescription opiates) to 3,971 (1,375 for heroin and 2,596 for prescription opiates) – a 38.6% overall increase, with a 110.2% increase for heroin and a 17.5% increase for prescription opiates.”
In response to the increasing rates of overdose deaths and demand for treatment, the JSAT article explores the questions of whether and how to expand access to statewide treatment services for opioid addiction – and, in particular, the treatment services’ cost-effectiveness on overall healthcare and medical service expenditures. The article is co-authored by the Vermont Blueprint for Health’s Mary Kate Mohlman, PhD, Beth Tanzman, MSW, and Craig Jones, MD, and by Onpoint’s Karl Finison, MA, and Melanie Pinette, MEM.
To provide insight, evidence, and a systemic response to Vermont’s public health emergency, the study uses the state’s all-payer claims database – the Vermont Health Care Uniform Reporting and Evaluation System (VHCURES) – to examine Vermont’s Medicaid expenditures for opioid addiction treatment and other services from 2008 to 2013. The authors chose to focus on the Medicaid population since Medicaid beneficiaries were (and continue to be) at higher risk for substance abuse and overdose during the study period, maintaining a 21% share of all substance abuse expenditures – roughly $5 billion – as of 2009.
For Vermont’s Medicaid population, the authors compare the healthcare expenditures between two groups with opioid addiction: (1) those receiving medication-assisted therapy (MAT), which includes the use of medications (i.e., methadone or buprenorphine) in combination with counseling and behavioral therapies and (2) those receiving non-medication treatment approaches (e.g., behavioral therapies alone). While MAT’s effectiveness has been demonstrated in reducing opioid use, its treatment strategies come with higher direct costs than alternatives; it has yet to be determined whether those associated costs are offset by a reduction in patients’ related healthcare expenditures.
The study’s authors set out to explore that trade-off for Vermont’s Medicaid population, finding that “the overall difference in annual average expenditures was lower for the MAT group, even with the cost of MAT.” In other words, despite MAT’s higher direct costs compared to non-MAT strategies, MAT patients had much lower healthcare expenditures with lower rates of inpatient admissions and outpatient hospital emergency department visits being two key factors in the difference.
In light of their findings and combined with MAT’s widely-considered effectiveness in treatment retention and reduction in opioid use, the authors suggest that Vermont’s expansion of MAT services for the Medicaid population “has the potential to produce better opioid addiction treatment results and lower overall health care costs compared to other approaches to opioid addition treatment.” For state Medicaid leaders looking to fight the opioid epidemic, the study provides a compelling case to expand early support for expanding MAT services rather than solely relying on “time-limited medication” or psychosocial and abstinence interventions. Furthermore, the study serves as a baseline by which the Vermont Blueprint can evaluate its Hub & Spoke program, a component of Vermont’s broader Health Home design, which is aimed at linking greater access to MAT with a network of primary and community resources.
- Journal of Substance Abuse Treatment
- Vermont Blueprint for Health
- "Impact of Medication-Assisted Treatment for Opioid Addiction on Medicaid Expenditures and Health Services Utilization Rates in Vermont," JSAT
To help the country transform its care delivery and payment methods to focus on value instead of volume, the U.S. Department of Health and Human Services (HHS) launched the Health Care Payment Learning and Action Network (LAN). The LAN’s mission is simple: accelerating the adoption of value-based payment systems and alternative payment models (APMs) while phasing out the traditional fee-for-service model under which “more services lead to higher payments, regardless of health outcomes.”
At the LAN’s 2016 Spring Summit in Tysons Corner, Virginia, professionals spanning the healthcare continuum – from providers and payers to administrators and local, state, and federal government leaders – shared experiences and lessons learned in developing and implementing APMs.
Onpoint and two of our partnering clients, the Vermont Blueprint for Health and the Health Collaborative of the Greater Cincinnati (Ohio) region, were invited to present on the topic of “Data Infrastructure to Support APMs at Scale,” a session moderated by Dr. Karen DeSalvo, a physician and public health expert who serves concurrently as the Acting Assistant Secretary for Health and the Director of the Office of the National Coordinator for Health Information Technology (ONC) at the HHS. The session included presentations by Craig Jones, MD, Director of the Vermont Blueprint for Health; Richard Shonk, MD, PhD, Chief Medical Officer of the Health Collaborative; William Golden, MD, MACP, Medical Director of Arkansas DHS/Medicaid; and Jim Harrison, MHA, FACMPE, President/CEO of Onpoint.
Drs. Jones, Shonk, and Golden each emphasized the importance of active stakeholder engagement across provider organizations, purchasers, and government organizations to ensure their success. While the reporting solutions, performance measures, and dissemination strategies vary across their initiatives, the presenters’ message was clear that strong leadership at the grassroots level combined with capable technical partners is key to all.
Harrison’s presentation focused on the important foundational elements underlying a reliable data system – what’s “under the hood” – those data validation, standardization, and analytic enrichment systems and processes that are essential to accurate and trusted downstream analytics. “Stakeholders of data collection and reporting initiatives, particularly in their earliest stages, take as a given the reliability of data validation and integration systems and, instead, place more value on a flashy front end or business intelligence interface,” he noted. “In the end, if rigorous quality assurance procedures are not in place, and end users identify errors in the data, trust and support will quickly be lost.”
Together, the presenters discussed how the successful scaling of APMs requires not only a critical mass of data across payers but also the infrastructure and subject matter expertise to effectively process, manage, and report practice results in a timely fashion and in comparison to trusted benchmarks.
This past Father’s Day weekend, the Onpoint Revolution (REVO) cycling team was back at it again for our second consecutive outing at the Trek Across Maine. The Trek, an annual three-day, 180-mile cycling journey across the state of Maine – from the mountains at Bethel to the sea at Belfast – is the largest fundraiser of its kind in the nation for the American Lung Association (ALA).
Over the past 30 years, the Trek has raised more than $23 million to support the ALA’s efforts to save lives by improving lung health and preventing lung disease. This year’s event, with some 2,200 riding cyclists and 650 registered volunteers, has so far collected more than $1.65 million dollars.
The Onpoint REVO team, which raised more than $2,500 for this year’s event, would like to thank all of our team’s donors and supporters for their strong encouragement and motivation. Thanks also go to the entire Trek event team for hosting a first-class, memorable experience.
With its scenic trail, inspiring stories from cyclists and volunteers, incredibly delicious foods, and truly worthy cause, Onpoint REVO will be back at the Trek 2017 Sunday River starting line. See you there!