Plenary: Doug Peddicord

8/9/2019 Plenary: Doug Peddicord

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The Best of Times for InformaticsThe View from Washington

Doug Peddicord

Washington Health Strategies Group

May 26, 2010



• AMIA’s Public Policy Work

–

• The Impact of Health Care Reform

• The Informatics Agenda Going Forward – ‘show me the money’ vs. ‘where’s the beef?’



AMIA Public Polic and Government

Relations

• Establishing relationships with legislators, policy,

• av ng a say n uenc ng eg s a on anregulation

• ‘Lobbying’



Public Policy and Government Relationsoa s an ec ves

• Make a difference for the biomedical and healthinformatics community; for AMIA members; and for AMIA

• Build relations with and educate Con ress about issues important to AMIA and its members

• Present AMIA as a resource to members of Congress

• Spread awareness about AMIA, health informationtechnology and informatics

• Provide objective input into the public policy discourseand help inform public policymakers



Positionin AMIA• AMIA’s 4,000 members advance the use of health

information and communications technolo in clinical

care and clinical research, personal health management,public health/population, and translational science, withthe ultimate ob ective of im rovin health. Our memberswork throughout the health system in various clinicalcare, research, academic, government, and commercialor anizations.

• AMIA is a source of informed, unbiased opinions onpolicy issues relating to the national health information

n ras ruc ure, uses an pro ec on o c n ca anpersonal health information, and public healthconsiderations.



• Find a champion for your point of view

(Members matter) – e.g., AMIA 10 X 10• Make connections – constituents, grassroots

contacts and personal relationships make a

difference• or e – prov e e ers o suppor , prov e

testimony, recruit co-sponsors

‘ ’• y u – w y u ,support or oppose when the time comes



•

– What do you want? – Who won’t like it?

– Anecdotes and hard data both matter (but brevity is

always key; one-pager is a term of art on the Hill)

– When asked, provide feedback (opinions, examples,answers, alternatives) immediately – 12 to 24 hours

,try 2 to 3 hours – being timely is as important asbeing right



• The re ulator rocess is more o en and

transparent – primacy and recency are lessimportant (but you still have to show up!)

• sta s ng re at ons ps w t n t e regu atoryagencies is more likely to be based on expertise;’

• Precision and clarity are key – think like a lawyer(or an English major)

• Be thorough – and respond within the timeallowed



‘ ’

• Public policy advocacy is a contact sport: in-

person, by phone, by e-mail, etc.; “ninetypercent of life is just showing up”

• Primacy and recency are powerful determinants

of influence, as is repetition• a s mpor an onnec ons persona ,

constituent) – expertise – responsiveness –

• Participation (Hill Day, for example) is essential



– ARRA



• Administrative Simplification – with the goal ofreducing overhead costs and creating ane ec ron c ea care env ronmen

• But the misalignment of incentives and lack ofinteroperability and other standards is

– educating, advocating, doing demos, etc.



–

• The legislative process on steroids: the 111t

Congress convenes on January 6, 2009 – and‘ ’

on February 17

– Energy & Commerce (Medicaid) takes the lead

• ‘ ’ – and HIT (!)



.

and physicians•

• $1.5 billion to HRSA

.

• $8.2 billion to NIH

.



• ’

Codification and funding of ONC

HIT incentives (W&M)

HIT standards (HELP) Workforce (Wu, Carper)

‘Meanin ful use’ W&M

Privacy (E&C, HELP)



Carrot and Stick Approach

•$17.2 billion for HIT funding will bedistributed through Medicare and Medicaid

•Carrot: Incentives will be offered to both

physicians and hospitals (the first‘payment year’ will be no earlier than2011)

fees will be reduced for ‘non EHRphysician users starting in 2015



The Price To Be Paid – HIPAA 2

• Breach notification

• Ban on sale of PHI

• xpan e pa en access r g s

• PHR provisions

• Restricted disclosures for self-pay

• ccoun ng or sc osures or rea men ,Payment, and Operations



•

and relevant parts of Privacy rules

• BA Agreements required for HIEs, RHIOs

• Limits re: minimum necessar and Limited DataSets

• Much tougher enforcement



• (Guidance re:) when PHI is considered “not”

• GINA

• Meaningful Use payment incentives

•• eRX for Controlled Substances



• Guidance on minimum necessary

• Guidance regarding de-identification of PHI• Promulgation of regulations on whatinformation is to be included in the accounting

of disclosures by covered entities and business

• ‘Omnibus’ rule implementing new marketing,

‘ ’,extension of jurisdiction over BAs and PHRs;im roved atient access etc.



Affordable Care Act



Health reform promises to usher in a new era in American

health care, supporters say

It will:

• Cover 32 million uninsured

• Improve affordability of coverage for millions now having difficulty

paying health insurance premiums, medical bills, or accumulatedme ca e t

• Eliminate donut hole in Medicare Rx coverage; institute a newvoluntary long-term care financing program

• Begin to move to an organized integrated delivery system withcoordinated care, reducing errors, duplication, and waste



Source of Insurance Coverage Pre-Reform

an n er or a e are c ,

162 M (57%)ESI

159 M (56%)ESI

54 M (19%)Uninsured

16 M (6%)Other

Uninsured

24 M (9%) Exchanges(Private Plans)

35 M (12%) Medicaid

15 M (5%)Nongroup

51 M (18%) Medicaid

10 M (4%)Nongroup

er

Pre-Reform Affordable Care Act

mong 282 m on peop e un er age 65



2010 Health Reformmp emen a on me ne

2018

Insurance PrescriptionTax ReformsEmployersReforms

• 2010 protections, incl. high-risk pool, ban lifetime caps

• 2014 expanded reforms

• Individual mandate

Drugs• Follow-on biologics pathway

• Medicaid rebate increase

• Improved Medicare Rxcoverage, including branded

• Increase Medicare tax for high-income earners

• Limit FSAs

• Tax high-cost plans

• Employer and individualpenalties

• Small business tax credit

• Eliminate Part D deduction

• Penalties for employers withmore than 50 FTEs not offering

coverage• Auto-enrollment for large

• State-based exchanges & taxsubsidies

• National long-term careprogram

scounts

• Industry excise tax

• Comparative EffectivenessResearch

• Industry excise taxes

Medicare Medicaid ualit Workforce

employers

• 90-day waiting period limits

• $523b payment reductions• Improve Part D & prevention

coverage

• Increase Part B & D premiums

• Independent PaymentCommission IPAB

• Expand eligibility to 133% FPL• Increase primary care

reimbursement

• Enhance federal matchingfunds

• Streamlined enrollment

• National QI strategy• CMS Innovation Center

• Pilots on bundled payments,medical home, ACOs

• Expand PQRI

• Advisory Committee todevelop national strategy

• Loans & scholarships toincrease supply and training

• Redistribute GME slots



A P R I L J U L Y S E P T E M B E R E N D O F 2 0 1 0

State option to expand Temporary high risk Young adults on’

Annual review ofremium increases

e ca o a u s o133% FPL

Employer retiree healthbenefits reinsurance

Small business taxcredits

No pre-existing

Public reporting byinsurers on share ofpremiums spent on non-medical costs

condition exclusionsfor children

Prohibitions againstlifetime benefit caps &

Coverage and no cost-sharing for preventivecare in Medicare

resc ss ons

enrollees in "donut hole"



-

2 0 1 1 2 0 1 3

Insurers must spend at least 85% of premiums Insurer administrative simplification

medical costs or provide rebates to enrollees

50% discounts on brand-name drugs to

Medicare part D enrollees in the donut hole

Limits on contributions to flexible spendingaccounts to $2500/year

Over-the-counter drug costs reimbursementrestrictions in flexible spending accounts andaccount based health plans

Increased tax on non-medical distributions fromea t sav ngs accounts s

Establish national, voluntary insurance programfor purchasing community living assistanceservices and supports (CLASS program)



-

2 0 1 4 2 0 1 8

Medicaid expanded to at least 133% FPL Excise tax on high cost employer

Insurance market reforms including no rating onhealth

State insurance exchanges

Premium and cost sharing credits for exchangeplans

Premium increases a criteria for carrier

Increase in small business tax credit

Individual requirement to have insurance



• Medicare payroll tax increases by 0.9% for

n v ua s earn ng more t en , an coup es

earning more than $250,000 – and a new 3.8% tax onunearned income

• Individual mandate – With exceptions, individuals are

required to have health insurance and will be penalized. .income)

• Em lo er mandate – em lo ers with more than 50 full-

time employees must provide insurance, and will beassessed a penalty as a percentage of payroll



Additional directions to ONC; e.g., funding fora study of workforce training costs

Additional HIT incentives; e.g., increasedpayments to ‘meaningful’ users by private(non-public) insurers

HIT standards (HELP)

Privacy – fending off ‘HIPAA 3’

Anticipating and addressing unintendedconsequences



• Sec. 1104. Administrative Simplification

– Operating Rules

–

• Sec. 1561. HIT Enrollment Standards and Protocols – Interoperable and secure standards for enrolling individuals in

Federal and State programs.



• Sec. 6703. Elder Justice Act.

– Certified Electronic Health Record Grant Program• New systems, upgrades, or for staff education and training

• Grantees must participate in state-based health information exchanges

• Appropriates $52.5 million over 3-years beginning in FY 2011

• Sec. 10109. Additional Financial and Administrative.

– Additional operating rules for any additional standards

– ICD-9 to ICD-10 Crosswalk• - - oor na on an a n enance omm ee mee ng y anuary ,

2011.

• Viewed as a code set.



What’s Next For The PPACA?

• ‘Corrections’ and implementing regulations

• Migration of HIT emphasis to new sites of care (LTC,MH)

• Comparative effectiveness research (CER)

• Patient safety• Consumer engagement

• Quality initiatives: bundled payments, medical home,

• Implementation of ICD 10

• Connectin Meanin ful Use to Pa ments



The Informatics Agenda Going Forward



‘Show Me The Money’ vs. ‘Where’s The

ee

• ’

Sentinel Initiative, NIH CTSAs to multi-agencyCER, beginning to deliver on the promise ofinformatics will be key; the Meaningful Use

process illustrates the tension between thosew o wou mp emen oo s versus ose w oaim to transform health care; [relatively] ‘big

’ ‘ scandals’; extraordinarily short timelines mayoccasion some bi misste s



•

• Pay for quality, bundled care, accountable careversus rovider autonom

• Data stewardship versus privacy [privacy never

oes awa• How long will the unusual influence of the Policy

and Standards Committees last?

• The unknown politics of health care post mid-term elections



• Workforce and Training (ONC, HHS),

CTSAs)

• , ,FDA, CDC, NIH)

–



Thank you

• Questions, comments?

Doug PeddicordWashington Health Strategies Group

d [email protected]

Plenary: Doug Peddicord

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