Governor Bredesen on TennCare (Health Affairs)

In an on-line posting (22-May- 2007) for the journal Health Affairs, Governor Bredesen discusses TennCare. (Health Affairs 26, no. 4 (2007): w456-w462).

• Follow this link for the interview

In an article entitled "Next Steps For Tennessee: A Conversation With Gov. Phil Bredesen," Alan Weil summarizes the Governor's observations. Quoting from the abstract: In this conversation, conducted during the February 2007 meeting of the National Governors Association, Gov. Phil Bredesen of Tennessee discusses his views on health care, health information technology, and the challenges of changing a massive system with many moving parts. He talks about his involvement in the State Alliance for E-Health, which is working on privacy, licensure, and data communications across state lines. He discusses the state's TennCare program; his views on effective managed care; and his Cover Tennessee program, which seeks to provide low-income workers with an innovative low-cost insurance product focused on preventive care. It is perhaps misleading to take any quote out of conduct, but the Governor's philosophy on patient-provider relationships and his emphasis on value comes through. One representative exchange. Weil: Your TennCare experience didn’t sour you on your view that managed care is an appropriate delivery system? Bredesen: Oh, no. I absolutely believe in managed care, practiced correctly. There are a lot of things out there under the rubric of “managed care,” some of which don’t do any managing of care at all. They just put another intermediary in between and then argue about rates. But the notion of putting the primary care physician truly in charge, putting some economic incentives for effective treatment in there, putting some emphasis on preventive care and early access to care—all things that HMOs, properly constructed, try to do—I absolutely think that’s the wave of the future. On the care of children: I believe that children ought to have really broad access to care. There shouldn’t ever be any limitations on their getting care because of the unwillingness of a parent to pay a copay or something like that. When you get to adults, I don’t feel nearly so strongly. This is a free country, and adults make decisions about what’s important to them.

Cover Tennessee Featured in Wall Street Journal, April 18, 2007

The Cover Tennessee Initiative was featured in the April 18 Wall Street Journal (front page)

• Follow this link to the article (subscription required)
• Follow this link for an interactive map on the uninsured

Quoted from the article: [People] in the program only get coverage up to $25,000 for health expenses annually, and only $15,000 of that can go to hospital bills. If she becomes seriously ill or has a major accident, [they will] be just as vulnerable as [they were] before. [They will] have to either pay the bills herself or ask the hospital for charity care. The limits put Tennessee in sharp contrast with Massachusetts and California, two other states that are part of the U.S. trend toward reconsidering universal coverage. Plans in the two states envision people paying more of their own medical bills at first, in exchange for protection against catastrophic costs.

In an interview, Gov. Bredesen says he listened to focus groups and queried blue-collar folks, such as a waitress at a waffle restaurant, to devise his plan. "They weren't interested in buying insurance for catastrophic events. They wanted access to the emergency room next month, access to the pharmacy next month," he says. "Let's give people what they want instead of what some advocate says they want."

The governor says the working poor can't afford $2,000 deductibles, and he questions whether Massachusetts and California can pay for their more-ambitious plans.

Governor Bredesen Addressess HIMSS Conference

Governor Bredesen delivered the keynote to HIMSS 2007 on Tuesday, February 27. On Monday, the keynote speaker was Steve Ballmer of Microsoft, on Wednesday, its Colin Powell, on Thursday the speaker was the Secretary of HHS.

• Follow this link for the full text of the Governor's speech

The governor discussed his role with the National Governor's Association, provided some insights on the unique and highly complex nature of health care an other global problems, and provided three advice on how to get things done. As he said "where I can claim some expertise is in the art of getting things done; getting the right things done." He said "the task of leadership is almost never problem-solving, but rather finding common ground on which diverse ideas and interests can progress." He said we have to do two things: We have to alter the economics of health care and we have to "forge a system that is much more centered on the individual." In an effort to move health "out of the laboratory and into the real world," he argued for the need to have "some central direction and driving and our federal government is about the only place that can happen." He outlined three things that can move things forward. First, establish a simple set of standards, a "1.0" if you will. He cited the progress made over the last year but emphasized both the number and the difficulty in implementing standards saying "it's as if you're being asked to write very detailed specifications for Version 5.0 of something before Version 1.0 is up and running." Second, he suggested e-prescribing as a "beachhead" that offers real clinical advantages, limits the universe of products and transactions, and yet raises practical solutions for many of the issues of confidentiality and patient identification that await us. It is a way of "doing limited, simple things for nearly 100% of patients rather than delving much more deeply and encountering much more complexity with 2% or 5%." Third, he argued for adoption. He used the term "frontier in getting practitioners to join" and addressed how evolutionary steps combined with the right incentives will change behavior and improve care.

• Follow this link for the Fierce HealthCare Review
• Follow this link for the Government HealthIT review

AHRQ Ambulatory Safety and Quality Initiatives Announced

The Agency for Healthcare Research and Quality has announced four new programs as part of an ambulatory safety and quality (ASQ) initiative. This posting should not be considered definitive.

• To access the four announcements, follow this link of pursue each link individually below:

The four initiatives are:

1. ASQ: Risk Assessment in Ambulatory Care: This announcement has a broad view on ambulatory care that includes the ambulatory care clinician, as well as the patient cared for in ambulatory settings and across high risk transitions in care. Research will focus on assessing the risks associated with ambulatory care that have not yet been fully elucidated. Unlike the rest of the ASQ program, this announcement will not include a primary focus on health information technology.
2. ASQ: Improving Quality through Clinician use of Health IT: This announcement has a primary focus on the ambulatory care clinician. Research will focus on strategies to improve medication management and the delivery of evidence to the point-of-care resulting in improved clinical decision-making and clinical quality for priority conditions. Issues to be addressed include the relationship between Health IT and workflow redesign, systemic barriers to Health IT adoption, care for patients with multiple chronic conditions, enhanced patient-centered models of care delivery, and improved use of effective alert strategies for decision support.
3. ASQ: Patient-Centered Health IT: This announcement has a primary focus on patients and their interaction with the ambulatory health care system. Research will focus on strategies to improve the patient experience of care through the use of health IT. It will include work to improve the delivery of patient-centered health information to ensure patients and clinicians have the information they need to make better health care decisions. Specific topics to be addressed include shared decision-making and patient-clinician communication, personal health records, integration of patient information across transitions in care, and patient self-management of chronic conditions.
4. ASQ: Enabling Patient Safety and Quality Measurement through Health IT: This announcement has a primary focus on integrating patient safety and quality measurement with information technology. Research will focus on strategies to improve transparency for patients in ambulatory care through the development, deployment and export of quality measures from electronic health record systems. Issues to be addressed include measure development across episodes of care, clinical data needs for quality measurement export and reporting, and the reporting of quality data for improvement.

Governor Bredesen to Co-Chair National Governors Association Effort

November 6, 2006. The National Governors Association Center for Best Practices (NGA Center) today announced the leadership of the recently established State Alliance for e-Health. Tennessee Gov. Phil Bredesen and Vermont Gov. Jim Douglas will oversee consensus efforts to improve the nation's health care system through the effective and efficient use of health information technology (HIT). The State Alliance provides a nationwide forum through which stakeholders can work together to identify inter- and intrastate-based HIT policies and best practices and explore solutions to programmatic and legal issues related to the exchange of health information. As co-chairs of the State Alliance, Governors Bredesen and Douglas will guide the efforts of governors, elected state officials and others with expert guidance to help them develop real-world solutions and model practices for improving the quality and efficiency of health care.

• Follow this link to the press release

The MidSouth eHealth Alliance Data Sharing Agreements and Supporting Documents

As of September, 2005, the MidSouth eHealth Alliance (MSeHA) and the AHRQ/TN State regional demonstration project is receiving comprehensive clinical data (labs, reports, diagnoses, etc.) from 15 organizations and is in operation in several emergency departments in the greater Memphis Area.

Our work led us to conclude that data-sharing agreements are critical. This process was based on data-sharing and other documetns from the Markle Connecting for Health Policy Group. The process took much longer than expected but served as a vital means of bringing over 50 people within the region to a more common, patient-centered goal.

The MidSouth eHealth Alliance is a non-profit company chartered specifically to manage the data exchange demonstration project and is supported by multiple sub-groups and an inclusive operations committee working continually on updating policies and procedures. We present on this site three documents produced in the course of our work.

• MSeHA_participation.pdf. This is the data sharing agreement based on the Markle work. Our ammendments are not included.

• Registration_Policy_with_exhibits.pdf. Our Registration Policy also our Registration Application. The applications are exhibits to the policy. These are submitted for approval. Once they are signed by the Board Chairman they become Registration Agreements.

• Operations Committee.pdf . The Operations Committee corresponds with the management committe mentioned in the Markle Connecting for Health Framwork documents. Much attention was given to composition and charter. The Committee is a board committee and the membership reflects ALL Participants regardless of whether or not they have a seat on the board.

Some additional policies and related documents will be released at a later date.

Press Coverage:

• Healthcare IT News (4 October, 2006)
• NHIN Watch (9 October, 2006)

FORE / AHIMA Report

On September 12, 2006, AHIMA/FORE released a report produced under contract with the Office of the Network Coordinator. The report is entitled Development of State-Level Health Information Exchange Initiatives.

• Follow this link to the AHIMA/Fore Site - StateRHIO.org

The findings are fairly straightforward:

• Most state-level HIE initiatives are still in an early stage of development;
• They differ in their origins, drivers, and goals;
• They reflect the uniqueness of their market characteristics;
• They used a wide variety of approaches;
• They are all rapidly evolving organizations committed to improving healthcare in their states.

Among the key recommendations are the following FIVE:

I. Institute mechanisms to promote strategic synergy between state and federal health information exchange (HIE) agendas and initiatives:

• Establish a coordinating body to promote communication and collaboration among states and between states and federal agencies to advance HIE. This coordinating body will address areas of concern and opportunities for effective action through collaboration. It will ensure clear communications with and among states and a voice for state issues in the federal agenda. Consider how the American Health Information Community and Office of the National
• Coordinator can work with state and national policy makers to address the barriers state-level HIE initiatives encounter.
• Develop mechanisms to engage state-level HIE initiatives in the development and deployment of relevant federal initiatives, including feedback on the effect of the federal HIT and HIE agenda.

II. Identify salient financial models for sustainable HIE that state-level HIE initiatives can apply:

• Inventory and describe in detail HIE projects that have achieved financial sustainability and are demonstrating positive outcomes or appear to have identified sufficient revenues and cost data to argue for financial sustainability.
• Identify revenue models currently in use that have generated real savings or revenue and improvement.
• Analyze the programmatic details of each model.

• Describe pros and cons for each: ease of implementation, the infrastructure needed, requisite state-level policy features, the critical mass of stakeholders that need to be involved, the market characteristics that make the model feasible, how healthcare is affected or improved, the estimated costs and revenue from the model, and the expected timing for design and implementation.

  Recommend implementation approaches.

• Identify the top few most feasible options for early successful HIE implementation.
• Identify models the complexity and cost of which suggest that they be deferred.
• Recommend how to disseminate these results.

III. Conduct an analysis in the areas listed below to understand and leverage the role and influence of public and private payers in advancing HIE initiatives, and develop and implement a payer involvement strategy for HIE.

• Roles payers (public and private) have in statewide and local HIE initiatives:

The criticality of involving payers (public or private),

When engagement is most beneficial, How to engage payers

The feasibility of a national strategy to create common methodologies for payer contribution to HIT financing.

• The importance of state Medicaid and Medicare programs’ participation in state-level HIE initiatives:

Ways in which Centers for Medicare & Medicaid Services CMS) policy might accelerate or constrain the ability of state Medicaid to take actions to facilitate HIE.

Identify how to engage CMS and other public payers early in the design process to ensure aligned agendas.

How adoption of Medicaid Information Technology Architecture (MITA) affects HIE.

Identify how to ensure integration of Medicare and Medicaid population data for HIE purposes.

Make recommendations for any federal statutory changes that may be necessary to integrate Medicaid and Medicare in this way.

• The private payer perspective (including traditional health plans and self-funded plans):

Business goals, strategic direction, collaborative and competitive advantage as it relates to multi-stakeholder HIE.

Specifically consider how the evolution of payer-sponsored personal health records (PHRs) may affect HIE initiatives.

• Identify ways for payers to collaborate and support HIE.
• Identify and describe risks that payers may inhibit HIE or block innovation.
• Identify and consider any limitations or downsides of market-driven evolution of HIE with respect to payers.
• How public payers influence and affect private payer behavior.
• How states’ payer mix affects HIE (e.g., number of payers, types of payers, respective market share).
• The effect of federal regulation of employer benefits (e.g., mployee Retirement Income Security Act (ERISA), Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other regulations on state-level HIE.
• The role of public employee and retiree coverage and care (e.g., U.S. Department of Veterans Affairs, U.S. Department of Defense, federal employee program, state employee program) in HIE.

IV. Advance understanding of how state policy makers and government can best be involved in state-level HIE initiatives:

• Identify the most feasible and productive ways for state governments and policy makers to provide leadership for HIE.

Should the state designate the state-level HIE initiative?

If so, how is this best accomplished (e.g., governor, Department of Health, Medicaid, state legislature, state licensure division, by means of consensus, bidding, appointment)?

State government should communicate internally and coordinate between the various state agencies and departments to develop and implement a unified approach for the state HIE agenda and collaborate on ways to reduce internal barriers to statewide HIE.

• Develop models of how state government can collaborate with the private sector to develop public-private vehicle to advance HIE, including:

How to engage state government while remaining flexible to respond to market demands for healthcare (e.g., healthcare costs, availability, quality, effect on business climate).

Role of state government in the relationship (e.g., more as a regulator or more as a partner similar to economic development function). Consider the minimal role that state government can play in creating an environment for engaging portions of the private sector that can respond to market demand issues.

Options for formal entities or vehicles that involve public and private sectors in HIE, including pros and cons of each.

How to take advantage of opportunities available only to a state-level public-private HIE initiative.

Examine what has worked in other industries.

How to maintain the necessary balance required to grow the public-private partnership.

Consider developing standard language that federal, state, and other purchasers of healthcare can include in their contracting cycle to facilitate the deployment of HIT and ensure interoperability while not negatively affecting the business climate unnecessarily.

• Engage with NCSL, National Governors’ Association (NGA), and other key stakeholder groups to discuss these issues.

V. Develop ways to support state-level HIE initiatives, including:

• Develop a plan for creating a “learning community” of state-level HIE initiatives:

Accelerate information sharing through education and communication mechanisms, such as webinars, discussion forums, listserv, periodic meetings(e.g., regional, national, quarterly, annually).

Continue to refine the State-Level Health Information Exchange Initiative Development Workbook developed through this project and/or create supplementary tools based on it.

Examples of such tools include PowerPoint presentations, consumer-education booklets, and other materials deemed valuable by the state.

Explore development of a Web site as a resource.

Consider developing content to educate all stakeholders on the benefits of HIE, framing it as a global healthcare and economic issue rather than simply a technology initiative.

• Determine the ways to reach out to and engage states in the learning community through coordinated efforts of various entities (e.g., through NGA, NCSL).
• Support for HIE Executive Directors from initial formative stages through more advanced operations of the state-level HIE initiative through consulting, mentoring, and formal training resources.