Download Organizational and Legal Issues - Public Health Data Standards

Organizational and Legal Issues
-- Developing organization and
governance models for HIE
Day 2 -Track 5 – FIRST SESSION – RHIO GOVERNANCE
CONNECTING COMMUNITIES for BETTER HEALTH
2nd Annual Learning Forum and Exhibition
WALTER SUAREZ, MD, MPH
PRESIDENT, PUBLIC HEALTH DATA
STANDARDS CONSORTIUM
Governance Issues
Most models call for involvement of all stakeholders, including:
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Providers (through their local professional associations)
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Plans (individually and/or through their local trade association)
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Private (HMOs, others)
Public (Medicaid, Medicare)
Purchasers
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Individuals (MDs, RNs, RPh, Others)
Institutional (Hospitals, Nursing Homes, others)
Private employers/employer coalitions
Public employers (state, local)
Public Health
Quality Improvement Organizations (QIOs)
And then also….
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Patients (consumers/unions)
Researchers/academia
Vendors
Governance Issues
There are unique issues across states
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Relative strength of key components (public health; purchasers; health
plans; providers)
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Market consolidation/fragmentation
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State regulatory constrains
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Geography
The significance (and challenge) of getting all members at the table:
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RHIO Organization must have a defined role/goal that is addresses each
member’s needs:
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Providers – connectivity to support clinical care, quality improvement, patient safety
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Plans – improve business processes to support plan administration
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Purchasers – quality measurement, accountability, value-based purchasing and P4P
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Public Health – improving health of population; enhancing monitoring and surveillance;
providing population-based reference data for clinical decision making
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QIOs – New business role under Medicare/CMS Scope of Work
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What about patients? Researchers? Vendors?
Why RHIOs Need to Discover/Invent Themselves
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No cookie-cutter approach. When you’ve seen one…. You’ve seen one
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Internal market dynamics drive process for establishing a regional initiative
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While at the end regional organizations might look somewhat similar
(“independent multi-stakeholder non-profit”), each community needs to go
through the organizing process from start to end:
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Process validates the need/value of regional effort
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Process allows establishment of trust
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Process ensures buy-in by participating organizations
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Process ensures ongoing commitment from organizations
There are state laws that will affect the formation of regional organizations
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Privacy
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Health plan regulations
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Provider regulations
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Public health laws
Building a “Sustainable Business Model”
Governance need to be established first
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Will decide the mission and purpose of RHIO
The Governance will then need to determine WHAT is the RHIO going to
DO and HOW is the RHIO going to do it?
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Convener/Facilitator/Educator on Standards
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Pilot tester/Prototype developer
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Buyer vs Builder of infrastructure (vs leveraging existing private
infrastructure and Internet)
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Buyer vs Builder of value-added services
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Aggregator of data (repository)
Transaction switcher/router
Administrator of cross-system patient linkage system
Clinical support systems
Role in establishing privacy and security
Role in disseminating information
Role/product/service for consumers/patients?
Building a “Sustainable Business Model”
The Governance will need to create a business plan including timeline of
implementation, start-up/maintenance costs, and methods for
paying for these costs (upfront contributions from participants,
grants, ongoing fees, state funding, etc)
Differences between existing vs new organizations
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Existing organizations will need to ‘re-purpose’ their mission to
adopt/adapt to new role; business plan would then follow
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New organization will need to establish governance, determine purpose
and scope of activities, develop funding
The TRUST Factor
Three levels of Trust:
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Within competing constituencies (i.e. among hospitals or among health
plans in the region)
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Between represented constituencies (i.e. between providers and payers
or payers and purchasers/employers)
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With the public (in the community)
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Organized patient/consumer advocates
Consumers/patients at large
Significance of trust with public will depend on the ROLES of the
organization
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What is the interaction with the public?
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Does the public know (care?) what the regional organization is
about?
Public Representation, Non-Profit Status and Trust
Representation of “The Public” is one of the hardest issues to deal with
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“We all represent The Public” (providers, plans, employers, public health)
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“Employers represent The Public” (their employees)
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“Government represents the Public” (public health, public programs)
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Consumers REALLY represent The Public
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Who to select? (individuals; advocates; unions)
Non-profit Status Does Not Ensure Public Trust
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In many states most/all hospitals and health plans are non-profit!
Public Health CAN serve as a neutral, trusted convener party
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Transition out of role as convener after ‘founding’ organizations
establish mission/goals/priorities for group and define
organizational approach (independent non-profit)
Statewide vs Community-based Organizations
Are the roles and responsibilities different?
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Depending on their inter-dependencies and relationship, one might
become an ‘overseer’ and the other be responsible for operationalizing
the core components of the RHIO in a smaller region/area.
Is there a need for both levels?
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It all depends on the market/region
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In some states, a statewide organization can suffice
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In other states, there might not be a statewide organization, and
community-based organization might need to be formed
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Yet in other states, a statewide organization (RHIO?) might be formed to
‘oversee’ activities, and community-based organizations in areas within
the state might exist to ‘operationalize’ components of the RHIO.
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There might be also areas where a regional community-based
organization is formed to covered various states, and within each state
there are either statewide organizations or smaller community-based
organizations that operationalize the components of the RHIO
Statewide vs Community-based Organizations
Need for further federal action
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Federal guidelines can be provided to explain the possible scenarios and
reinforce the co-existance of multiple models for RHIO development
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Federal guidelines should not define a single approach to RHIO
formations and models.
Financial Models and Financial Incentives
Financial Models will depend on WHAT regional organization is doing:
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Convener/Educator/Standards facilitator
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Financial Approach: Membership-based
Innovator/Pilot Developer
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Financial Approach: Grants
Products and services
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Financial Approach: User fees
Financial Incentives
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RHIOs might facilitate/promote the use of financial incentives to support
the adoption of HIT/Standards in the market
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RHIOs should stay away from ‘standardizing’ the contractual
relationships between payers and providers related to financial incentives
and pay for performance
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Might constitute restriction of trade
Could result in stiffening innovation in quality management
Creates conflicting dual roles as convener/facilitator/promoter of the
adoption of standards, and at the same time, measuring and having
a financial impact on those organizations that are members