California Provider Directory Collaborative

Transcription

1 1 California Provider Directory Collaborative Prepared for the 2017 CAHP Annual Conference Sarah Summer, Associate General Counsel and Director of State Policy and Advocacy Jonah Frohlich, Managing Director, Manatt Health April 13, 2017

2 Agenda 2 Introduction Provider Directory Utility Scope & Value Proposition Data Specifications Next Steps

3 Blue Shield Commitment 3 Blue Shield of California commits $50 Million to strengthen the health care delivery system, in particular the Medi-Cal delivery system, through programs that are intended to improve infrastructure at the plan and provider level, including, but not limited to the following: The development of a statewide centralized provider directory database for the purpose of creating a single portal for consumers to access information, for providers to access and update their data, and for health plans to meet their legal obligations regarding provider directories and invite all California health plans, including Medi-Cal managed care plans, to participate.

4 How it works now 4 Plan A Plan B Plan C Not today Nope Are you in my network? Are you taking new patients?

5 An Old Problem with New Importance 5 Post-ACA, consumers increasingly rely on provider directories to review networks when choosing a plan New network designs use limited network size as a tool to manage cost and improve quality. Longstanding challenges around the accuracy of provider data are magnified by: Provider Confusion Quickly changing data Outdated systems and processes Reliance on factors outside the plans control Complicated by complex and uncoordinated regulatory requirements: Federal Requirements (Medicare, Medicaid, QHP) State Requirements (SB 137, DHCS, and Covered California)

6 But How Do We Fix It? 6 In 2016, multiple pilots confirmed that the technology is there to support a centralized database. So if technology is not the barrier, what is? Stakeholder alignment & buy-in, Clearly defining scope and objectives, A clear process with the right level of stakeholder engagement.

7 Agenda 7 Introduction Provider Directory Utility Scope & Value Proposition Data Specifications Next Steps

8 Supporting a Statewide Provider Directory Utility Process to Date 8 Objective: Guide a multi-stakeholder process to support the creation of a statewide provider directory utility California Provider Directory Summit August 3, 2016 Outputs Confirmed priority use cases and the need for ongoing stakeholder collaboration on provider directory issues. Data Definitions Work Group + Community of Practice September 2016 Ongoing Transparent and collaborative stakeholder process Data Definitions Work Group (completed work in January) Reviewed data specifications for SB 137 data attributes and developed recommended specifications Commented on draft SB 137 Uniform Provider Directory Standards Community of Practice (ongoing) updates, access to Work Group materials, meeting information, and webinar recordings with opportunities to comment on recommendations Advisory Committee September 2016 Ongoing Advises Blue Shield on development of a statewide directory

9 California Provider Directory Summit (August 2016) 9 Attendees Objectives Outcomes Over 80 attendees representing plans, providers, State government, consumer advocates, and vendors Provide policy update on national and state provider directory legislative and regulatory environment Highlight California stakeholders perspectives including provider, Marketplace, consumer, plan, and HIE and initiatives addressing provider directories Identify priority use cases and facilitate discussion of key provider directory functionality and data attributes 1. Informed stakeholders about the implementation of SB Confirmed primary and secondary use cases 3. Identified critical provider directory functionality provider data management and provider data access to support primary use cases 4. Created momentum for the creation of a collaborative stakeholder dialogue on critical provider data issues

10 Utility Use Cases Health plan publishing and maintenance of provider directories 2. Identification of the networks and plan products in which a provider participates 3. Consumer education and selection of health insurance coverage including Commercial, MA, Covered California, Medi-Cal, and other public and private insurance products 4. Provider search and lookup capabilities 5. Data submission, aggregation, audit, analysis, and reconciliation service Primary 6. Submission of provider network data to support regulatory processes (e.g., for network adequacy determination) 7. Health information exchange (e.g., provider index to support routing or Direct Messaging, referral and care team management) 8. Provider and payer credentialing and privileging 9. Provider index for treatment, payment and health care operations (e.g., claims processing, UM, etc.) 10. Provider index for all payer claims database 11. Provider index for (public) quality reporting Secondary Other Out of Scope

11 Provider Directory Utility Data Flows 11 DATA INPUTS Providers, groups, clinics & facilities Health plans Licensing & regulatory bodies HIEs Proprietary sources Data Validation UTILITY HOST & GOVERNING BODY Governance, Stewardship, Data Integrity, Regulatory, Finance PROVIDER DIRECTORY UTILITY Receive and store provider data Validate provider data Identify errors and conflicts; supports notification and resolution processes Enable role and rules-based access and controls Report and log errors, omissions, inconsistencies, and corrections; maintain audit logs Support APIs to enable data import and export DATA EXPORTS Health plan & other provider directories End Users: Consumers, purchasers, health plans, multi-plan directories, providers, public agencies

12 Critical Functions of a Provider Directory Utility UTILITY GOVERNANCE AND MANAGEMENT The utility must support functions that ensure its end-users have access to accurate, reliable, complete and affordable provider directory data. Governance: Act as a trusted steward by establishing inclusive governance processes, supported by consensus-based decision making Establish committees with industry participants to help guide business decisions, including data specifications, data standards and priorities Governance business requirements/expectations were addressed in the preceding discussion. Regulatory Compliance: Ensure users meet SB 137 requirements through participation in the utility, as well as other state and federal requirements Operations: Establish and maintain a directory infrastructure including processes and capabilities to procure and oversee technology vendors that will manage the utility data infrastructure and work flows Manage work flows that reinforce high data-quality standards Measure, manage and report performance Finance: Operate in a fiscally responsible manner, and provide affordable, high-quality products and services PROVIDER DIRECTORY UTILITY 12

13 Recap: Utility Value Proposition The Utility s value proposition lies in two distinct areas: regulatory compliance and reduced administrative burden 13 Regulatory Compliance The utility is being designed to be compliant with all relevant current and future SB 137 requirements. Working with DMHC and CDI to deem the utility s services as fulfilling SB 137-related regulatory requirements for plans. Additional benefits if the utility could support provider directory regulatory compliance with:* Medicare Advantage (MA) Medicaid Managed Care Medi-Cal Covered California/Qualified Health Plans *Deeming beyond SB 137 compliance will require coordination with DHCS and CMS Reduced Administrative Burden Enables streamlined collection and validation of provider and payer data: For plans: a pre-validated source of information for provider data For providers: A single portal to input and update data for all California plans Enhances accuracy and timeliness of data Note: Adoption by providers and plans must be broad and surpass a minimum threshold (e.g., at least half of all plans and providers)

14 Provider Directory Utility Governance Principles 14 Principle Representation Transparency Decision-making Responsiveness Efficiency Effectiveness Ethical conduct Innovation Sustainability Data quality Data stewardship Public good Description Public and private stakeholders, including consumers, are adequately and fairly represented Information on decisions and policies is regularly made available to the public and decisions are made in accordance with established policies, procedures,and rules Participants have a voice in decision-making and there is always a good faith effort to achieve broad consensus The governance structure, services, and organization are responsive and able to adapt to the changing needs and expectations of purchasers, providers, consumers, advocates, and other key stakeholders Cost effective use of available resources, including, reusing and leveraging available resources Performance is monitored and evaluated at regular intervals, and conscious effort is made to improve performance The public good is placed before individual interests and conflicts of interest are declared in a timely manner with persons abstaining from relevant decisions New solutions to problems are sought out and the climate is favorable to change and experimentation in the interest of improvement Decisions and operations support and enhance short- and long-term sustainability in a manner that is fair and impartial for all stakeholders Policies and processes should ensure privacy and security, timeliness, industry-accepted levels of data quality and integrity Supported by transparent processes and principles to manage data and relevant business processes Focused on delivering products and services that are in the public s best interests, and that meet the needs of consumers, providers, payers and other end-users

15 Agenda 15 Introduction Provider Directory Utility Scope & Value Proposition Data Specifications Next Steps

16 Data Definitions Work Group Charter 16 Charge Membership Deliverables Meeting Frequency Commitment Identify and define essential provider data attributes, processes and data quality standards for developing and maintaining consumer-facing provider directories members representing providers, health plans, consumers, government agencies, and health information exchanges (HIEs). Through a consensus-based and collaborative process, the Work Group will identified and recommended: Priority and secondary use cases Essential provider directory functionality Required data attributes and specifications, including: Definitions Sources Ownership & Accountability Processes for managing and maintaining data quality The Work Group will also review regulator proposals and provide input into the SB 137 rulemaking process. The Work Group met monthly via webinar for approximately 90 minutes between September 2016 and January Work Group members were asked to develop and comment on work products.

17 Work Group Membership 17 Name Title Organization Perspective 1 Sajid Ahmed Chief Information & Innovation Officer MLK Jr. Hospital Provider 2 Ahmed Al-Dulami Research Specialist Covered California Marketplace 3 Bill Barcellona Senior VP for Government Affairs CAPG Provider 4 Rim Cothren Executive Director California Association of HIEs HIE 5 Kavita Dave Senior Business Analyst, Provider Operations Blue Shield of California Health Plan 6 Rich Gold VP, National Provider Contracting & Network Development Kaiser Permanente Health Plan 7 Joseph Montoya Manager of Data Integrity, Health Plan Operations Molina Healthcare Health Plan 8 Kristina Rodriguez Director, Provider Network Management Operations, Western Region HealthNet Health Plan 9 Linette Scott, MD CMIO Department of Health Care Services Government 10 Sean Turner Senior Director, HIE and Community Care Dignity Health Provider 11 Nenick Vu Associate Director of Managed Care California Primary Care Association Provider 12 Stacey Wittorff Associate Director, Center for Health Policy CMA Provider

18 Work Group Community of Practice Feedback Loop 18 Manatt synthesized and presented feedback from the Community of Practice to the Work Group Work Groups 12 members each Discuss key issues Develop recommendations/ work products Community of Practice Open to the public Review and provide input on Work Group recommendations & work products Regulator Feedback CDI and DMHC Review and consider recommendations through SB 137 stakeholder process Feedback Loop

19 SB 137 Required Data Attributes Provider s name 2. Practice location or locations 3. Contact information 4. Type of practitioner 5. National Provider Identifier (NPI) number 6. The area of specialty, including board certification, if any 7. Provider s office address, if available 8. Name of each affiliated provider group currently under contract with the plan through which the provider sees enrollees 9. Admitting privileges 10. FQHC or clinic name 11. Non-English language, if any, spoken by a healthcare provider or other medical professional as well as non-english language spoken by a qualified medical interpreter on the provider s staff 12. Identification of providers who no longer accept new patients for some or all of the plan s products 13. The network tier to which the provider is assigned, if the provider is not in the lowest tier, as applicable. Nothing in this section shall be construed to require the use of network tiers other than contract and non-contracting tiers 14. The provider directory or directories may note that authorization or referral may be required to access some providers

20 Provider Data Specification Review 20 Owner Covered California CMS HL7 CAQH Gaine ANSI T-MSIS Input Covered California Provider Data Submission: Guidelines and Functional Specifications Federally Facilitated Marketplace Machine-Readable JSON Fast Healthcare Interoperability Resources (FHIR) Practitioner Model Data Dictionary Sanator Provider Registry Standards Guide X Implementation Guide Transformed Medicaid Statistical Information System (T-MSIS) Data Dictionary Compared, reviewed and synthesized specifications to create an SB 137 compliant provider directory document

21 EXAMPLE Data Specification 21 SB 137 Requirement Data Attribute Definition Responsible for Submitting Data Required/ As Applicable/ Optional Validation Source Lists SB 137 requirement Name Name Identifies one or more data attributes per SB 137 requirement Display Name Facility Name Defines each data attribute Identifies whether health plan or provider is responsible for data attribute Other names used by a provider and Provider / Group / which may be IPA / Clinic familiar to patients The DBA or preferred name of the facility as it is known by the public/consumers (not the legal name) Facility Indicates whether the data attribute is mandatory; mandatory only if applicable to provider type; or not required Optional Required Identifies potential validation source(s) for data attribute NA OSHPD (requires coordination with CDPH and ongoing crosswalk work group) The full specification is available for download through the Community of Practice at

22 Agenda 22 Introduction Provider Directory Utility Scope & Value Proposition Data Specifications Next Steps

23 Next Steps 23 Continue to seek feedback on data specifications and refine accordingly Develop governance model and criteria for utility host Define utility s business and operational requirements Questions? Interested in learning more? ProviderDirectory@manatt.com and join the Community of Practice.

24 Thank You! 24 Sarah Summer Associate General Counsel and Director of State Policy and Advocacy Blue Shield of California (415) Jonah Frohlich Managing Director Manatt Health (415)