Automate Blue Button Initiative Payor Workgroup Meeting

October 12, 2012

Meeting Etiquette

• Remember: If you are not speaking, please keep your phone on mute

• Do not put your phone on hold. If you need to take a call, hang up and dial in again when finished with your other call o Hold = Elevator Music = frustrated speakers and participants

• This meeting is being recordedo Another reason to keep your phone on mute when not

speaking• Use the “Chat” feature for questions, comments and items you

would like the moderator or other participants to know.o Send comments to All Panelists so they can be addressed

publically in the chat, or discussed in the meeting (as appropriate). From S&I Framework to Participants:

Hi everyone: remember to keep your phone on mute

All Panelists

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Agenda

Topic Time Allotted

Welcome and Announcements 5 minutes

Payor Workgroup Proposed Scope & Objectives 20 minutes

Straw Men Discussion 20 minutes

Next Steps / Reminders 5 minutes

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Announcements and Reminders

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• Meeting Reminders– Payor Workgroup Meetings are Fridays from 1:00 – 2:00 pm Eastern.– The next Community Meeting will be held on Wednesday, October 17, 2012. – Meeting information is on the Automate Blue Button Wiki Page:

http://wiki.siframework.org/Automate+Blue+Button+Initiative

Sub-Group: Payor Content

A payor- or PBM-generated Blue Button file must be both human-readable and machine-readable (interoperable).

A patient can download a copy of his/herMedical & Rx Claims records, read & print them out

A patient can point an application or service to their Blue Button file and parse it for value-added function, e.g. education; clinical decision support; personal finance

Use Cases

REQUIREMENTS AND ASSUMPTIONS

• File content standard must allow for common data elements in Blue Button ASCII files today

• Eligibility Dates• Diagnosis Codes• Procedure Codes• Rx Codes• Financial Information

IN SCOPE (TO BE CONSIDERED)

• Leverage existing elements defined by public & private payors

• Leverage existing standards if possible e.g. X12, HL7, cCDA extension

• Produce implementation guidance

CHALLENGESAND TACTICS

• Need for practical, lower-effort & low-maintenance standards that can be implemented, e.g. using existing standards

• Should be of value to downstream developers, e.g. personal health finance applications, education, decision support providers

• Should have sufficient data to be of some clinical utility

Health Financial Data: Issues Raised So Far

Health Financial Data• Is Financial data in-scope? – Unlike “traditional” clinical health data– Patient advocate organization represented in broader ABBI

community meetings have expressed it as a priority, however– Could be a “home run” for the ABBI Community if it enables

more affordable care. But if not us, who else will tackle this?– Solutions are out-of-scope; data standards & interoperability

in-scope, and pre-requisite for 3rd-parties to create solutions.• How are patients getting it today?

– Explanations of Benefit (EOBs) concern about proprietary network discounting information, may need QH Policy-like stipulations!

– Limited electronic access today (mostly PDF and/or “scraping” aggregators like Simplee & Cake Health)

Implications for Healthcare Affordability

Comments from Keith Boone• [Patients will not only] be able to track all of their clinical data, but they'll also be able to track costs of

particular illnesses.• The apps this content will support will be able link EOB data back to clinical data, so that patients can

understand the true cost of a given diagnosis. • Patients could also agree to share the content anonymously to third parties (in exchange for other services

using that data). • Thus, a patient could give access to anonymized data that links services, diagnoses and costs, to particular

aggregators. • The aggregators could agree (similar to the QH Policy Sandbox) to certain stipulations on use of the data,

with the patient. See http://wiki.siframework.org/Query+Health+Policy+Sandbox• The aggregator would then be able to analyze and generate cost information for illness, by provider, payer,

policy and region. Such data could be used to enable patients to obtain:– For a given diagnosis and plan, average costs for services and providers in their region.– For given diagnoses, the expected annual out-of-pocket costs for providers that the patient uses,

based on historical data.

• The upside for payers is that access to such data across payers will enable them to drive costs downward.

Source: “What ABBI can do for Healthcare Cost Transparency”, 9/13/12, http://motorcycleguy.blogspot.com/2012/09/what-abbi-can-for-for-healthcare-cost.html

Implications for Personal Healthcare Quality

Claims data-driven analytics focused on Clinical Decision Support & Quality are currently available to large self-insured

employers, but not directly to consumers

Through analysis of “rough” ICD-9, CPT, and NDC-coded data, these existing organizations can run “n-of-1” quality measures

for individual patients & consumers.

Implications for Personal Health Affordability

Claims data-driven cost prediction is currently available to insurers & large employers, but not yet directly to consumers

Individuals may be able to help predict & budget for their health care spending needs, if they have a level-playing-field &

access to the same data used by actuaries & underwriters.

Use Cases in Blue Button “App Ecosystem”

Emerging Blue Button App & Service Categories• Patient education• Care Coordination & PCMH activities & services• Quality-related applications & services for Accountable Care Organizations• Clinical decision-making, for both evidence-based decisions as well as

preference-sensitive care• Finding and understanding more affordable care options (e.g. brand vs. generic

medication)• Forecasting and planning a personal healthcare budget• Chronic disease management, including personal health tracking (e.g. diabetes)• Medication reconciliation & adherence tools• Integrity (errors, fraud & abuse) detection and assistance services• Patient-provider communication and scheduling (e.g. automatic pre-population

of initial visit forms, triage of health issues, and scheduling & transportation support)

Strawman 1: MyMedicare.gov Blue Button

MyMedicare.gov Blue Button Data FileCurrent footprint = ~35 million eligible lives

FIELDS SUPPORTED

• Demographics• Name• DOB• Address• Phone• Email

• Eligibility• Effective Date(s)• Plan Contract ID(s)• Plan Period(s)• Plan Name(s)

• Claims Summary• Claim ID• Provider ID• Service Dates

• Financial data by claim• Charged• Approved• Paid• Patient may be

billed• Diagnosis Code(s)• NDC Drug Code(s)• CPT Codes • UB04 Codes • NPI Codes

COMMENTS

• Include clinical quality data• A Codes – unbilled codes

used for quality reporting

Example: Medicare Blue Button

Mymedicare.gov

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Strawman 2: X12 835 : Health Care Claim Payment/Advice

X12 835 Version 5010 : required for nearly every insurance transaction

FIELDS SUPPORTED (TRANSACTION SET)

• Header Level• Amount• Payee• Payer• Trace number• Payment method

• Detail Level• EOB information• Adjudicated claims and

services• Summary level

• Provider adjustment

COMMENTS

Potential Standards

• Standards for sharing claims information with beneficiaries– ASC X12 835 (Electronic Admittance Advice) - Health plan that contains

multiple patient information to one provider – NCPDP D.0 telecommunication for pharmacy claims and remittance – ASC X12 837 (Health Care Claim Transaction Set) - File of 837 claims from a

healthcare provider will contain multiple claims destined to either one payer or clearinghouse for multiple payers• Claim Submission• Post Adjudicated Claims

– No EOB standard identified other than above• Typically a proprietary format exchanged

– Minnesota print standard format

• Other standards being considered for payer exchange of clinical information– Claims attachment to CCD– Payer data mapping to CCD– PHR to PHR standard being developed by HL7 / WEDI 14

Strawman 3: Create a new CDA EOB template

Potential XML template for CDA Implementation Guide

FIELDS SUPPORTED (TRANSACTION SET)

• Insurer Information• Payer ID• Name• Policy Info

• Patient Info• Identifier• Name• Address

• Provider Info• NPI• Identifier• Name• Address

• Diagnosis Table• Diagnosis

• Service Performed• Date(s) of service• Price billed• Negotiated Price• Amount Paid• Patient Responsibility• Notes

COMMENTS

• See http://motorcycleguy.blogspot.com/2012/09/what-abbi-can-for-for-healthcare-cost.html

Generic components of an EOB

• Payer’s Name & Address• Provider of services• Dates of service• Services or procedure code numbers• Diagnosis codes and/or Rx codes• Amounts billed by the provider• Reductions or denial codes• Claim control number• Subscriber’s and patient’s name and policy numbers• Analysis of the patient’s total payment responsibility

– Amount not covered– Co-payment– Deductibles– Coinsurance– Other insurance payment– Patient’s total responsibility

• Total amount paid by the payer

Next Steps & Reminders

• Homework– Please come back to next meeting (10/19) with the standard

that your current blue button file is getting pulled from. Be ready to present your sample blue button file. Consider sharing it on wiki / send to organizers to post in advance.

– Everyone: please send or post at least one comment on each straw-man standard so far. Please focus on utility & feasibility of implementing as a standard for payor-generated Blue Button.

• WEDI 2012 Fall Conference – Health IT Business & Policy Impact – Monday, October 22

Reminders / Contact

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• Meeting Reminders– The next Community Meeting will be held on Wednesday, October

17, 2012. – The next Payor Workgroup Meeting is Friday, October 19, 2012 @

1:00 pm Eastern. – http://wiki.siframework.org/Automate+Blue+Button+Initiative

• For questions, please contact your support leads– Initiative Coordinator: Pierce Graham-Jones (

pierce.graham-jones@hhs.gov)– Presidential Innovation Fellows: Ryan Panchadsaram (

ryan.panchadsaram@hhs.gov); Henry Wei, MD (henry.wei@va.gov) for Payor WG

– Project Manager: Jennifer Brush (jennifer.brush@esacinc.com)– S&I Admin: Apurva Dharia (apurva.dharia@esacinc.com)