Study and Report to: Identify Methods to Create Efficient Reimbursement Incentives to Improve Health Care Quality and Understand the Impact of Health IT in Underserved Communities and those with Health Disparities
George Washington University was awarded $1 million to cover two research projects which will examine efficient reimbursement incentives and  the impact of Health IT on delivering health care in underserved areas. Awards were made on July 17, and published July 21, 2010. They will be overseen by the Office of the National Coordinator (ONC) for Health IT.

“The purpose of this contract is to conduct two projects required under the American Reinvestment and Recovery Act of 2009. This statute includes The Health Information Technology for Economic and Clinical Health Act of 2009 (the HITECH Act) that sets forth a plan for advancing the appropriate use of health information technology to improve quality of care and establish a foundation for health care reform.

“The first project (Project A) will examine methods to create efficient reimbursement incentives for improving health care quality in federally qualified health centers (FQHCs), rural health clinics (RHCs), and free clinics. Project A requires a Report to Congress by February, 2011.

“The second project (Project B) will investigate the impact of Health Information Technology (HIT), including electronic health records (EHR), in communities with health disparities and in areas with a high proportion of individuals who are uninsured, underinsured, and medically underserved (including urban and rural areas). This project will also identify practices to increase adoption of HIT by health care providers in such communities and the use of HIT to reduce and better manage chronic diseases.

“The purpose of Project A under this contract is to examine methods to create efficient reimbursement incentives for improving health care quality in federally qualified health centers (FQHCs), rural health clinics (RHCs), and free clinics. This project was mandated in the American Recovery and Reinvestment Act (ARRA) of 2009 (P.L. 111-5, section 13113(b)), and requires, not later than 2 years after the date of the enactment of the Act, the submission of a Report to the appropriate committees of jurisdiction of the House of Representatives and the Senate. Project A will review and assess different reimbursement incentives that have been utilized in Medicare, Medicaid and by private payers and States. The study should then address whether or not these incentives can be duplicated among safety-net providers. Since the study was authorized in The Health Information Technology for Economic and Clinical Health (HITECH) Act (P.L. 111-5, Sec. 13113(b)), it should include a focus on the role of payment incentives for health information technology (HIT), including payment for telehealth services, and how these incentives can lead to improved health care.

“This study will investigate the impact of Health Information Technology (HIT) including electronic health records (EHR) in communities with health disparities and in areas with a high proportion of individuals who are uninsured, underinsured, and medically underserved (including urban and rural areas). The study will also identify practices to increase adoption of HIT by health care providers in such communities and the use of HIT to reduce and better manage chronic diseases. Legislative authority for this activity is found in the American Recovery and Reinvestment Act (ARRA) of 2009 (P.L. 111-5, Sec. 13101, Subtitle A, Sec. 3001).”

Project A:

“The need to reform current health care payment methods that promote inappropriate or inefficient behaviors and that impede progress toward better quality care has been established. The current basic payment systems reward overuse of services and use of high-cost complex procedures; it is understood that there is a wide variation in practice patterns and that these variations do not necessarily correlate with improved quality. Payment reforms are recognized as a key ingredient to promote high quality clinical, patient-centered, and efficient care. The concept of payment that rewards higher quality has begun to be accepted by payers and to take shape in ways such as through CMS demonstration programs, performance measures, and other private payer incentive programs. The evidence in support of various public- and private-sector programs designed to align payment incentives to promote better-quality care by rewarding providers who perform well has been reported. Current efforts to link health care payment to the quality and efficiency of care provided are shifting the reimbursement structure away from paying providers based solely on their volume of services.

“The current structure of reimbursement programs designed to promote quality often limit FQHC, RHC, and free clinic participation because of their unique payment methodologies. These types of providers generally bill Medicare on an institutional claim form which does not include certain critical data elements necessary for implementing quality incentive types of programs established by CMS and other payers. FQHC and RHC participation in previous quality incentive programs has been contingent on whether or not they elect to bill on a physician claim form and be paid according to the physician fee schedule. Changing to this billing approach would result in eligibility to participate in the demonstration programs.

“The Office of the National Coordinator for Health IT (ONC), in coordination with other offices in the Department, seeks to describe and assess methods to create efficient reimbursement incentives for improving health care quality in FQHCs, RHCs and free clinics, under the guidance provided in ARRA section 13113(b).”

Project B:

“The U.S. health care system faces multiple challenges that require new approaches to protecting the health of the American people and to providing essential health care services. These challenges include rising health care costs, ongoing evidence of poor quality and outcomes, an aging population with multiple chronic conditions, an ethnic and racial diversity in health care access and outcomes, and an increasingly complex health care system.

“Interoperable health information technology (HIT) includes a promising set of tools that can help address these issues by improving quality, safety and efficiency of health care. These technologies include telehealth, EHRs, and personal health records (PHRs), to enhance communication and access between patients and providers, as well as health information exchange (HIE) to facilitate appropriate sharing of health care data and coordination among health care practitioners.

Project A Goals:

“The goals for the project are to:

1. Provide a baseline understanding and assessment of reimbursement incentive programs in place or in the process of being implemented. This assessment shall include different categories of quality incentive programs, targeted goals and outcomes, methodologies for payment, and the types of providers participating in the programs. It should discuss provider reimbursement incentive initiatives in the planning stages or under discussion and how FQHCs, RHCs, and free clinics might participate in those quality-related incentive programs. Future reimbursement initiatives might include, for example, those under consideration in Congressional health reform legislation, initiatives under development at the Centers for Medicare and Medicaid Services, or state-specific reimbursement initiatives that could be generalized across FQHCs, RHCs and free clinics.

2. Provide options for potential approaches to increase the participation of FQHCs, RHCs, and free clinics in initiatives involving efficient reimbursement for improving health care quality.

3. Define the conditions, catalysts and barriers that facilitate and hinder FQHCs, RHCs, and free clinics programs’ participation in quality-related reimbursement initiatives.

4. Using an expert panel and regional meetings, identify the most promising methods and successful approaches to establish quality-related reimbursement programs that include FQHCs, RHCs, and free clinics. The methods and topics reviewed by the expert panel should take into account time-sensitive issues such as health care reform, accountable care organizations, episodes of care, medical home, and “meaningful use” HIT incentive payments. Topics should focus on pay for performance approaches that result in both cost reduction and quality improvement.

5. Create a set of options demonstrating what is needed to include and sustain participation of FQHCs, RHCs, and free clinics in quality-related incentive programs including barriers, gaps and successful strategies and suggestions for future opportunities. ”

“To accomplish these goals, the Contractor will conduct an assessment of current quality incentive reimbursement programs. The assessment will examine how these programs have been structured in the past and how they have evolved over time and the extent that these incentive programs are effective at achieving the intended outcomes (e.g. improved quality, efficiency). The Contractor will conduct an environmental scan that will provide an analytic framework for the project that can be used to clarify the types and characteristics of various public- and private-sector programs designed to align payment incentives to promote better quality of care. The environmental scan will include information from published as well as unpublished resources, open-ended discussions with payer organizations such as the Centers for Medicare and Medicaid Services as well as discussions with organizations representing FQHCs, RHCs and free clinics, and other resources, academia, and experts in health care financing. An important aspect of the environmental scan will be the identification of gaps, as well as recommendations for studies and approaches to fill those gaps. These identified gaps can be used to generate topics for additional research.

“The environmental scan will provide information to assist in the development of a slate of topics to be further evaluated in white papers to be developed. An expert panel will be convened to help guide the study content. The expert panel will work on identifying topics for a series of white papers based on a set of focused questions on key topic areas

“A meeting of internal and external stakeholders will be held to provide input in establishing methods to create efficient reimbursement incentives for improving health care quality in FQHCs, RHCs, and free clinics. The Contractor will follow the definitions for FQHCs, RHCs, and free clinics found in current federal guidelines. External stakeholders should include organizations such as the National Association of State Medicaid Directors, the National Association of Community Health Centers (NACHC), the National Association of Rural Health Clinics (NARHC), and the National Association of Free Clinics (NAFC). In addition, foundations and other organizations that have offered or studied quality incentive programs will be included in these meetings.

“The study will provide an assessment of whether and how FQHCs, RHCs, and free clinics can more effectively participate in quality incentive programs and will identify methods to create new appropriate reimbursement incentives for improving health care quality for these provider types. The final product will include a synthesis report with specific and practical methods regarding ways these programs can achieve quality improvement through payment incentives. The study will provide the Congress with information regarding innovative quality reimbursement incentives.”

Project B Goals:

“The goals for the project are to:

1. Assess the impact of HIT and EHR in communities with health disparities and in areas with a high proportion of individuals who are uninsured, underinsured, and medically underserved (including urban and rural areas);

2. Identify practices to increase the adoption of HIT by health care providers in such communities; and

3. Identify practices to increase the use of HIT to reduce and better manage chronic diseases.”

“In order to accomplish these goals, the contractor shall work closely with the ONC project officer to:
“• Assist in the formation and convening of an interdisciplinary panel of experts in HIT, frontline healthcare delivery, health disparities and quality measurement, quality improvement and other disciplines as necessary. The expert panel shall assist with all phases of the contract, as described in the following sections. The composition of the interdisciplinary panel shall be developed in consultation with the project officer and shall be approved by the project officer before appointments are made. The interdisciplinary panel of experts shall be no larger than 10 non-federal individuals.

“• Conduct an environmental scan and literature review using published and gray literature as well as interviews. The environmental scan should provide an analytic framework for the project that can be used to clarify the types and characteristics of model HIT adopters in the context of this study. As part of the environmental scan, the contractor will identify potential sources of data supported by rigorous research and robust studies that can be used for the analysis. Specific health information technologies and tools (including, but not limited to, electronic health records, electronic registries, public health information systems, telehealth, personal health records and health information exchanges) should be included in the environmental scan to evaluate whether and how these technologies might impact health disparities. The contractor will be required to select a reference point from which disparities can be measured; whether disparities should be measured in relative or absolute terms; the precision of the statistics used to measure disparities; the use and interpretation of summary measures of disparities; etc.

“• Develop and implement a study framework to examine the impact of HIT on communities with health disparities and in areas with a high proportion of individuals who are uninsured, underinsured, and medically underserved (including urban and rural areas). This assessment should provide information and recommendations regarding practices to increase the use of HIT by both patients and providers to reduce and better manage chronic diseases. “