May 2011 Ohio Healthcare Summit Presentation


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Kegler Brown Hill & Ritter's 2011 Ohio Healthcare Summit offered an in-depth look at National and Ohio Healthcare Reform, Legal Challenges, Regulation and Implications for Healthcare Providers, Medical Malpractice, and the Health Information Exchange.

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  • This is not new, but it is always surprising – 5% of us consumes about half of total health care spendingIf you can improve the value of care for that complicated, high-cost group – both in terms of improving quality and controlling costs – then you can start to have a real impact on health system performance overallBoth of these ideas – integrated not fragmented care, and focusing first on high-risk populations – are themes in national reform
  • Here is one of two ideas I hope stick with you after today: a fragmented health care system is expensive and dangerousOur system today is very fragmented, very expensive, and very dangerousIt is organized around providers, not patients, and it rewards volume not valueBut you can imagine transforming the current system over time into something that is more integrated and focused on patient needs, where: providers work together, reimbursement rewards value, not volume information is available to improve care, and the focus is on getting the right care in the right place at the right timeBut where do we begin?Here is the second idea: we need to focus first on the complicated cases that have the most to gain from integrated care
  • Governor Kasich created this organizational structure through executive order.OHT reports to the Governor – I will be working closely with Governor Kasich and his Policy Director, Wayne Stuble.We have a core team to provide leadership across agencies: I will focus on policy Elise Spriggs is our Director of Government Affairs Eric Poklar is our Director of Communications and Monica Juenger is our Director of Stakeholder RelationsOur role is to support and align work in your departments. We do not want to disrupt the processes that are working well, or distract talent from the task at hand – but we do want to take issues that for whatever reason have been stuck in the mud and move them forward. We want to make decisions.It’s a challenge – but I have no fear, mainly because of the team of excellent directors Governor Kasich recruited into the health and human services cluster.I want to introduce you to them now: Tracy Plouck, ODMH, and John Martin, DODD, who you know Bonnie Kantor, ODA, Orman Hall, ODADAS, and Dr. Ted Wymyslo, DOH (2/15) and John McCarthy, Medicaid director, who I will ask to say a few words in a minute.
  • John McCarthy
  • Greg – overview of topics
  • John Martin – DODD success story
  • GREG
  • Aging-BKB - keep
  • Greg – overview of topics
  • Greg
  • Dr. Wymyslo
  • Dr. Wymyslo
  • Greg – Team Introduction
  • Enactment of two laws
  • External Context:
  • 38.4% of practices indicated that operating costs increased as a result of the EHR 25.9% of practices indicated that operating costs decreased as a result of the EHR
  • eHI approach to the ACO NPRM:Comments focused on areas where EHRs, HIT and HIE are specifically referencesAddition comments on areas where EHRs, HIT and HIE are not specifically referenced but we determine a nexus to our interest in driving improvement in the quality, safety and efficiency of healthcare through information and technology
  • Cleveland Clinic, the Mayo Clinic, Intermountain Healthcare or the Geisinger Health System—are the models for the Obama administration's accountable care organization (ACO) proposalinstitutions that were the inspiration for the program are reluctant to participate unless big changes
  • May 2011 Ohio Healthcare Summit Presentation

    1. 1.
    2. 2. Health Care Reform – An Overview<br />presented by Kristy Britsch<br />2011 Ohio Healthcare Summit<br />May 12, 2011<br />
    3. 3. GINA<br />Title I of GINA Prohibits discrimination in health coverage based on genetic information as well as the collection of such information in certain circumstances <br />Prohibits group health plans and group health insurance issuers from:<br />Increasing premiums or contribution amounts based on genetic information<br />Requiring an individual or family to undergo genetic testing<br />Requesting or requiring genetic information prior to or in connection with enrollment for underwriting purposes<br />
    4. 4. GINA<br />Title II final regulations became effective January 10, 2011<br />Prohibits an employer from using genetic information to make employment related decisions, from requesting or requiring genetic information, with limited exceptions, from retaliating against individuals based on genetic information and from disclosing genetic information<br />
    5. 5. GINA<br />Provided certain requirements are met, an employer will NOT be liable under Title II of GINA for acquiring genetic information if it is:<br />Acquired inadvertently;<br />Acquired as part of health or genetic services provided on a voluntary basis, including a voluntary wellness program;<br />Family medical history acquired to comply with FMLA certification; <br />Acquired through commercially or publicly available sources;<br />Acquired by an employer that conducts DNA testing for law enforcement purposes (forensic lab, identification of human remains).<br />
    6. 6. Extended Effective Dates Under PPACA <br />Nondiscrimination Requirements <br />Was effective for plan years on or after September 23, 2010 <br />Effective date has been delayed until regulations are issued<br />Comments on new rules are due by March 11, 2011<br />A non-grandfathered fully-insured plan is prohibited from discriminating as to eligibility or benefits in favor of highly compensated employees<br />Penalties for Noncompliance<br />$100 per individual per day for as long as violation continues<br />Compare to self-insured penalty, which is the loss of tax benefits for the HCE who benefited from the discrimination<br />
    7. 7. Extended Effective Dates Under PPACA <br />Employer W-2 Reporting (Delayed until 2012)<br />Employers must calculate and report the aggregate cost of applicable employer sponsored health insurance coverage on the employee’s W-2<br />
    8. 8. Extended Effective Dates Under PPACA<br />60-day Notice for Material Modifications effective for plan years on or after March 23, 2012<br />Clarified by DOL; originally believed to have been March 23, 2010<br />However, until federal agencies provide standards on benefits and coverage explanations, employers are not required to comply with this requirement<br />
    9. 9. Extended Effective Dates Under PPACA<br />Automatic Enrollment<br />Effective January 1, 2014, employers with 200 or more full-time employees offering health coverage must enroll new full-time employees with the opportunity to opt-out <br />In a FAQ in December 2010, DOL indicated that until EBSA issues regulations, employers will not be required to comply with this rule<br />
    10. 10. PPACA Impact on ALL Health Plans:September 23, 2010<br />No rescission of coverage except for fraud or intentional misrepresentation of a material fact <br />Elimination of lifetime limits for “essential health benefits” <br />Elimination of pre-existing conditions for children under age 19<br />This prohibition will be extended to ALL individuals effective January 1, 2014<br />
    11. 11. PPACA Impact on ALL Health Plans:September 23, 2010<br />Medicare Part D donut hole will be eliminated<br />Retiree Reinsurance Program Effective June 1, 2010<br />Only available to early retirees defined as individuals between the ages of 55 and 64 who are not eligible for Medicare and who are not active employees of the employer who maintains the plan <br />
    12. 12. PPACA Impact on ALL Health Plans:September 23, 2010<br />Extend dependent coverage to age 26<br />Coverage is required even if dependent is married<br />Coverage must be provided even if dependent does not otherwise qualify as the employee’s dependent for tax purposes <br />Children who were previously dropped because of age from dependent coverage will also be able to re-enroll<br />Re-enrollment option only applies to plans that already offer dependent coverage<br />
    13. 13. PPACA Impact on ALL Health Plans:September 23, 2010<br />Extend dependent coverage to age 26 (continued)<br />For non-grandfathered plans, coverage must be offered to dependent even if eligible to enroll in another employer group health plan <br />Grandfathered plans need not offer coverage to adult children who are eligible to enroll in another employer group health plan until January 1, 2014<br />Cost of employer-provided health coverage with respect to an adult child is tax-free until end of calendar year in which the child turns age 27<br />Ohio dependent coverage is extended to age 28<br />
    14. 14. PPACA Impact on ALL Health Plans:September 23, 2010<br /><ul><li>Group health plans can only impose annual limits on the coverage for “essential health benefits” that exceed a restricted annual limit as determined by HHS
    15. 15. $750,000 limit per individual for plan year on or after September 23, 2010. Increases to $1,250,000 on or after September 23, 2011</li></li></ul><li>PPACA Impact on ALL Health Plans:September 23, 2010<br />Effective June 23, 2010, establishment of high-risk pool for individuals to obtain coverage due to health status. Remains in effect until Exchanges are created in 2014<br />
    16. 16. PPACA Impact on ALL Health Plans:September 23, 2010<br />Nursing Mothers: Affects employers with 50 or more full-time (at least 30 hours per week) employees <br />New provision added to the Fair Labor Standards Act (the “FLSA”)<br />Employers covered by FLSA must provide “reasonable” breaks to mothers to express milk for their infants up to one (1) year old<br />Employers must provide a private location, other than a restroom<br />
    17. 17. PPACA Impact on ALL Health Plans:September 23, 2010<br />Preventative Health Services and Cost-Sharing<br />Effective for plan years on or after September 23, 2010, a non-grandfathered plan may not impose cost-sharing requirements (such as co-pays, co-insurance, or deductibles) for certain preventative services<br />
    18. 18. PPACA Impact on ALL Health Plans:September 23, 2010<br />Preventative Health Services and Cost-Sharing (continued)<br />Four types of preventative services will be covered at no charge to the individual, including:<br />Screenings such as colon cancer tests, breast cancer screenings, screening of pregnant women for vitamin deficiencies, smoking cessation services, tests for diabetes, high cholesterol and high blood pressure tests <br />Routine vaccines, including child immunizations and tetanus boosters <br />Well-child visits, vision and hearing tests for children and weight counseling <br />Preventative care for women (breast cancer screenings)<br />
    19. 19. PPACA Impact on ALL Health Plans:September 23, 2010<br />A non-grandfathered plan may not impose a pre-authorization requirement for a person seeking obstetrical or gynecological care<br />A non-grandfathered plan that covers emergency department services:<br />May not impose a pre-authorization requirement<br />Must cover services regardless of whether the health care professional is a participating provider<br />May not impose greater coverage restrictions for non-participating provider services than are imposed for participating providers<br />May not impose greater cost-sharing requirements for out-of-network services than are imposed for in-network emergency room services <br />
    20. 20. PPACA Impact on ALL Health Plans:September 23, 2010<br />Choice of Primary Care Provider<br />A non-grandfathered plan that requires or provides for an individual’s designation of a health care provider as “primary,” must permit an individual to designate any participating primary care provider who is available to accept that individual<br />Plan must permit the designation of a pediatric physician as the child’s primary care provider<br />
    21. 21. PPACA Impact on ALL Health Plans:September 23, 2010<br /><ul><li>Internal Claims and Appeals:
    22. 22. Expanded definition of “adverse benefit determination”
    23. 23. Notice of benefit determinations for urgent care claims must be provided within 24 hours of receipt of claim
    24. 24. Avoid conflicts of interest
    25. 25. Upon review of a claim denial, claimants must be allowed to review their file and present evidence/testimony. Plans/insurers must provide, free of charge, any new or additional evidence considered, relied upon or generated by the plan or insurer in connection with the claim, and a reasonable opportunity for claimant to respond</li></li></ul><li>PPACA Impact on ALL Health Plans:September 23, 2010<br /><ul><li>Internal Claims and Appeals (continued):
    26. 26. Notices regarding claims and appeals must be provided in a culturally and linguistically appropriate manner
    27. 27. Detailed notices of adverse benefit determinations and the availability of internal and external appeals
    28. 28. Coverage must be provided pending outcome of an internal appeal
    29. 29. Strict adherence to the internal claims and appeals process is required (claimant will be deemed to have exhausted the internal claims and appeals process if plan/insurer fails to comply) </li></li></ul><li>PPACA Impact on ALL Health Plans:September 23, 2010<br />External Review Process<br />If an individual’s internal claim is denied, the individual will have the right to appeal to an independent reviewer pursuant to the standards established by the National Association of Insurance Commissioners (“NAIC”) <br />States should adopt the NAIC standards before July 1, 2011<br />Self-funded plans must comply with claims and appeals process consistent with the federal external review procedures<br />
    30. 30. PPACA Impact on ALL Health Plans:September 23, 2010<br />Federal External Review Process: DOL Technical Release 2010-01 provides a safe-harbor and outlines the procedures for the federal external review process (standard and expedited external review)<br />
    31. 31. PPACA Impact on ALL Health Plans:September 23, 2010<br />Standard External Review Process<br />Requests for external review must be allowed under the plan and a claimant must file the request within 4 months after notice of an adverse determination of final internal adverse determination<br />A preliminary review must be conducted by the plan within 5 days of receiving an external review request<br />Within 1 day after completion of the preliminary review, the plan must issue notification in writing to the claimant<br />Plan must assign an accredited Independent Review Organization (“IRO”) to conduct the external review. The IROs decision is binding except for other remedies available under state or federal law. IRO will review claim de novo (i.e., will not be bound by previous decision of plan sponsor). IRO will make final decision within 45 days.<br />Upon receipt of notice of a final external review reversing an adverse benefit determination or final internal adverse benefit determination, the plan must immediately provide coverage or payment<br />
    32. 32. PPACA Impact on ALL Health Plans:September 23, 2010<br />Transparency in Coverage Disclosures<br />Effective for plan years on or after September 23, 2010, a non-grandfathered plan will be required to submit to the HHS information regarding the following:<br />The plan’s claims payment policies and practices; <br />Periodic financial disclosures;<br />Data on enrollment; <br />Data on disenrollment; <br />Data on the number of claims that are denied; <br />Data on rating practices; <br />Information on cost-sharing and payments with respect to any out-of-network coverage; <br />Information on enrollee and participant rights. <br />
    33. 33. PPACA Impact on ALL Health Plans:September 23, 2010<br />Uniform Explanation of Coverage (Mini-SPDs)<br />Must be written in culturally and linguistically appropriate manner to explain health benefits under the plan <br />Must include uniform set of definitions and medical terms and must describe cost-sharing requirements and plan term limits and exclusions<br />Must be provided to participants at time of enrollment<br />Uniform Explanation of Coverage is in addition to the SPD <br />Distribution deadline of 24 months after the enactment of healthcare reform (i.e., March 23, 2012)<br />HHS is to issue guidance addressing the Mini-SPDs by March 23, 2011<br />
    34. 34. PPACA Impact on ALL Health Plans:January 1, 2011<br />HSAs, FSAs, HRAs: Expenses for over-the-counter medications will no longer be eligible for reimbursement<br />HSAs, FSAs, HRAs: Eligible medical expense = prescription or insulin<br />Plans must be amended by June 30, 2011<br />Simple Cafeteria Plans: Effective for tax years after December 31, 2010, small employers may adopt a new type of cafeteria plan<br />
    35. 35. PPACA Impact on ALL Health Plans:January 1, 2013<br />Medicare Payroll Tax Increase<br />Increase in Medicare Part A tax from 1.45% to 2.35% applicable to single individuals earning more than $200,000 and married individuals earning more than $250,000<br />Small Business Tax Credit<br />Eligible employers (less than 25 full-time employees) will get a tax credit equal to a portion of its health insurance premiums <br />Phase I: 2010 – 2013: May claim a credit of up to 35% of health insurance premiums for each tax year if employer contributes at least 50% of total premium cost<br />Phase II: After 2013: May claim tax credit of up to 50% of employer’s contribution toward employees’ premiums if employer contributes at least 50% of total premium<br />
    36. 36. PPACA Impact on ALL Health Plans:January 1, 2013<br />FSAs: Salary reduction contributions to a health FSA are limited to $2,500 per year<br />Contributions to dependent care FSAs remain at $5,000 per year <br />
    37. 37. PPACA Impact on ALL Health Plans:January 1, 2014<br />Elimination of pre-existing conditions for all individuals<br />No annual limits on dollar value of coverage on essential health benefits<br />Grandfathered plans that offer dependent coverage must offer coverage to adult children until age 26 regardless of whether or not the child is eligible to enroll in another employer health plan<br />
    38. 38. PPACA Impact on ALL Health Plans:January 1, 2014<br />Waiting Periods<br />Cannot impose coverage waiting period that exceeds 90 days<br />Out-of-Pocket Limits<br />Effective January 1, 2014, a non-grandfathered group health plan cannot impose a total cost sharing for a year that exceeds the out-of-pocket limits that are applicable to high-deductible health plans<br />Currently, these limits are $5,950 for individual coverage and $11,900 for family coverage<br />
    39. 39. PPACA Impact on ALL Health Plans:January 1, 2014<br />Mandate to Provide Health Insurance<br />Employers with 50 or more full-time employees are required to offer health coverage or pay a penalty<br />Penalty for failure to provide coverage is $2,000 per full-time employee (applicable if at least one full-time employee receives insurance on the Exchange) <br />Penalty for failure to provide affordable coverage is $3,000 for each employee enrolled in Exchange coverage<br />Part-time employees are included and calculated as full-time employees<br />
    40. 40. PPACA Impact on ALL Health Plans:January 1, 2014<br /><ul><li>Health Insurance Exchanges
    41. 41. States must establish “Health Insurance Exchanges” to offer qualified health benefit plans
    42. 42. Exchanges are initially limited to individual markets and to employers with 100 employees or less
    43. 43. Effective January 1, 2017, States may allow employers with over 100 employees to access coverage through Exchanges
    44. 44. Individuals must purchase insurance for the minimum essential health coverage or pay penalty of the greater of $95, or up to 1% of income (penalty will increase each year)</li></li></ul><li>PPACA Impact on ALL Health Plans:January 1, 2014<br />Vouchers: Employers must provide free choice vouchers for lower income employees who qualify for an affordability exemption<br />Employers who offer minimum essential coverage and who pay a portion of coverage must also provide “qualified employees” with a voucher that can be applied to the purchase of insurance through an Exchange<br />Voucher must equal the amount the employer would have paid to provide coverage for the employee under its group health plan<br />
    45. 45. PPACA Impact on ALL Health Plans:January 1, 2014<br />Vouchers (continued): <br />A “Qualified Employee” is an individual:<br />who does not participate in the employer’s group health plan; <br />whose required contribution for the employer sponsored minimum essential coverage exceeds 8% (but is less than 9.8%) of his/her household income;<br />whose household income does not exceed 400% of the poverty level <br />
    46. 46. PPACA Impact on ALL Health Plans:January 1, 2018<br />Excise tax on Cadillac Plans <br />Insurers (employer if self-insured) will pay 40% excise tax on high value Cadillac Plans with values exceeding $10,200 limit for individual coverage and $27,500 for family coverage<br />
    47. 47. PPACA Impact on Non-Profit Hospitals<br />If a non-profit hospital fails to meet any of the following requirements, its tax-exempt status under Code Section 501(c)(3) will be revoked<br />Community health needs assessment requirements; <br />Financial assistance policy requirements;<br />Limitations on charges requirements;<br />Billing and collection requirements. <br />
    48. 48. Grandfathered Plans Under PPACA <br />A “grandfathered plan” is any group health plan or health insurance coverage in effect as of March 23, 2010<br />Grandfathered plans are not required to comply with all of the requirements under PPACA<br />To maintain grandfathered status, a plan must include a statement in any plan materials to be provided to participants that describes plan benefits and must include a statement<br />
    49. 49. Grandfathered Plans Under PPACA <br />(continued)<br />Plan sponsors must retain all plan documents in effect on March 23, 2010 to prove terms of plan at this time<br />A grandfathered plan will lose its exemption from some of PPACA’s requirements if a plan significantly reduces benefits or increases employee premium contributions by more than 5% points<br />
    50. 50. How to Lose Grandfathered Status <br />Elimination of benefits (elimination of all or substantially all benefits to diagnose/treat a particular condition);<br />Increase in co-insurance (i.e., increase in cost-sharing);<br />Increase in co-payment (increase in a co-payment for any service by more than the greater of (a) $5.00 or (b) medical inflation plus 15%);<br />Increase in deductible or out-of-pocket maximum;<br />Decrease in employer contribution rate;<br />(….continued)<br />
    51. 51. How to Lose Grandfathered Status <br />Changes to annual limits;<br />Issuance of new (not renewed) insurance policy;<br />Transfer of employees (transfer of employees to another plan);<br />Change of insurer (Effective Nov. 15, 2010, was removed as an event to lose grandfathered status);<br />Merger, acquisition, restructuring anti-abuse rules (if principal purpose of merger, acquisition, or restructuring is to cover new individuals under a Grandfathered Plan, the plan will lose grandfathered status)<br />
    52. 52. Grandfathered Plans <br />The following WILLNOT cause a loss of grandfathered status:<br />Change in plan premiums;<br />Adjustments to employer contributions, premiums, co-payments and deductibles;<br />Adding new benefits; <br />Changes required to comply with state/federal law;<br />Changes to comply voluntary with the Healthcare Reform law;<br />Change in self-insured plans’ TPA;<br />Renewal of a previous policy, certificate, or contract of insurance;<br />Decrease in employee contribution rate. <br />Change of insurer (Effective November 15, 2010)<br />
    53. 53. Constitutional Challenges to PPACA <br />26 States have challenged the constitutionality of PPACA<br />Alabama, Alaska, Arizona, Colorado, Florida, Georgia, Indiana, Idaho, Iowa, Kansas, Louisiana, Maine, Michigan, Mississippi, Nebraska, Nevada, North Dakota, Ohio, Pennsylvania, Virginia, South Carolina, South Dakota, Texas, Utah, Washington, Wisconsin and Wyoming <br />2 Federal Judges have upheld law under Commerce Clause (Western District of Virginia and Michigan) <br />2 Federal Judges have ruled PPACA unconstitutional (Florida and Virginia) <br />
    54. 54. Constitutional Challenges to PPACA<br />Principal Challenge to PPACA is the Commerce Clause<br />States challenging PPACA argue that the Commerce Clause does not give Congress the authority to mandate that every American buy health insurance or pay a fee/penalty<br />Other Challenges are Spending Clause and Taxing Power<br />Related to Medicaid program; PPACA greatly expands eligibility rules under Medicaid and imposes unprecedented costs and burdens on states, and this exceeds Congress’s authority under the Spending Clause <br />Tax Issues: Penalty imposed for noncompliance with PPACA’s individual mandate is unconstitutional as an improperly apportioned direct tax <br />
    55. 55. Constitutional Challenges to PPACA<br />Federal District Judge, Judge Vinson, in Florida ruled on February 1, 2010, that the individual mandate and the entirety of PPACA was unconstitutional<br />Federal government cannot regulate inactivity through the Commerce Clause and refusing to buy health insurance is inactivity<br />The individual mandate is so thoroughly interwoven into PPACA as a whole that the FL court could not sever that provision and rule only to its constitutionality<br />
    56. 56. Constitutional Challenges to PPACA<br />First time a federal court has ruled the entirety of PPACA to violate the Constitution <br />Federal government has already filed its appeal from the Florida ruling by Judge Vinson with the Court of Appeals for the 11th Circuit<br />Oral arguments begin in June <br />
    57. 57. Constitutional Challenges to PPACA<br />The matter will eventually reach the U.S. Supreme Court<br />Not sure when, but before 2012 elections? <br />There has been no injunction against the implementation of PPACA so nothing practical has changed for employers, insurers and individuals<br />Remains to be seen whether states will put the brakes on the implementation of PPACA, particularly on states’ preparation for the creation of Exchanges<br />
    58. 58. Thank You!<br />Kristy N. Britsch<br />Kegler Brown Associate<br /> <br />(614) 462-5412<br />65 East State St., Suite 1800, Columbus OH 43215<br />
    59. 59. 2011 Ohio Healthcare Summit<br />State of Healthcare Reform in Ohio<br />Thursday, May 12, 2011<br />Élise Spriggs<br />Director of Government Affairs<br />
    60. 60. Medicaid is Ohio’s Largest Health Payer<br /><ul><li>Provides health coverage for low-income children, parents, seniors, and people with disabilities
    61. 61. Covers 2.2 million Ohioans (1 in 5) including 2 in 5 births1
    62. 62. Spends $18+ billion annually all agencies, all funds (SFY 2011) 1
    63. 63. Accounts for 4.0% of Ohio’s total economy and is growing2
    64. 64. Funds are federal (63.69%) and state (36.31%)3</li></ul>SOURCES: (1) Ohio Department of Job and Family Services, (2) SFY 2011 estimate based on $18.0 billion in Medicaid spending per ODJFS and $498 billion Ohio gross domestic product per the State of Ohio Office of Budget and Management, and (3) Federal Register Vol. 76 No. 22 page 5811.<br />
    65. 65. Ohioans Covered by Employer-Sponsored Health Insurance, Medicaid, or Uninsured<br />Employer-Sponsored Insurance<br />Uninsured<br />Medicaid<br />Source: Ohio Colleges of Medicine Government Resource Center, “Quantifying the Impact of the Recent Recession on Ohioans: preliminary findings from the 2010 Ohio Family Health Survey” (February 16, 2011)<br />
    66. 66. Federal Health Care Reform:<br />Government Coverage Expansions<br />Private Insurance<br />$89,400 for a family of 4<br />400%<br />Health Benefit Exchange<br />Federal Poverty Level<br />$30,843 for a family of 4<br />138%<br />Medicaid Expansion<br />Medicaid<br />Medicaid Expansion<br />Medicaid Expansion<br />Source: X<br />
    67. 67. Ohio’s Health System Performance<br />Health Outcomes – 42nd overall1<br />42nd in preventing infant mortality (only 8 states have higher mortality)<br />37th in preventing childhood obesity<br />44th in breast cancer deaths and 38th in colorectal cancer deaths<br />Prevention, Primary Care, and Care Coordination1<br />37th in preventing avoidable deaths before age 75<br />44th in avoiding Medicare hospital admissions for preventable conditions<br />40th in avoiding Medicare hospital readmissions<br />Affordability of Health Services2<br />37th most affordable (Ohio spends more per person than all but 13 states)<br />38thmost affordable for hospital care and 45thfor nursing homes<br />44thmost affordable Medicaid for seniors<br />Sources: (1) Commonwealth Fund 2009 State Scorecard on Health System Performance, (2) Kaiser Family Foundation State Health Facts (updated March 2011)<br />
    68. 68. A few high-cost cases account for most Medicaid spending<br />3%<br />1% of the Medicaid population consumes 23% of total Medicaid spending<br />4% of the Medicaid population consumes 51% of total spending<br />Source: Ohio Department of Job and Family Services; SFY 2010 for all Medicaid populations and all medical (not administrative) costs<br />
    69. 69. SOURCE: Adapted from Melanie Bella, State Innovative Programs for Dual Eligibles, NASMD (November 2009)<br />
    70. 70. “The critical flaw in our health care system … is that it was never designed for the kind of patients who incur the highest costs. Medicine’s primary mechanism of service is the doctor visit and the emergency room visit. It’s like arriving at a major construction project with nothing but a screwdriver and a crane.”<br />Source: The New Yorker (Jan 24, 2011).<br />
    71. 71. Medical Hot Spot:Emergency Department Utilization: Ohio vs. US<br />Hospital Emergency Room Visits per 1,000 Population<br />29%<br />Source: American Hospital Association Annual Survey (March 2010) and population data from Annual Population Estimates, US Census Bureau:<br />
    72. 72. Medicaid Hot Spot:Medicaid Enrollees Who Get Care Primarily from Hospitals*<br />* Indicating a lack of primary care and/or care coordination<br />Source: Ohio Department of Job and Family Services for SFY 2010. Note that medical costs include those incurred by MCPs and paid by FFS, excluding institutionalized consumers and their costs. Consumers may have been in both FFS and MC delivery systems within SFY 2010. This analysis includes consumers costs in both systems.<br />
    73. 73. Medicaid Hot Spot:Hospital Admissions for People with Severe Mental Illness<br />Avoidable hospitalizations per 1000 persons for ambulatory care sensitive conditions (avoidable with proper treatment)<br />Source: Ohio Colleges of Medicine Government Resource Center and Health Management Associates, Ohio Medicaid Claims Analysis (February 2011)<br />
    74. 74. Ohio Medicaid Spending Trend9 percent average annual growth, 2008-2011<br />$20.8<br />+8%<br />Billion<br />$19.3<br />+7%<br />$18.0<br />+14%<br />$15.8<br />+4%<br />$15.2<br />+12%<br />$13.5<br />+ 42.8%<br />Source: Office of Health Transformation Consolidated Medicaid Budget, All Funds, All Agencies; actual SFY 2008-2010 and estimated SFY 2011-2013; “All Other” includes Federal Funds and Non-General Revenue Funds (non-GRF)<br />
    75. 75. The current Ohio HHS Medicaid organization<br />Governor<br />Health<br />Aging<br />ADAS<br />MH<br />DD<br />JFS<br />Medicaid Single State Agency<br />56 Combined<br />County Boards<br />130 County Offices<br />88 County Boards<br />12 Area Agencies on Aging<br />130 Local Health Departments<br />Source: Legislative Service Commission, “Total Medicaid Spending by Agency” (State Fiscal Year 2010).<br />
    76. 76. John R. Kasich, Governor<br />Leadership Team<br /><ul><li> Elise Spriggs, Government Affairs
    77. 77. Eric Poklar, Communications
    78. 78. Monica Juenger, Stakeholder Relations</li></ul>Greg Moody, Director<br />Policy Teams<br />“All Cabinet Agencies, Boards and Commissions shall comply with requests or directives issued by OHT, subject to supervision of their respective directors.”<br />Consultant Team<br />“OHT shall contract with state and/or private agencies for services in order to facilitate the implementation and operation of the OHT’s responsibilities.”<br />Stakeholder Partners<br />Prioritize stakeholder communication<br />Dr. Ted Wymyslo(Health)<br />Bonnie Kantor (Aging)<br />Orman<br />Hall<br />(ODADAS)<br />Tracy Plouck(ODMH)<br />John Martin (DODD)<br />Michael Colbert <br />(JFS)<br />John McCarthy (Medicaid)<br />Source: Ohio Governor John R. Kasich, Executive Order 2011-02K (January 13, 2011)<br />
    79. 79. Executive Order<br /> Plan for the long-term efficient administration of the Ohio Medicaid Program and act to improve overall health system performance. In the next six months:<br />Advance the Administration’s Medicaid modernization and cost-containment priorities in the operating budget;<br />Initiate and guide insurance market exchange planning;<br />Engage private sector partners to set clear expectations for overall health system performance; and<br />Recommend a permanent Ohio health and human services organizational structure and oversee transition.<br />Source: Ohio Governor John R. Kasich, Executive Order 2011-02K (January 13, 2011)<br />
    80. 80. The Vision for Better Care Coordination<br /><ul><li>Create a person-centered care management approach – not a provider, program, or payer approach
    81. 81. Services are integrated for all physical, behavioral, long-term care, and social needs
    82. 82. Services are provided in the setting of choice
    83. 83. Easy to navigate for consumers and providers
    84. 84. Transition seamlessly among settings as needs change
    85. 85. Link payment to person-centered performance outcomes</li></li></ul><li>Medicaid Hot Spot:Enrollment Spending by Top Managed Chronic Conditions<br />Consumers with TWO OR MORE of the top managed chronic conditions<br />Consumers with ONE of the top managed chronic conditions<br />Consumers without one of the top managed chronic conditions<br />Source: Ohio Department of Job and Family Services. Institutionalized consumers excluded. Based on SFY 2010 total medical cost either by ODJFS or Medicaid managed care plans. Top managed conditions = Diabetes, CAD, CHF, Hypertension, COPD, Asthma, Obesity, Migraine, HIV, BH, & Sub. Abuse.<br />
    86. 86. Ohio Health Transformation Priorities<br />Improve Care Coordination <br />Integrate Behavioral and Physical Health<br />Rebalance Long-Term Care<br />Modernize Reimbursement<br /><br />
    87. 87. A Case Study in Transformation:<br />Ohio Department of Developmental Disabilities<br />
    88. 88. Ohio Medicaid Spending per Member per Month by Setting<br />People with developmental disabilities<br />$12,937<br />$8,473<br />$5,568<br />$4,819<br />$1,418<br />People with other disabilities or over age 65<br />$4,463<br />$4,584<br />$4,067<br />$2,058<br />$1,869<br />$1,695<br />$1,356<br />$530<br />Other children and parents<br />$298<br />$254<br />Source: Ohio Department of Job and Family Services. Includes claims incurred from July 2009 through June 2010 and paid through October 2010; cost differences between institutional and waiver/community alternatives do not necessarily represent program savings because population groups being compared may differ in health care needs.<br />
    89. 89. Ohio Medicaid Residents of Institutions Compared to Recipients of Home and Community Based Waivers<br />Home and Community Based (Aging, JFS, and DD waiver recipients)<br />Facility-Based<br />(NF, ICF/DD, Developmental Center residents)<br />Source: Ohio Department of Job and Family Services; based on average monthly recipients for SFYs 2006-2010.<br />
    90. 90. Medical Hot Spot:Per Capita Health Spending: Ohio vs. US<br />Source: 2004 Health Expenditure Data, Health Expenditures by State of Residence, Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, released September 2007; available at<br />
    91. 91. Medicaid Hot Spot:Per Enrollee Medicaid Spending: Ohio vs. US<br />Source: 2007 The Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on data from Medicaid Statistical Information System (MSIS) and CMS-64 reports from the Centers for Medicare and Medicaid Services (CMS), 2010.<br />
    92. 92. Unused Nursing Home Capacity<br />In 70 counties more than 10% of beds are empty<br />Ashtabula<br />Lake<br />21.0%<br />Lucas<br />11.8%<br />Fulton<br />15.4%<br />Williams<br />9.2%<br />Ottawa<br />25.6%<br />Geauga<br />35.1%<br />6.6%<br />Cuyahoga<br />Wood<br />14.1%<br />Sandusky<br />Erie<br />Defiance<br />Henry<br />Trumbull<br />Lorain<br />14.6%<br />14.0%<br />16.4%<br />19.4%<br />23.2%<br />14.5%<br />13.6%<br />Portage<br />Huron<br />Paulding<br />Summit<br />Seneca<br />Medina<br />10.8%<br />14.6%<br />29.4%<br />10.4%<br />14.4%<br />16.1%<br />Putnam<br />Mahoning<br />Hancock<br />21.2%<br />14.8%<br />9.9%<br />Van Wert<br />Wyandot<br />Crawford<br />Ashland<br />Wayne<br />Stark<br />Richland<br />17.8%<br />Allen<br />14.5%<br />14.7%<br />11.9%<br />16.6%<br />Columbiana<br />14.5%<br />13.5%<br />15.6%<br />12.0%<br />Hardin<br />21.3%<br />Marion<br />Carroll<br />Auglaize<br />Holmes<br />Mercer<br />Morrow<br />13.0%<br />13.8%<br />18.6%<br />8.0%<br />15.9%<br />21.1%<br />Tuscarawas<br />Knox<br />Jefferson<br />Logan<br />16.3%<br />Shelby<br />21.2%<br />17.1%<br />12.5%<br />Union<br />Harrison<br />Coshocton<br />8.0%<br />Delaware<br />11.9%<br />9.2%<br />17.2%<br />11.2%<br />Darke<br />Champaign<br />Licking<br />18.5%<br />31.8%<br />Miami<br />Guernsey<br />15.7%<br />Belmont<br />9.6%<br />20.4%<br />Franklin<br />Muskingum<br />10.0%<br />Clark<br />12.6%<br />Madison<br />10.4%<br />16.5%<br />7.0%<br />Noble<br />Montgomery<br />Preble<br />Fairfield<br />Perry<br />Monroe<br />22.3%<br />Greene<br />11.5%<br />9.5%<br />12.3%<br />17.8%<br />8.5%<br />Pickaway<br />13.4%<br />Morgan<br />7.2%<br />Fayette<br />7.2%<br />Hocking<br />Washington<br />9.2%<br />Butler<br />Warren<br />13.3%<br />Clinton<br />10.5%<br />15.1%<br />9.8%<br />19.4%<br />Ross<br />Athens<br />7.8%<br />Vinton<br />6.6%<br />Hamilton<br />25.4%<br />Highland<br />12.7%<br />10.5%<br />Meigs<br />Nursing Facility Surplus<br />Pike<br />Clermont<br />11.7%<br />Jackson<br />12.0%<br />11.7%<br />Percentage of total bed days vacant<br />10.5%<br />Brown<br />Adams<br />Scioto<br />20.0%<br />6.6% - 10.4%<br />Gallia<br />13.6%<br />12.3%<br />13.7%<br />10.5% - 12.5%<br />Lawrence<br />12.6% - 16.3%<br />13.5%<br />16.4% - 23.0%<br />23.1% - 35.1%<br />
    93. 93. Rebalance Long Term Care<br />Enable seniors and people with disabilities to live with dignity in the settings they prefer<br />RECOMMENDATIONS:<br /><ul><li>Create a Single Point of Care Coordination
    94. 94. Consolidate and Streamline Waiver Programs
    95. 95. Reward Person-Centered Outcomes in Nursing Homes
    96. 96. Expect Greater Efficiency from NF and Waiver Providers
    97. 97. Decrease payments to “hold” empty beds
    98. 98. Reduce the nursing home franchise fee
    99. 99. Saves $427 million all funds over the biennium</li></li></ul><li>Research suggests that person-centered care is associated with improved organizational performance including higher resident and staff satisfaction, better workforce performance and higher occupancy rates. <br />Source: 2010 Annual Quality Report, Alliance for Quality Nursing Home Care and American Health Care Association<br />
    100. 100. Ohio Health Transformation Priorities<br />Improve Care Coordination <br />Integrate Behavioral and Physical Health<br />Rebalance Long-Term Care<br />Modernize Reimbursement<br /><br />
    101. 101. Balance the Budget<br />Contain Medicaid program costs in the short term and ensure financial stability over time<br />RESULTS:<br /><ul><li>A sustainable system
    102. 102. $1.4 billion in net savings over the biennium
    103. 103. Align priorities for consumers (better health outcomes) and taxpayers (better value)
    104. 104. Challenge the system to improve performance (better care and cost savings through improvement)</li></li></ul><li>Total Ohio Medicaid Expenditures, SFY 2010<br />Source: Ohio Department of Job and Family Services and the Governors Office of Health Transformation. Managed care expenditures are distributed to providers according to information from Milliman. Hospitals include inpatient and outpatient expenditures as well as HCAP Home and community services include waivers as well as home health and private duty nursing.<br />
    105. 105. Medicaid Budget:Savings and Investments<br />in millions<br />Source: Office of Health Transformation (March 15, 2011)<br />
    106. 106. Medicaid Budget:Impact on Rates by Provider<br />Estimated change in rate<br />Source: Office of Health Transformation (March 15, 2011)<br />
    107. 107. What this budget does NOT do<br />Does not cut eligibility<br />Does not cut optional services, including dental<br />Does not make arbitrary across-the-board cuts<br />Does not resort to smoke and mirrors<br />Does not count hypothetical savings<br />
    108. 108. Thank you.<br />Élise Spriggs, Director of Government Affairs<br />Governor's Office of Health Transformation 77 South High Street, 30th Floor Columbus, Ohio 43215 Phone: 614-752-2784<br />Email:<br />
    109. 109. The View From DC<br />Presented by <br />Jennifer Covich, Chief Executive Officer, eHealth Initiative<br />
    110. 110. eHealth Initiative<br />Since 2001, only national, non-partisan group that represents all the stakeholders in health care<br />eHI counts over 200 of the most influential organizations amongst its members<br />In 2005, eHI launched Connecting Communities, coalition representing more than 250 HIE initiatives <br />eHI advocates for the use of health IT that is practical, sustainable and addresses stakeholder needs, particularly those of patients.<br />
    111. 111. EHRs, HIES, and ACOs…Oh my! <br />
    112. 112. Agenda Today<br />Current State of the Field<br />Electronic Health Records<br />Health Information Exchange<br />What does the advent of Accountable Care Organizations (ACOs) mean?<br />The Government’s Big Plan<br />
    113. 113. Enactment of Two Laws<br />87<br />Stimulus Package-The American Recovery and Reinvestment Act (ARRA- 2009): $20B to support adoption of health IT.<br />Health Care Reform-The Patient Protection and Affordable Care Act (PACCA) creates a national, voluntary shared savings program for accountable care organizations (ACOs), strengthens primary care (Medical Homes) and incentivizes care coordination<br />
    114. 114. Trends in Health Care Reform<br />Payers: <br />Transfer risk to delivery system and consumers<br />Pay for performance & outcomes, not volume<br />Provides array of health services (information, DM, Case Management)<br />“We are a health services company that happens to sell health insurance”<br />Providers<br />Medical Homes  ACOs <br />HIT enabled<br />Workforce shortages, especially in primary care and ancillaries<br />Patients/consumers<br />Greater financial stake and purchasing discretion <br />Self-reliance: new consumer models emerging. Role of social networks<br />88<br />
    115. 115. EHR Adoption<br />
    116. 116. Meaningful Use<br />Use of certified EHR technology:<br />In a meaningful manner<br />For electronic exchange of health information to improve the quality of care <br />To submit clinical quality measures to CMS<br />
    117. 117. Meaningful Use<br />2013<br />2011<br />2015<br />Shift From Process Reporting to Outcomes Reporting<br />Improved Outcomes<br />Functional Process Objectives<br /><ul><li>Outcomes, clinically based measures
    118. 118. More patient-generated data
    119. 119. Dynamic quality reports
    120. 120. Patient access to data, rather than access to copies of data
    121. 121. Real-time syndromic surveillance
    122. 122. Claims and clinically based measures
    123. 123. Streamlined enrollment, eligibility and claims
    124. 124. CPOE for all order types
    125. 125. Use Clinical Decision Support to achieve specific outcome
    126. 126. Increased clinical documentation in EHR
    127. 127. Health summaries for continuity of care
    128. 128. Registry reporting and reporting to public health
    129. 129. Process, claims based measures
    130. 130. Transmit prescriptions
    131. 131. Generation of patient list
    132. 132. Capability to exchange clinical data
    133. 133. Patient e-copies of their discharge and visit summaries
    134. 134. Quality and immunization reporting</li></li></ul><li>Status of EHR Adoption<br />80% medical practices already adopted an EHR <br />72% said they are satisfied with the EHR system<br />13.6% of medical practices indicated that they are currently able to meet all 15 core MU criteria<br />26.5% of practices indicated that productivity increased as a result of the EHR <br />30.6% of practices indicated that productivity decreased as a result of the EHR <br />Of the practices still using paper records, 28.8% were in the process of selecting an EHR system <br />Electronic Health Records: Status, Needs, and Lessons 2011, (The Medical Group Management Association).<br />
    135. 135. CIOs and EHR adoption<br />More CIOs say they are accelerating plans to implement EHRs, with 40.5 percent reporting such plans in March vs. 35.6 percent in November 2010 (CHIME Survey, April 2011)<br />Capturing and submitting data for quality measures has become the most frequently cited concern of CIOs<br />Nearly 75 percent of responding CIOs say they are concerned about legislative proposals to repeal incentive funding, including the EHR Medicare and Medicaid Incentive Program.<br />
    136. 136. Kübler-Ross Model of EHR Adoption <br />Denial – This is a joke. These people don’t understand medicine and this Obamacarething will soon go away and we’ll return to normalcy.<br />Anger – This is a cruel joke. This EHR thing is just a government ploy to punish doctors and enslave them. There’s nothing in this for me and you want me to pay for it?? We are all going to stop taking Medicare, Medicaid and all your government plans, which don’t even pay for my receptionist, see what you do then.<br />The Kübler-Ross Model of EHR AdoptionBy MARGALIT GUR-ARIE<br />
    137. 137. Kübler-Ross Model of EHR Adoption <br />Bargaining – This is not happening to me. I am a doctor. If I stop playing their game, they’ll have no way to touch me. I will only take cash, at least for a while, until this thing blows over. I’ll practice good medicine, and in time everybody will come to their senses and see that this is the right way to care for people. <br />Depression – What’s the point? Why did I have to sacrifice my entire life and work like a dog for these ungrateful people? There’s no respect any more. There is no gratitude. There’s no money in this either. I should have gone to law school<br />
    138. 138. Finally….<br />Acceptance – This EHR is really primitive. Costs a fortune, but the hospital kicked in for most of it. They want to measure my performance; fine with me. I’m a good doctor and I take good care of my patients. I don’t like using the computer in the exam room. My nurse does though, but you should see her texting, and my receptionist says it’s better than the old system. I wish I could get the hospital labs, but they’re still faxing them over.<br />The Kübler-Ross Model of EHR AdoptionBy MARGALIT GUR-ARIE<br />
    139. 139. A Real Issue: Staffing Shortages<br />More than 60 percent of responding CIOs reported that IT staffing deficiencies will possibly (51 percent) or definitely (10 percent) affect their chances to implement EHR and receive funding.<br />More than 70 percent of respondents reported that their organizations lack staff to implement clinical applications.<br />Respondents from smaller hospitals reported the lowest percentage of open positions. <br />IT Staffing Shortages, October 2011<br />
    140. 140. The National Landscape on HIE<br />
    141. 141. eHI on HIE<br /><ul><li>Since 2004, eHealth Initiative (eHI) has tracked the progress of organizations and initiatives across the country working in this area.
    142. 142. Health information exchange is the act of transferring health information electronically between two or more entities.
    143. 143. eHI has identified and collected information on 234 active health information exchange initiatives (HIEs) in the country.
    144. 144. eHI and its membership support HIEs through research, education and advocacy for HIEs. </li></ul>99<br />
    145. 145. 100<br />Why It Won’t Work<br /> “That it will ever come into general use, notwithstanding its value, is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble, both to the patient and to the practitioner because its hue and character are foreign and opposed to all our habits and associations.”<br />
    146. 146. 101<br /> “That it will ever come into general use, notwithstanding its value, is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble, both to the patient and to the practitioner because its hue and character are foreign and opposed to all our habits and associations.”<br />from The London Times in 1834<br />Commenting on ...<br />the “stethoscope”<br />
    147. 147. 102<br />Obligatory Confusing Diagram<br />Labs<br />Payer 1<br />Labs<br />Payer 2<br />Payer 6<br />Specialist 1<br />Specialist 2<br />Hospital<br />Specialist 6<br />Specialist 3<br />Labs<br />Hospital<br />Specialist 5<br />Specialist 4<br />Payer 3<br />Payer 5<br />Hospital<br />Labs<br />Labs<br />Payer 4<br />5/12/11<br />= Patients<br />102<br />
    148. 148. 103<br />National Landscape on HIE<br />
    149. 149. What Are Communities Doing?<br />104<br />
    150. 150. eHI Stages of Development <br />OPERATIONAL<br />105<br />
    151. 151. 106<br />2010 Stages of Development<br />
    152. 152. 107<br />Operational InitiativesActually Transmitting Data<br />
    153. 153. 108<br />Who Is Engaged? <br />
    154. 154. 2009<br />109<br />
    155. 155. 110<br />2010<br />
    156. 156. Why is this so hard?<br />Public Good<br />Demonstrating Value and ROI<br />Continuing to Offer Valuable Services<br />
    157. 157. 112<br />Challenges Faced by All<br />
    158. 158. Privacy<br /><ul><li>Initiatives are creating methods to address the complexities of security and privacy. More organizations are creating systems which allow patients to control the level of access to their information.</li></ul>36 have an opt-in policy where patients must give consent to have their data included. <br />81 have an opt-out policy, where patients’ data is automatically included but they can choose to withdraw. <br />27 unsure<br />113<br />
    159. 159. Sustainable Initiatives: How Do They Do It?<br />114<br />
    160. 160. 115<br />Revenue Sources for Ongoing Operations-<br />
    161. 161. 116<br />Stakeholders Paying Participation Fees <br />
    162. 162. What Service Are They Paying For?<br />Connectivity to EHRs (15)<br />Alerts to providers (12)<br />Consultation/referral (12)<br />Results Delivery (12)<br />Alerts to providers Drug-to-drug (11)<br />Health summaries for continuity of care (11)<br />Clinical documentation (10)<br />Electronic prescribing (10)<br />117<br />
    163. 163. Characteristics of Sustainable Groups<br />Established organizations<br />Involvement of multiple stakeholders- the more the merrier is true - in this case<br />Paying participants<br />Focus on limited number of data and functionalities<br />Active physician engagement<br />A business, not a project<br />Money does not erase need for time<br />118<br />Page 118<br />
    164. 164. Value from HIE<br />
    165. 165. 120<br />Measures of Financial Success <br />
    166. 166. Patient Engagement With HIE<br />More consumers involved in governance<br />71 in 2010, up from 22 in 2009<br />More patients viewing data<br />44 operational initiatives allowed review access in 2010, up from 3 in 2009<br />More patients adding information to health status<br />31 operational initiatives allowed patients to add information on their health status, up from 7 operational initiatives in 2010 <br />Provide electronic communication between patients and care providers<br />33 operational initiatives provide in 2010<br />More patients provided access to health education information<br />30 operational initiatives in 2010<br />121<br />
    167. 167.
    168. 168. Accountable Care Organizations<br />
    169. 169. Creation of ACOs<br />Networks of providers within Medicare system includes physicians, hospitals and health systems. <br />Aim is to improve the quality of care, save money, with any savings to be shared by the government and the ACOs<br />Centers for Medicare and Medicaid Services (CMS) released a proposed rule at the end of March, how the program will work, how much financial risk medical providers will face, and what type of data the organization need to collect. <br />
    170. 170. General Thoughts on ACO Rule<br />HIEs are essential for the success of ACOs <br />Example: The underlying assumption is that ACO will access patient records from providers not participating in the ACO via HIE<br />CMS is increasing the demands for exchange of information among providers and individuals<br />This will support the demand for robust HIE <br />CMS is offering flexibility the ACOs to determine the strategy for information exchange that best meets their needs<br />
    171. 171. ACO NPRM Specific Comments<br />Quality measure reporting in the ACO NPRM should align with meaningful use quality measure reporting yet recognize that all measures in MU are not applicable to all providers participating in the ACO <br />Retrospective Assignment of Beneficiaries<br />Beneficiary assignment in ACOs that relies on retroactive claims data will require interoperable EHRs and standards that may not currently exist<br />
    172. 172. Comments<br />Meaningful Use Requirement for PCPs:<br />The 50 percent threshold requirement for certified EHR use among PCPs is high and could hinder participation in the ACO.<br />The certified EHR use requirement is not extended beyond PCPs. <br />Is this a challenge to care coordination with non-PCPs participating in the ACO, and providers offering care to the beneficiary outside of the ACO?<br />
    173. 173. Concerns About ACO Program<br />Some key groups reluctant to participate unless changes made<br />College of Healthcare Information Management Executives argues that allowing patients to limit access to their medical data could impede efforts to provide accountable care<br />
    174. 174. The Government’s Plan<br />
    175. 175. Federal Health IT Strategic Plan<br />5 Goals, 15 Objectives, 50 Strategies for 2011 - 2015<br />Achieve adoption and information exchange through meaningful use of Health IT<br />Improve care and population health, and reduce health care costs through use of Health IT<br />Inspire confidence and trust in Health IT<br />Empower individuals with Health IT to improve their health and the health care system<br />Achieve rapid learning and technological achievement<br />
    176. 176. eHI Comments on Federal HIT Plan<br />The Strategic Plan must be inclusive of healthcare settings and providers<br />The objectives and strategies should clearly articulate the expectation that HIT and HIE will support empowerment of individuals as participants in the healthcare system<br />Think expansively about the ability of HIE to support the Strategic Plan goals<br />The Strategic Plan should support connectivity and exchange between the healthcare delivery system and the public health system<br />
    177. 177. Federal HIT Strategic Plan<br />ONC, in its coordinating role, must be aware of and plan for the concurrent federal healthcare activities across federal departments <br />Recommended the establishment of a Coordinating Committee that defines alignment and coordination of federal activities, and with opportunities for public participation<br />It is important to add an evaluation component and modifications based on experience<br />Plan HIT that supports the greater use of personalized medicine <br />Foster HIT adoption without requirements that mandate uniform use of HIT across medical specialties<br />
    178. 178. Big discrepancy in EHR adoption in small practices, rural communities, etc.<br />Web-based solutions<br />Defining and sharing sustainable business models continues to be focus<br />Focus is not on the Government funded SDEs, RECs, etc. for the experience factor<br />Significant gap with staffing and expertise in HIE—organizations with experience<br />133<br />Final Thoughts<br />
    179. 179. Where to Find More Info<br />
    180. 180. 135<br />Contact Information <br /><br />135<br />
    181. 181.
    182. 182. Legal Challenges to PPACA and the Current Regulatory Environment Surrounding HIT and Meaningful Use<br />presented by Jeff Porter2011 Ohio Healthcare Summit<br />May 12, 2011<br />
    183. 183.
    184. 184.
    185. 185.
    186. 186.
    187. 187.
    188. 188. Meaningful Use<br />
    189. 189. Update on Meaningful Use<br />
    190. 190. In July of 2010, the Department of Health and Human Services released the proposed final rule for Stage 1 meaningful use of EHR.<br />
    191. 191. Since that time, the HIT Policy Committee has been engaged in public hearings and soliciting testimony regarding the future stages of meaningful use.<br />
    192. 192. Stage 2 recommendations are likely to be issued in the summer of 2011.<br />
    193. 193. The HIT Policy Committee released proposed meaningful use objectives and measures for stages 2 and 3. The Committee received comments until February 25, 2011.<br />
    194. 194. During the comment period, 422 organizations submitted comments regarding the proposed objectives and measures<br />
    195. 195. Among the comments there was support for several new objectives:<br />Electronic prescribing for discharge prescriptions<br />Electronic clinical progress notes<br />Patient-provider secured messaging<br />
    196. 196. There was less support for objectives such as:<br />List of care team members<br />Advanced directives for EPs<br />
    197. 197. Many hospitals, Physicians and EHR vendors generally supported slowing down timeline for meaningful use.<br />
    198. 198. You can find a copy of the HIT Policy Committee’s Proposed Objectives and Measures here:<br /><br />Or contact me at<br />
    199. 199. Shared Savings Program or Accountable Care Organizations<br />
    200. 200. Medicare Shared Savings Program or Accountable Care Organizations<br />Medicare Shared Savings Program proposed regulations were released March 31, 2011 by:<br />CMS, Centers for Medicare and Medicaid Services<br />Office of Inspector General<br />IRS<br />FTC<br />Official proposed regulations were in April 7 Federal Register<br />
    201. 201. Comment Period on Regulations<br />Comments due by May 31st (FTC/IRS) and June 6th (CMS/OIG) to various organizations involved.<br />Program set to begin January 1, 2012 (maybe).<br />Regulations were over 400 pages long.<br />
    202. 202. General Facts Regarding Medicare Shared Savings Program<br />Providers who are eligible to form ACOs:<br />ACO professionals in group practice arrangements<br />Hospitals employing ACO professionals<br />Networks of individual practices of ACO professionals<br />Critical Access Hospitals<br />Partnerships or joint venture arrangements between hospitals and ACO professionals<br />Other providers and suppliers may participate in ACOs.<br />
    203. 203. General Facts Regarding ACO’s<br />Must create a legal entity (e.g., corporation, partnership, LLC) that is recognized by the state, has a Tax Identification Number (TIN) for purposes of:<br />Receiving and distributing funds;<br />Repaying shared losses;<br />Establishing, reporting, and ensuring ACO participant and ACO provider/supplier compliance with program requirements, including quality performance standards; and<br />Performing other functions as identified in statute.<br />Must provide for a shared governance model that provides all participants with appropriate proportionate control over decision-making process.<br />
    204. 204. Some Basic Considerations<br />ACO must have 5k Medicare fee for service lives attributed in base period.<br />If ACO’s lives drop below 5k, CMS will establish Corrective Action Plan and ACO must exceed 5k in next year of agreement or will be ineligible.<br />
    205. 205. Some Basic Considerations<br />ACO governing body should consist of:<br />Representatives from each provider/supplier participant<br />Medicare beneficiary representatives<br />At least 75% of body must be participants in ACO<br />May include non-providers (e.g. health plan management companies)<br />May include community representatives<br />
    206. 206. Contract with CMS<br />Three year contract<br />CMS considering new possible start date of July 1, 2012 in addition to January 1, 2013 (but then would be 3.5 year agreement).<br />60-day Termination (will result in forfeit of shared savings.)<br />CMS will approve/deny applications prior to the end of the calendar year in which the applications are submitted.<br />
    207. 207. Further Thoughts on Medicare Shared Savings or ACO Program<br />Highly intensive regulation <br />Overall rules on participation in NPRM could dampen participation<br />Broad waivers of Stark and Anti-kickback laws do apply, but caution is still required<br />Rules tend to favor hospitals creating ACO, if only for the 5,000 live requirement<br />
    208. 208. Further Thoughts on Medicare Shared Savings or ACO Program<br />Two-sided savings/loss model poses some risks, especially considering that quality measures must be met to obtain shared savings<br />Additional costs in running ACO need to be considered<br />Need to have a compliance office on staff who reports to the board and is not legal counsel to ACO<br />CMS expects that at least 50% of physicians in an ACO to achieve Stage 1 meaningful use<br />
    209. 209. Thank You!<br />Jeff Porter<br />Kegler Brown Director, Health Care Regulation & HIT Practice co-chair<br /> <br />(614) 462-5418<br />65 East State St., Suite 1800, Columbus OH 43215<br />
    210. 210. Healthcare Regulation and the Implications for Healthcare Providers<br />presented by Ralph Breitfeller2011 Ohio Healthcare Summit<br />May 12, 2011<br />
    211. 211. Stark: Self Reporting<br />Different from reporting non-Stark issues to OIG.<br />Voluntary Self-Referral Disclosure Protocol (SRDP) posted 9/23/10.<br />Reduced penalties for self reporting of overpayment.<br />Statute requires reporting by the later of: (1) within 60 days after overpayment identified; OR, (2) the date the cost report is due.<br />SRPD allows additional time to investigate complicated issues.<br />
    212. 212. Stark: Self Reporting Protocol<br />Must provide all relevant information, including corrective action.<br />If already under government investigation, must disclose this fact to CMS.<br />Must provide all supporting documents without assertion of privilege.<br />Submit detailed financial analysis.<br />Statement of why disclosing party believes there is a violation, including legal analysis.<br />Circumstances by which violation was discovered and measures taken.<br />History of similar conduct and other violations.<br />Certification by CEO or CFO.<br />
    213. 213. Stark: Self Reporting Mitigation Factors<br />Nature and extent of violation<br />Timeliness of Disclosure.<br />Cooperation.<br />Litigation risk.<br />Financial condition of disclosing party.<br />
    214. 214. HIPAA: Civil Monetary Penalty<br />First HIPAA penalty issued by the HHS Office of Civil Rights (OCR).<br />Issued against Cignet Health of Prince George’s County.<br />$4.3 million.<br />Proposed determination states that Cignet failed to provide 41 individuals with timely access to medical records. Each day was a separate violation (45 CFR 164.524), resulting in $1.3 million.<br />
    215. 215. HIPAA (cont.)<br />Cignet failed to cooperate:<br />Refused to produce documents.<br />Complied with subpoena only after Court enforced.<br />Made no effort to resolve complaints.<br />Failure to cooperate resulted in finding of willful neglect of Privacy Rule. An additional $3 million, 16 CFR 160.401.<br />
    216. 216. Signature on Lab Requisition<br />Final Physician Fee Schedule Rule for 2011 requires physician or qualified NPP sign a requisition for clinical diagnostic Lab test.<br />On 12/10/10, CMS announced it would not enforce during Q1-2011.<br />On 3/31/11, CMS announced it would rescind the rule; HOWEVER, it now appears that they will have to comply with APA.<br />Meanwhile, CMS will not enforce the rule and has so instructed contractors.<br />
    217. 217. 340B Drugs<br />Discharge Prescription:<br />From HRSA website 2/7/2011:<br />Can 340B drugs be used for discharge prescriptions?<br />The Office of Pharmacy Affairs continues to stand by its long held position that the 340B program is an outpatient drug program.<br />Eligible entities have the responsibility to ensure that drugs purchased under 340B be limited to outpatient use and provided to patients who meet the requirements of the current patient definition.  <br />340B drugs can be used for discharge prescriptions to the extent that the drugs are for outpatient use. Whether a drug qualifies as outpatient and the individual meets the definition of patient depends upon the factual circumstances surrounding the care of that particular individual.<br />If an entity uses 340B drugs, it should be able to explain why the entity is responsible for the use of the drugs on outpatient basis and have auditable records that demonstrate compliance with 340B requirements.<br />
    218. 218. 340B (cont.)<br />Definition of a Patient<br />the covered entity has established a relationship with the individual, such that the covered entity maintains records of the individual's health care; and <br />the individual receives health care services from a health care professional who is either employed by the covered entity or provides health care under contractual or other arrangements (e.g. referral for consultation) such that responsibility for the care provided remains with the covered entity; and <br />the individual receives a health care service or range of services from the covered entity which is consistent with the service or range of services for which grant funding or Federally-qualified health center look-alike status has been provided to the entity. Disproportionate share hospitals are exempt from this requirement. <br />An individual will not be considered a "patient" of the entity for purposes of 340B if the only health care service received by the individual from the covered entity is the dispensing of a drug or drugs for subsequent self- administration or administration in the home setting. An individual registered in a State operated AIDS drug purchasing assistance program receiving financial assistance under title XXVI of the PHS Act will be considered a "patient" of the covered entity for purposes of this definition if so registered as eligible by the State program. <br />
    219. 219. Primary Care Incentive Program<br />ACA authorizes 10% incentive payments to primary care physicians and NPP:<br />(1) who have a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; as well as nurse practitioners, clinical nurse specialists, and physician assistants; and <br />(2) For whom primary care services accounted for at least 60 percent of the practitioner’s allowed charges under Part B for a prior period as determined by HHS. <br />
    220. 220. Hospital Surgical Incentive Program<br />In Health Professional Shortage Areas (HPSA):<br />must be enrolled in Medicare as a general surgeon. <br />the amount of the incentive payment is equal to 10 percent of the payment for the surgical services furnished by the general surgeon occurring in a ZIP code that is located in an area designated as a primary care HPSA. <br />
    221. 221. Reprocessing of Claims<br />ACA made corrections and changes to fee schedule, retroactive to 1/1/2010.<br />Large volume of claims will be reprocessed.<br />CMS instructed contractors to begin reprocessing the first week of March 2011.<br />Claim submitted at charge lower than the revised 2010 schedule will not be automatically reprocessed. Will need to request manual reopening.<br />CMS considers these circumstances to be “good cause” for extending the 1 year period for reopening.<br />
    222. 222. Waiving beneficiary’s cost-sharing portion of increase<br />OIG has issued a policy that it will not sanction a provider who waives the beneficiary’s cost-sharing increase:<br />This policy statement applies only to waivers of Retroactive Beneficiary Liability owed by beneficiaries for items and services furnished during the Retroactive Period. Once new, increased payment rates are implemented, Providers are expected to calculate and collect cost-sharing amounts for items and services furnished after the Retroactive Period based on the new, increased payment rates. <br />This policy statement applies only to waivers of Retroactive Beneficiary Liability, which is the increase in the beneficiary's cost-sharing amount attributable to the commensurate increase in payment rates by operation of new Federal statutes or regulations. This policy does not apply to waivers of beneficiary cost-sharing amounts that were calculated using the prior, lower payment rates. <br />This policy statement applies only to waivers of Retroactive Beneficiary Liability if: <br />Providers uniformly offer the waivers to all of their affected beneficiaries (~, without regard to the types of items and services furnished to a beneficiary or a beneficiary's diagnosis); and <br />Providers do not offer the waivers as part of any advertisement or solicitation.<br />This policy statement does not apply to waivers of Retroactive Beneficiary Liability if the waivers are conditioned in any manner on the provision of items, supplies, or servIces. <br />
    223. 223. Thank You!<br />Ralph Breitfeller<br />Kegler Brown Of Counsel, Health Care Regulation & HIT Practice co-chair<br /><br />(614) 462-5427<br />65 East State St., Suite 1800, Columbus OH 43215<br />
    224. 224. Medical Malpractice:What To Do If You Get Sued<br />presented by Traci McGuire2011 Ohio Healthcare Summit<br />May 12, 2011<br />
    225. 225. Discussion<br />Litigation process<br />If you have been sued:<br />what you should and should not do <br />How to help yourself<br />
    226. 226. Nuts and Bolts: Medical Malpractice<br />What is it? <br />Any act or failure to act by a health care professional which deviates from the acceptable standard of care and causes injury to a patient.<br />
    227. 227. Nuts and Bolts: Medical Malpractice<br />Standard of Care<br />The standard of care is that of a reasonable physician in the light of present day scientific knowledge in that field of specialty.<br />
    228. 228. Nuts and Bolts: Medical Malpractice<br />Patient must prove, by a preponderance of the evidence:<br />a physician had a duty to provide medical treatment <br />a physician breached the duty to provide treatment in accordance with the applicable standard of care<br />the patient suffered an injury that was proximately caused by the physician’s failure to provide treatment in accordance with the standard of care<br />
    229. 229. Anatomy of a Lawsuit<br />What you should know about the litigation process <br />Lawsuits take a long time<br />Discovery – information sharing<br />Medical records, office charts, xrays, monitoring strips – any information, hard copy or electronic, that is part of the patient’s medical chart<br />Information about your malpractice carrier, medical training, credentials and history as a physician<br />Deposition<br />
    230. 230. Anatomy of a Lawsuit<br />What you should know about the litigation process <br />Expert testimony <br />Damages<br />Lost wages<br />Present and future medical care<br />Pain and suffering<br />Large percentage of medical malpractice cases settle or are otherwise dismissed before trial<br />
    231. 231. Top 10 things you SHOULD and SHOULD NOT do if you are sued!<br />Immediately notify your professional malpractice insurance carrier and your lawyer.<br />2. Set up a separate correspondence file for all communication with your malpractice liability carrier and your lawyer. <br />Do not keep it with the patient’s medical record.<br />Be wary of quick communications – emails<br />3. Honest and candid communication is key.<br />Do not hide any information.<br />Do not destroy any information – do not throw it away or delete it.<br />
    232. 232. Top 10 things you SHOULD and SHOULD NOT do if you are sued!<br />Do not alter, clarify or supplement the medical record for any reason.<br />Do not discuss the facts or details about the lawsuit with anyone other than your attorney.<br />Do not talk to the patient or the patient’s attorney or the patient’s family members.<br />Do not talk to the media.<br />
    233. 233. Top 10 things you SHOULD and SHOULD NOT do if you are sued!<br />6.If asked by your lawyer, prepare a narrative of the events and the treatment provided.<br />Give it to your lawyer – do not put it in the patient’s chart.<br />Carefully and fully honor any request for documents – including medical records.<br />8.Do not do extra medical research.<br />
    234. 234. Top 10 things you SHOULD and SHOULD NOT do if you are sued!<br />9.Help your attorneys.<br />Learn the medicine<br />Identify and select your experts<br />Make contacts with the other medial professionals involved in the care and treatment<br />10. Set aside enough time to meaningfully participate in the case. <br />Do not try to fit patients in during meetings with your attorney, the trial or your deposition<br />Be prepared for the unpredictable nature of the legal process and the lengthy timetable<br />
    235. 235. How Can You Help Yourself?<br />Good bedside manner<br />Positive experience influences a patient’s decision to sue or not to sue<br />Appreciate the importance of documentation<br />If something is not documented in the record, we can not prove it happened<br />Pay attention to documentation details – common errors<br />Failure to indicate the time<br />Failure to sign<br />Failure to date<br />Illegible writing<br />Lack of information<br />
    236. 236. How Can You Help Yourself?<br />Communicate clearly and thoroughly<br />With patients<br />With other doctors and medical professionals – including residents<br />Be a good listener<br />Take communications from others seriously<br />Other medical professionals, including nurses, respiratory therapists, residents, etc. – they are the eyes and ears of the patient<br />Family members<br />
    237. 237. Thank You<br />Traci McGuire<br />Kegler Brown Hill & Ritter<br />65 E. State Street, Suite 1800<br />Columbus, Ohio 43215<br /><br />Direct: 614/462-5408<br />
    238. 238. Fred Richards, COO/CIO<br />Ohio Health Information Partnership<br />
    239. 239. Who is the Ohio Health Information Partnership?<br />5/12/11<br />194<br />
    240. 240. The Ohio Health Information Partnership<br /><ul><li>Nonprofit partnership
    241. 241. State-designated Regional Extension Center and Health Information Exchange
    242. 242. Federal funding through Office of National Coordinator of HIT, Department of Health & Human Services
    243. 243. Board members have vested interest in its success </li></li></ul><li>OHIP’s Founders<br />5/12/11<br />196<br />
    244. 244. How can we help achieve the State’s health transformation objectives?<br />5/12/11<br />197<br />
    245. 245. Medicaid Hot Spots<br />Overall health care fragmentation<br />Emergency department dependency<br />Avoidable admissions<br />Lack of primary care coordination<br />Behavioral health<br />Nursing home care<br />Patients with other chronic conditions<br />Medicare and Medicaid coordination<br />5/12/11<br />198<br />
    246. 246. Addressing the Hot Spots<br />Regional Extension Center Services<br />Helps providers adopt EHRs and achieve meaningful use<br />Health Information Exchange<br />Connects providers so they can electronically exchange data to better coordinate care<br />5/12/11<br />199<br />
    247. 247. Regional Extension Center Services<br />You may be one of the 6,000 priority primary care physicians or health professionals who can take advantage of federal funding for free REC services. <br />Assess your practice to prepare for electronic health records<br />Select, adopt and implement an EHR system<br />Help you reach “meaningful use” under federal provisions<br />Assist in getting federal incentives -- $44,000 from Medicare or $64,750 from Medicaid for each physician or eligible professional within your practice<br />3,702<br />Care Summaries<br />e-Prescribing<br />5/12/11<br />200<br />
    248. 248. HIT Training Program<br />1,500 Graduates in June in Midwest<br />80% have College Degree<br />Job Board Coordination<br />5/12/11<br />201<br />
    249. 249. Health Information Exchange<br />5/12/11<br />202<br />
    250. 250. Assessing HIE Benefits<br />5/12/11<br />203<br />Which benefits align with your strategic goals?<br />
    251. 251. Priorities for Meaningful Use<br />Structured Lab Results<br />Care Summaries<br />e-Prescribing<br />5/12/11<br />204<br />
    252. 252. FQHCs<br />and CMHCs<br />Payers<br />State<br />Local<br />HealthBridge<br />NHIN<br />3 Major Labs<br />Registries<br />Other<br />200 Touch Points to 80% EMR<br />750 Providers<br />6,000-10,000 Physicians<br /> 8,000 Physicians<br />50-80 EHR<br />Vendors<br />174 Hospitals<br />80 IntegratedDelivery Systems<br />5 OHIP Preferred EHR Vendors<br />Medicaid<br />Health Information Exchange<br />Public Health<br />Pharmacy<br />Database<br />5 Major Payers<br />5/12/11<br />205<br />5 Major MCOs<br />
    253. 253. HIE Planning and Preparation<br />ONC Planning<br />HIE State Plan <br />Privacy White Paper<br />Sustainability Plan<br />HIE Procurement<br />RFP Process<br />Medicity Selected as Vendor<br />5/12/11<br />206<br />
    254. 254. Experienced Vendor<br />Ohio joins Delaware, Colorado, Vermont and Michigan <br />5/12/11<br />207<br />
    255. 255. Phasing of HIE Services<br /><ul><li>20 Hospitals
    256. 256. 200 Offices
    257. 257. 20 Hospitals
    258. 258. 200 Offices
    259. 259. 10 Hospitals
    260. 260. 100 Offices</li></ul>208<br />Confidential, For Internal Discussion Only<br />
    261. 261. HIE Financing<br />5/12/11<br />209<br /><ul><li>Hospital Integration Costs
    262. 262. To be covered by grant funds
    263. 263. Ongoing Subscription Fees
    264. 264. Hospital fee based on annual discharge volumes
    265. 265. Physician fee will be minimal to encourage adoption
    266. 266. Optional fees for additional services such as ePrescribing or EMR Lite</li></li></ul><li>Stakeholder engagement<br />5/12/11<br />210<br />
    267. 267. Supporting Hospitals<br />Adams County Regional Medical Center<br />Aultman Health Foundation<br />Barnesville Hospital<br />Berger Health System<br />Brown County Regional Healthcare<br />Bucyrus Community Hospital<br />Catholic Health Partners<br />Cleveland Clinic<br />Dunlap Community Hospital<br />Fairfield Medical<br />Genesis Healthcare System<br />Health Alliance of Greater Cincinnati<br />Humility of Mary Health Partners (CHP)<br />Kettering Health Network<br />Madison County Hospital<br />Marietta Memorial Hospital<br />Mary Rutan Hospital<br />MedCentral Health System<br />Mercer County Health System<br />O’Bleness Memorial Hospital<br />OhioHealth<br />Ohio State University Medical Center<br />Pomerene Hospital<br />Promedica Health System<br />Salem Community Hospital<br />Southeastern Medical<br />Southwest General Health Center<br />St. Rita's Hospital (CHP)<br />Summa Health System<br />University Hospitals<br />Wood County Hospital<br />Wooster Community Hospital<br />5/12/11<br />211<br />
    268. 268. Supporting Associations<br />Academy of Medicine of Toledo and Lucas County<br />Academy of Medicine of Cleveland and Northern Ohio<br />American College of Obstetricians +and Gynecologists <br />Butler County Medical Society<br />Columbus Medical Association<br />Ohio Academy of Family Physicians<br />Ohio Chapter of American College of Pediatrics<br />Ohio Council of Behavioral Health and Family Providers <br />Ohio Hematology<br />Oncology Society<br />Ohio Hospital Association<br />Ohio Osteopathic Association Ohio State Medical Association<br />Ohio Ophthalmological Society<br />Scioto County Medical Society<br />Society of the American College of Osteopathic Family Physicians<br />5/12/11<br />212<br />
    269. 269. Supporting Organizations<br />Insurers<br />Aetna<br />Anthem Blue Cross and Blue Shield<br />CareSource<br />Medical Mutual of Ohio<br />Unison Health Plan<br />United Healthcare<br />Government<br />Ohio Board of Regents<br />State of Ohio<br /> Additional<br />Americare Community Care<br />Center for Healthy Communities<br />Ohio Association of Community Health Centers<br />One Community<br />Ohio KePRO<br />5/12/11<br />213<br />
    270. 270. For More Information<br />Visit<br />Contact Doug Green<br /><br />614.664.2614<br />Contact your OHIP regional partners<br /><br />5/12/11<br />214<br />