Enlarging Our Vision of Sustainability: HIEs As Infomediaries Doug Emery, MS Director, Payment Policy eHealth Initiative and Foundation 11/7/2018

Overview The Emerging National Consensus The Problem: Information Asymmetries and Third-Party Reimbursement The HIE Economic “Double-Whammy” Overcoming Institutional Inertia: The Problem of Value Calculation The Need for a National Database Stage 1 HIE Business Models: Transaction Based Stage 2 HIE Business Models: Infomediary Based Conclusion 11/7/2018

Information Asymmetries Kerr White, “The Ecology of Medical Care” New England Journal of Medicine 1961 Kenneth Arrow, “Uncertainty and the Welfare Economics of Medical Care” The American Economic Review 1963 Jerry Solon et al, “Delineating Patterns of Medical Care” New England Journal of Medicine 1967; Solon JA ,et al., “Episodes of Medical Care: Nursing Students’ Use of Medical Services” American Journal of Public Health 1969 11/7/2018

Third-Party Reimbursement Ex Ante Market or Medical Insurance Market Ex Post Market or Medical Delivery Market CPT-4, ICD-9, NDC, DRG, etc. So, we have 19th Century cottage industry delivering 21st Century medicine under a 20th Century reimbursement system 11/7/2018

HIE Economic “Double Whammy” Nearly all healthcare dollars programmed into insurance pools No Established Markets for Revenue 11/7/2018

Creating a Complex Market Stakeholder Involvement in HIE Efforts: All Respondents 54% 46% 45% 43% 42% 40% 35% 33% 32% 30% 29% 28% 23% 22% 0% 10% 20% 50% 60% Community Health Clinics Specialty Care Physicians Health IT Suppliers Local Public Health Dept Independent Labs Primary Care Physicians Pharmacies Independent Radiology Centers Quality Improvement Organization Hospitals State Public Health Dept. School-based Clinics Patient or Consumer Groups Health Plans Pharmacy Benefit Management Employers or Purchasers 11/7/2018

Most Difficult Challenges to Local Health Information Exchange Securing upfront funding- 91% of all respondents cited “securing upfront funding” as either a very difficult or moderately difficult challenge. Developing a sustainable business model- 84% of all respondents cited “developing a sustainable business model” as a very difficult or moderately difficult challenge. 11/7/2018

HIE Revenue and Funding Trends 11/7/2018

HIE Revenue and Funding Trends 11/7/2018

HIE Revenue and Funding Trends 11/7/2018

Demonstrating the Value of Health Information Exchange Must create value for all participants, both globally and for each stakeholder interest HIE applications must be accessible and efficiently provide information that influences care delivery at the point of care Without demonstrated value- there is no sustainable business plan Any applications covered by the program should be “interoperable” and standards-based Coordination and collaboration within the region or community is critical. 11/7/2018

Overcoming Institutional Inertia: The Problem of Value Calculation 11/7/2018

“Go-To”: Grants Connecting Communities Awards Program Investigate of the conditions and actions necessary to bring competing stakeholder interests and attain a sustainable, interoperable series of functionalities.   Build an ideal business model common principles and strategies for achieving sustainability HIE Build an economic theory that identifies and takes into consideration the unique HIE marketplace.   Collaborative approach with awardees and key business, financial and economics experts eHI tools to analyze market readiness conditions, cost parameters, revenue streams and, cost/benefit value cases 11/7/2018

Stage 1 HIE Business Models: Transaction Based Physicians Hospitals HIEs/RHIOs Other Ancillaries Labs & Pharmacies 11/7/2018

Stage 2 HIE Business Models: Infomediary Based Public Health and Consumers Providers HIEs/RHIOs Payers and Purchasers Medical Device and Pharma Manufacturers 11/7/2018

Conclusion 11/7/2018 National or Regional Superhub Hospitals HIE Data Base Module Physicians Statistical Module Discovery Module Health Information Exchange/RHIO Labs Study Module Radiology Hypothesis Pharmacies Clinicians 11/7/2018

Market Structure of an EOC Purchasing Paradigm Insurers Organizing Payment Around Acute and Chronic Episodes Health Plans Health Insurance Market ~~~~~~~~~ ~~~~~~ ~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~ Total Care of Complex Populations (Global Capitation) Chronic Care (Management Fees) Frail Elderly AIDS Some Cancers Rural areas Natural Monopolies Episodic Care (Global Fees) CHF Diabetes High-Risk OB Rare Disease Plan and provision of care are integrated Total Delivery High-Risk Delivery Hysterectomy Cataract Hip Replacement Knee Replacement Breast Cancer Lung Cancer Peptic Ulcer Acute Mental Health Outpatient Mental Health Stroke Carotid Endarterectomy Gal Stones Gal Bladder Removal Colorectal Cancer PTCA Severe Coronary Syndrome CABG End-Stage Renal Disease Prostate Cancer Urinary Stones Chemical Dependency 11/7/2018 Medical Delivery Market

Director, Payment Policy eHealth Initiative and Foundation Doug Emery, MS Director, Payment Policy eHealth Initiative and Foundation www.ehealthinitiative.org 818 Connecticut Avenue, N.W., Suite 500 Washington, D.C. 20006 202.624.3241 Doug.emery@ehealthinitiative.org 11/7/2018