How AZ Drives Health Equity for American Indian Populations Through HIE

Arizona's Medicaid agency, the Arizona Healthcare Cost Containment System (AHCCCS), has launched several health information exchange (HIE) initiatives in recent years in efforts to improve health equity for the American Indian population.

Health disparities among American Indian/Alaska Native (AI/AN) people are vast, ranging from greater difficulties affording healthcare to poor maternity care access and high infant mortality rates.

Over the last five years, AHCCCS has incorporated HIE incentives into its differential adjusted payment (DAP) program, according to Melissa Kotrys, CEO of Contexture, the HIE that covers Arizona and Colorado.

"It started with incentivizing acute care hospitals in Arizona, and now we have HIE incentives built into the DAP program and collaboration with Medicaid across many different populations," Kotrys said during a Civitas 2022 Annual Conference presentation. "In the last year, we have included incentives for HIE participation for Indian Health Service and tribally owned 638 facilities."

The incentive, which requires bidirectional data sharing with the HIE, includes a 2.5 percent increase over the standard Medicaid reimbursement rate.

A separate AHCCCS program called the American Indian Medical Home (AIMH) reimburses participating organizations per member per month for care coordination. Tiers three and four in the AIMH program have incentives that require bidirectional HIE participation, Kotrys explained.

When AHCCCS first offered the AIMH program, San Carlos Apache Healthcare, a tribal facility in Eastern Arizona, was working towards its certification as a patient-centered medical home (PCMH). The advanced care model calls on primary care, specialty care, and community health providers to work together to coordinate care to drive patient wellness.

Lapriel Dia, chief nursing officer at San Carlos Apache Healthcare, said the organization began its PCMH journey in early 2015.

"Coincidentally, American Indian Health offered this incentive program along the way," she explained. "Since we were already providing patient-centered medical care for our patients, it was one more thing that would help us take care of our patients and get them where they need to go."

Dia noted that AIMH designation with AHCCCS was a journey, as San Carlos Apache had to improve care access by implementing a 24-hour call line for patients. The organization also had to join the HIE to obtain the highest reimbursement rate, level four.

She emphasized that connecting to the HIE and participating in the AIMH program allows the organization to provide more services and have more people on care teams.

"The incentive program works for us," Dia said. "We're able to staff so that we can take care of these 15,000 members."

"The hospital is pretty comprehensive, but there are some things that we can't do," she pointed out. "If somebody needs orthopedic surgery, we have to send them out. How do we ensure that they get the rehab they need in those instances? That transition of care is really important. That's where our HIE partnership will enhance the care we're giving."

Kotrys said that as Arizona works to improve health equity for the American Indian population, these HIE initiatives will help drive quality measurement and improvement.

"The goal of this partnership is to share data with an effort to ensure that we're coordinating care, and then we can measure the outcomes so that we can see what impact this better interoperability of data is having on the community as a whole," Kotrys said.

Frederick Chang, DO, MMM, FHM, a physician informaticist from the University of Arizona who works with AHCCCS, created a proof of concept demonstration based on the AIHM project for submitting CMS clinical quality core measures using HIE and AHCCCS claims data.       

Before the collaboration, Chang and AHCCCS officials considered using claims data alone to examine diabetes control. However, they faced challenges with data access.

"It was difficult because providers aren't incentivized to submit CPT codes for hemoglobin A1C lab data," he explained. "They'll bill for the visits, but they're not going to send in the labs, so we couldn't do this on our own using claims data."

Chang said that the dual-data pipeline approach aims to utilize HIE data to support the new request from CMS for electronic clinical quality measures (ECQM).

"The idea is that you're already submitting data to the HIE, so why make providers submit to ACHCCSS when we could just take data from the HIE and combine it to fulfill this new request from CMS for digital clinical quality measures," he explained.

"American Indians have a high rate of diabetes, so we wanted to look at that," Chang said.

Compared to Whites, American Indians are twice as likely to have type two diabetes and three times as likely to die from type two diabetes.

Chang said AHCCCS was able to gather claims data from 2018 to 2020 for approximately 20,000 IHS members.

"When we sent that to the HIE for their help, we had a pretty high match rate of 96 percent," he said. "When it returned lab data, we had about 12,000. Through these two pipelines of AHCCCS's claims data and then Contexture's lab data, we could start some preliminary analysis."

The NCQA core measure for hemoglobin A1C core control applied to 39 percent of IHS members in 2018, 37 percent of members in 2019, and 42 percent of members in 2020.

"All clinical providers suspected that diabetes would be poorly controlled due to the pandemic for many reasons, but here at AHCCCS, we had some final objective evidence," Chang added.

"We were able to demonstrate the proof of concept of taking two pipelines, but we still have some missing IHS sites, and we have some planned discussions with the medical directors on the ACHCCCS side for this," he said.

Primarily, Chang said two IHS sites were providing the bulk of data.

"There are only a few tribal entities in Arizona that proactively have a feed sending data to the HIE," Kotrys explained. "The preference for IHS is to query their Four Directions Hub through eHealth Exchange to pull that information back."

"That is good for point-of-care access to data, but for doing this full analysis on populations across the Medicaid program, if that data's not proactively being sent into the HIE, it's difficult, so going forward, we'll have more proactive coordination," she noted.