A CDC REACH, NIH, OPHS and HRSA CHC grantee applies lessons learned to create a new paradigm for community

health care financing and delivery

Census 2010 Population / % served: Grant County: 29,514 / 55.4%Hidalgo County: 4,894 / 74.4%Total Svc. Area: 34,408 / 60%Pop. Per Sq. Mile = 4.6

Grant Hidalgo NM U.S.

Population under age 18 22%1 31.7%2 25.5%1 24.5%1

Under age 18 in poverty 29.1%3 32.3%3 24.1%3 18.2%3

Population 65 and over 19.4%-3 13.6%2 12.8%1 12.6%1

Population in poverty 19%3 21.3%3 17%3 13.2%3

Median Income $36,2393 $34,2363 $43,7193 $52,0293

Hispanic 48.8%4 56%4 42.1%4 12.5%4

Speak English less than

“very well”

9.4%5 15.6%5 11.9%5 8.1%5

1. U.S. Census Bureau, 2006-2008 American Community Survey2. U.S. Census Bureau, Census 2000 Summary File 1, Matrices P 13 and PCT 123. U.S. Census Bureau, Small Area Income and Poverty Estimates, 20084. U.S. Census Bureau, Census 2000 Summary File 1, Matrix PCT115. U.S. Census Bureau, Census 2000 Summary File 3, Matrices P19, P20, PCT13, and PCT14

Community Grant Hidalgo NM U.S.

Percent uninsured (under age 65) 23.5%1 28.4%1 25.8%1 15.5%2, 3

Medicaid Enrollment 20.8%4 19.1%4 21.6%4 14.1%5,6

Medicare Enrollment 22.5%7,8 18.3%7,8 14.3%9 14.3%5,6

Practice HMS NM U.S.

Percent uninsured 20% 25.8%1 15.5%2, 3

Medicaid Enrollment 35% 21.6%4 14.1%5,6

Medicare Enrollment 17% 14.3%9 14.3%5,6

HMS – Core Services� Primary Medical Care

� Family Medicine with Ob� Pediatrics� Internal Medicine

� Mental Health Services� Psychiatry� Psychology� Substance Abuse

� Dental� Full Range� Implants

� Specialty Consultation� ECHO

� Center for Health Innovations� FORWARD New Mexico� National Center for Frontier

Communities� Non-Profit Management Ed.� National REACH Coalition� Community Development� HMS Resource / Program

Development � Research and Evaluation

• Family Support (Non-Clinical Svcs.)

• Categorical Interventions• Eligibility• General Support• Family Assistance

Different Kinds of PC/PH Integration� Structural

� State Plan Priorities� Primary Care

� Obesity

� Clinical Preventive Services

� Mental Health

� Health Councils / Behavioral Health Collaboratives� Planning

� Collaboration

� Co-location/Commons� Cooperation

� MOU’s/MOA’s

� Functional� Integrated Mission /

Strategic Plan� Health Priorities:

� Patient� Community� Population

� Coordination � Service Implementation

� Co-Determined� C0-Delivered

� Contracts/Categorical Services – State � B&CC� Dental Indigent Services� Primary Care� Smoking� School Based Health � Parenting / Fatherhood

� Operational

� Health Services Delivery

� Clinical Prevention

� Comp/ PC

� Management

� Family Support Services

� Social Marketing / Ed.

� Care Coordination

� Outreach

� Coverage /Other Eligibility

� Social Interventions� Education

� Employment / Housing

� Economic Devel0pment

� AKA The Hidalgo Plan

Primary Care and

Public Health Integration

� Hidalgo Plan Perspectives

� Service Systems Integration

� Improved Population Health

� Reduced Per Capita Cost

� Fully Integrated Financial Modeling

� Fully Integrated Electronic Records� Social, Educational , Medical and Health Data

Payments Drive System - Current

� Payment Priorities� Diagnosis / Treatment

� Delivery System� Procedure Focused� Technical and Expensive � Invasive

� Health Outcomes� Not a Priority � Requires Separate, Unequal

Systems� Categorical Interventions

� Cost Outcomes� Bottom Line Focus� Unaffordable

Payments

Delivery

Outcomes

The Spiraling Cost Incentives

Medicare and MedicaidPay for PhysicianTraining (GME)

+/-70% of NM Medical CarePayments are Public

THE RVU / Payment System Encourages

Investments in High Cost Procedures, Drugs, and

Tests

Almost 100% of Medical CareInvestments are Private

ROI

Got Health?

Volume andIntensity

Relative Value……..

$$$

Evaluation and Management CodesWell Child ChecksClinical Preventive ServicesChronic Disease Management

$50

$5,000

ProceduresHigh End Testing

The Payment SystemSupports High Cost Health

Care Investments, Not Prevention and Management

Coding System

One Approach to Changing Incentives and Reducing Cost

Change the Slope of the RVU/ Payment System to Reduce Return On Investment at the

High End

$$$

Evaluation and Management CodesWell Child ChecksClinical Preventive ServicesChronic Disease ManagementMeaningful Use / PCMH

$75

$4,500

ProceduresHigh End Testing

Bend the curve

Increase the Incentives forBetter Health by Prioritizing Prevention and Management

Coding System

The Hidalgo Plan: Accountable Health Services

Change the Systemto Meet Health Goals of

the Public

A Different Approach

Payments Still Drive System, but…..• Payment Priorities

– Health Improvements

– Primary Care

• Outcomes

– Improved Population Health

– Lower Health Care Costs

– More People in a Health System

• Delivery System

– Population Focused Priorities

– Prevention Oriented Teams

– Management and Support Teams

– PC Diagnosis and Treatment –Medical / Accountable Home

Payments

Outcomes

Delivery

Health Focused Incentives

Primary Care 3.0

ROI

ManagedReferralSystem

Community-Determined Interventions

Community

Investments

Restructured HospitalPayments

Sub-Specialty Relations

Why We Think This Works

� Improvement in population health requires addressing socioeconomic determinants of health, including … inequality and primary care availability and access – Barbara Starfield

� HMS – CDC REACH CA – “LA VIDA” reduced average HBA1c levels in 500 Hispanic patients with Diabetes from 8.4 to 7.6 after only one visit with CHW in a year. Now a CEED / Legacy CDC dissemination program in NM, AZ and Missouri

PLUS…….

There’s More� REACH Model Extensions

� HMS – ACF/OPHS Grant – “GUTS” – Teen Parent Support. � NM Repeat Teen Pregnancies 22% / Guts 10.8%

� Teen HS Drop Out Rate 8.6% after one year 5.4%.

� HMS – UNM – Molina “Care Coordinators” Contract� Reduced cost of most expensive Medicaid patients 65%

� Capitation payment method

� New – NIH / REACH into Hypertension

� Hidalgo Plan Acceptance

Supportive EffortsACA State Support

� PCMH

� ACO

� Community Transformation Grants

� CMS – FQHC Financing / Innovations

� CHC Expansion / Construction $

� Workforce Development

� Exchanges

� HB 35

� Medicaid

� Department of Health

� UNM

� Molina MCO

Exchange Preparation� Either

� Health Insurance Cooperative

� Health Action NM

� Non-Profit Created late 2010

� Community Health Insurance Program

� Management Services Agreement

� Molina Health Plan

� Also supports Hidalgo Plan ($80,000)

� ACO Development

During 2010, HMS rotated 56 students and residents through its 11 locations:

Medical Providers Dental Providers Midwifery and Family Nurses

6 Pediatric Residents

6 Family Practice Residents

1 Family Practice Resident

3 Physician Assistants

1 Medical Assistant

10 Dental Residents

5 Dental Students

18 Nursing Students

1 Family Nurse Practitioner

Masters in Public Health

2 students

Masters in Counseling

3 students

LEGEND:

University of New Mexico

Arizona School of

Dentistry & Oral HealthVista College Western New

Mexico University

New Mexico State University

Frontier School of Midwifery & Nursing

Memorial Medical Center

HB 35� Medicaid Creates Task Force

� Develop Demonstration Project

� Carve out Hidalgo County

� Pool Medicaid Patients

� Payments Support Base (Capitated / Budgeted)

� Meaningful Incentives

� Shared Risk

� Reports to Legislature 8/12

� Companion activity CMS / HRSA ?

University of New Mexico� Primary Partnership

� Community Driven University Participation

� Aligning 2020 Goals / County Report Card

� Health Commons Model Development

� Health Extension Model Origin in NM

� Independent Research and Evaluation� Publication

� Care Coordination Model Development

� Training – Recruitment – Workforce - CME

� Tele-medicine (Project ECHO)

� Contract Subspecialty Care

Charlie Alfero, CEO

530 DeMoss St.

Lordsburg, NM

575-542-8384 ext. 403

575-538-1618 (c)

Calfero@hmsnm.org

www.hmsnm.org