Payment Reform for Primary Care – Minnesota DHS efforts

Jeff Schiff, MD MBAMedical Director

Minnesota Health Care ProgramsMinnesota Department of Human Services

Current payment reform efforts in Minnesota

• Payment for Performance– Q care Diabetes and Cardiovascular goals

• Care Coordination– Intensive Care Coordination– Provider Directed Care Coordination– DIAMOND – depression care in primary care

Today

• Rationale

• History

• Current legislation

• Implementation plans and issues

Primary Care Orientation

• 13 industrialized countries characterized on strength of primary care health system

• More primary care orientation associated with better early childhood outcomes –– Low birth weight– Post neonatal mortality– Infant mortality

Starfield, Health Policy 2002; 603:201-218

Primary Care Orientation

• In the US, the number of primary care physicians per population was the only characteristic consistently related to better outcomes, including overall mortality rates, mortality rates from heart disease and cancer, neonatal mortality, life span, and low birth weight.[i]

• In contrast, the number of specialty physicians per population was related to worse [or no change in] outcomes in all these areas[i]Shi L. Primary care, specialty care, and life chances. Int J Health Serv.1994; 24 :431 –458

Primary Care

Reimbursement based primarily on the quantity of services delivered, rather than on quality forces primary care physicians onto a treadmill, devaluing their professional work life. The short, rushed visits with overfilled agendas that cause patients dissatisfaction simultaneously breed frustration in physicians….Public policy on primary care does not exist…A covenant is needed between those who pay for health care and those who deliver primary care: primary care must promise to improve itself, and in return, payer must invest in primary care.

-Bodenheimer, NEJM 355:861-864

Primary Care

Ultimately, the payment of primary care physicians might be a blend of fee for service, monthly fees for practices serving as patient-centered medical homes, and additional bonuses for meeting quality and efficiency performance goals.

Goroll, AH J Gen Internal Med referenced by K Davis NEJM 356:1167

Minnesota history from 2004

• Medical home learning collaborative– Pediatric practices– 10 sites– MCHB funding– Improvement collaborative

• Parent/provider teams• Measure improvement over time• Triennial meetings to support practice teams

Medical home now

• 21 sites

• Over 5000 children

• Second grant cycle and state funding

• Minimal payment to practices

• Major study of public patients in MH underway

Breakthrough learning collaborative

• Teams of – Pediatrician– Care coordinator– Parents of two families

Breakthrough learning collaborative

• 21 teams

• Triennial state meetings – learn about– Medical home and components– Change management

• Meet every two weeks in the intervals to plan and implement change at the practice level

• PDSA experts

Breakthrough Series(9-12 month time frame)

Select Topic

Planning Group

Develop Framework & Changes

Participants

Prework

Supports

E-mail Visits

Phone Assessments

Senior Leader Reports

LS 1 LS 3LS 2

Summits,

Guides,

Publications,

etc.

A D

P

S

A D

P

S

Which system is the unit of health care practice, intervention, measurement, focus? (Batalden)

Geopolitical, market system

Macrosystem

Mesosystem

Microsystem

Individual care-giver & patient

system

Self-care system

Clinical microsystem

• A small group of people who work together in a defined setting on a regular basis to provide care and the individuals who receive that care.

• It has clinical and business aims, linked processes, a shared information environment and produces services and care which can be measured as performance outcomes. These systems evolve over time and are (often) embedded in larger systems/organizations.

• As any living adaptive system, the microsystem must: (1) do the work, (2) meet staff needs, (3) maintain themselves as a clinical unit.

Batalden, P, at St. Thomas 9 05

Possible implications relevant for leading health care redesign &

improvement1. Patients and professionals will increasingly realize they

are part of the same systems…and to do well, their microsystems must thrive.

2. Clinicians and health professional educators will place new priority on experiential learning and discovery.

3. Authority and authenticity can meet in the new, increasingly transparent and lifelong efforts to develop and form health professionals.

Batalden, P, at St. Thomas 9 05

Dovetails with national attention to Medical Home

• Requires definition

• More than primary care

• Disparity reduction

Primary Care Orientation What is Primary Care?

• accessibility for first-contact care for each new problem or health need,

• long-term person-focused care ("longitudinality"), • comprehensiveness of care in the sense that care is

provided for all health needs except those that are too uncommon for the primary care practitioner to maintain competence in dealing with them, and

• coordination of care in instances in which patients do have to go elsewhere. I]

[i] B Starfield and L Shi. The Medical Home, Access to Care, and Insurance: A Review of Evidence.” Pediatrics 113(5):1493-1498.

What is a medical home?

• Primary care based care coordination

• Partnership with parents

• Linkages to community resources

• And…

And…

• Continuous improvement process

• Improved office systems to– Track and monitor progress– Evaluate outcomes

PDCC legislative proposal

• Care coordination components defined by the DHS

• Patients selected by DHS to benefit from care coordination

• Average of $50 per month payment

Model development

• ~ 200,000 of 670,000 clients in our Fee for service population

• ~106,000 disabled• Calculation of 5% savings per client per year

compared to similar clients (patients would have annual health care costs over $12,000)

• For a clinic seeing 100 patients with this level of care coordination need - $50x12monthsX100 patients= $60,000

• Initial budget page based on serving 2500 patients after two years

Legislation passed

Pick your moral hazard

• This model –compliance with care coordination requirements, diagnosis inflation

• Current system- overuse of the visit/ procedures, lack of care coordination

• Global primary care capitation – under use of services/ specialists referrals, primary care physician as gatekeeper

• Pay for performance – teach for the test

Implementation challenges

• Defining clinics capable of providing PDCC

• Defining client pool

• Stratifying payment rates

• Evaluation of outcomes

Defining clinics

• Creating care coordination criteria beyond a payment for primary careExamples:

Care plan components and distribution

Dedicated care coordinator time and access

• Community fair process

• Different service than waiver case management, county case management, etc.

Where does care coordination live?

ProviderProvider Directed Care

CoordinationCommunity based Case management

Negotiated coordination

Community Fair Process – current work

• PDCC steering committee

• PDCC interest group

• PDCC criteria workgroup

PDCC clinic criteria workgroup

• Positions defined by steering committee/ department

• Facilitated discussion

• Create specific criteria for care coordination to objectively verify clinics

• Report out and receive input from the interest group

• Ultimate decision rests with Commissioner

Workgroup membership

• Providers

• Patients and advocates

• Health systems

• Plans

• Disability and Mental health sections

Tight, but representative group

Patient selection

• Initial cohort- patients with high use of avoidable costs

• Future efforts– Risk adjusted predictive modeling stratification around

$50 average– Avoidance of penalization for utilization improvement– Patient selection for likelihood of impact

Evaluation

• Quality goals (Q care)

• Patient engagement

• Service utilization

Additional tools and products

• CAPS grant – MTG I

• ICC predictive modeling group

• Value Exchange- MN HIVE (Health Information Value Exchange)

• DIAMOND

Medicaid Transformation Grant

• Communication and Accountability for Primary Care Systems– Two way communication tool between the DHS and

providers• Submit care plan information- criteria to be determined and

prioritized on advise from PDCC/ CAPS workgroup• Receive claims based patient information• Submit care coordination claims• Augmented prior authorization

– Begin to track clinical information across the FFS system (Value exchange)

ICC predictive modeling

• Intensive care coordination pilot care model• Patient selection based on CDPS and ACG and

additional components• Care delivery via disability service provider• Incrementally increase ability to stratify care

coordination payment by patient complexity• Improve evaluation of care coordination based

on stratified measures

MN HIVE – Minnesota’s development of a value exchange

• Medicaid Transformation Grant II cycle

• Support the four cornerstones in Minnesota

• Community wide health information exchange

• Community quality metrics – Minnesota Community Measurement/ Stratis/ ICSI

DIAMOND project

• ICSI lead

• Differential care coordination payment for primary care based depression care

• Based on IMPACT model of defined care coordination, screening, treatment, and referral

• Community wide effort including plans, providers, purchasers