Minnesota’s Vision: Health Care Homes (aka Patient-Centered Medical Homes)  State Name: “Minnesota” comes from Dakota Indian words meaning “sky-tinted waters,” or “sky-blue waters.” Often nicknamed “land of 10,000 lakes.”  Statehood: Minnesota became a state in 1858 and was the 32nd state in the union.  Size: 12th largest state in the United States.

Minnesota Starts from a Good Place: Health Care Delivery  Ranked as one of the top 2 or 3 healthiest states  History of collaboration and innovation in the health care delivery system Largely non-profit environment High concentration of large, integrated, multi- specialty group medical practices in urban and rural practices Institute for Clinical Systems Improvement (ICSI) Minnesota Community Measurement Active large purchasers

Minnesota Starts from a Good Place: Payers  Among the nation’s lowest uninsurance rates  Strong employer base  Significant presence of local health plans  Health plans are required to be non-profit to participate in Medicaid managed care, contracts with public employee insurance programs or workers’ compensation.  MN has MinnesotaCare a subsidized insurance program (since 1992, pre-SCHIP)

Minnesota Starts from a Good Place: Primary Care MN HCH Capacity Assessment: 707 primary care clinics

Minnesota Still Faces Challenges  Rising health care costs in the state are unsustainable.  Our health care system creates poor value and has misaligned incentives.  Private insurance continues to erode, and the number of uninsured is rising.  Health care quality is low relative to the amount spent, and unevenly distributed across the population.  The way we pay for health care services leads to distortions in the types of health care that gets delivered.

Cumulative Health Care Cost Growth vs. Other Economic Indicators Note: Health care cost is MN privately insured spending on health care services per person, and does not include enrollee out of pocket spending for deductibles, copayments/coinsurance, and services not covered by insurance. Sources: Minnesota Department of Health, Health Economics Program; U.S. Department of Commerce, Bureau of Economic Analysis; U.S. Bureau of Labor Statistics, Minnesota Department of Employment and Economic Development

2008 Health Reform Law: Minnesota’s Vision

Framework for Minnesota’s Vision: IHI’s Triple Aim  Improve population health  Improve the patient/consumer experience  Improve the affordability of health care

Care Delivery & Payment Redesign: A Great Health Care Home… Is satisfying for patients, families, providers and clinic staff!

Two Foundational Pieces of Legislation  2007: First “medical home” legislation. Provider Directed Care Coordination for patients with complex illness in the Medicaid FFS population (now Primary Care Coordination, or PCC)  2008: Health care reform legislation requires health care homes (HCH) for all Medicaid / SCHIP / state employees / privately insured in Minnesota

Primary Care Coordination: PCC Health Care Homes: HCH  Both programs promote care coordination and focus on achievement of outcomes. –PCC: focuses on most chronically ill fee-for- service Medicaid patients –HCH: focuses on all patients who have or are at risk of chronic or complex conditions, can benefit from the services of a HCH and are interested in participation  Both have new payment options for per- person care coordination

2008 HCH Legislation… the standards developed by the commissioners must meet the following criteria:  use of primary care  focus on high-quality, efficient, and effective health care services  use of health information technology and systematic follow-up, including the use of patient registries  provide consistent, ongoing contact with a personal clinician or team of clinical professionals  ensure appropriate comprehensive care plans for their patients with complex or chronic conditions  measure quality, resource use, cost of care, and patient experience;  use of scientifically based health care, patient decision-making aids  encourage patient-centered care

Care Coordination Payments: Legislative Requirements  DHS / MDH develop a system of per-person care coordination payments to certified HCHs by 1/1/2010, MN [256B.073] and MN [62U.03]  Health plans include HCHs in their provider networks by 1/1/2010  Fees vary by thresholds of patient complexity  Development considers the feasibility of including non-medical complexity information.  Payment conditions and terms for health plans shall be developed “in a manner that is consistent with” the system for public enrollees.  Health Plans and DHS make care coordination payments by 7/1/2010

Care Coordination Payments: The Goal of Critical Mass Included (~40% of Minnesotans): Medicaid/State-funded Public Programs (11%) State Employees Fully-Insured Private Insurance (small employer groups and individual policies) (28%) Not Included (~60% of Minnesotans): Medicare (14%) Self-Insured Private Insurance (large employer groups) (40%) Uninsured (7%)

Health Care Homes: Program Development Tasks  Identification of outcomes  Criteria for participation  Verification process  Common payment methodology  Incorporation of collaborative learning  Measurement of results  Community-wide communication

Health Care Homes: Standards and Criteria  facilitates consistent and ongoing communication among the HCH and the patient and family, and provides the patient with continuous access to the patient’s HCH;  uses an electronic, searchable patient registry that enables the HCH to manage health care services, provide appropriate follow-up and identify gaps in patient care;  includes care coordination that focuses on patient and family-centered care;  includes a care plan for selected patients with a chronic or complex condition, involve the patient and, if appropriate, the patient’s family in the care planning process; and  reflects continuous improvement in the quality of the patient’s experience, the patient’s health outcomes, and the cost-effectiveness of services.

What Makes Minnesota’s Vision for Health Care Homes Unique?  Statewide approach, public / private partnership  Rule with HCH standards for certification, with an onsite verification process.  Development of a payment methodology, per-person care coordination payment  Integration of community partnerships with the HCH  Outcomes measurement with accountability  Required participation in a state-sponsored HCH learning collaborative  Statewide health information technology plan in place  Integration of patient and family centered care concepts

Who Can Apply for HCH Certification? An eligible provider is a physician, nurse practitioner or physician assistant that works as part of a team that takes responsibility for the patient’s care and provides the full range of primary care services including:  first point of contact acute care  preventive care  chronic care Providers are certified. A clinic is certified when all the clinic’s providers meet the requirements for certification.

Certification as HCH is Voluntary  Certification requirements are met at certification  Recertification at the end of year one and annually thereafter  A variance may be granted for good cause or when failure to grant a variance would result in hardship

Health Care Homes: Certification and Measurement

Outcomes Measurement Requirements  HCHs must submit data to the statewide measurement reporting system  Outcomes measures are based on the clinic’s total population  The commissioner announces annually: –HCH outcome measures –Benchmarks to determine whether a HCH has demonstrated sufficient progress  These are determined through a community work group process.

Challenges: Clinic Readiness to Begin HCH Implementation?  Two studies over the past few months: – 72% and 83% of primary care clinics self- identified they are working on health care home and they plan to seek certification. N = 375 / 400  In one study 15% of clinics replied that they did not know about the certification.  Do clinics really understand the transformation required?

Challenges: Consumer Gaps in Understanding HCH Concepts  Only 50% of patients agreed or strongly agreed that they understood the meaning of Health Care Home N=688 consumers, MDH HCH Capacity Assessment Report

Challenges: Payment Methodology for Care Coordination Payments  Is the per person care coordination fee the right billing model?  Can we design a billing process for types of payers?  What about cost neutrality for clinics, payers and patients?  Skepticism: Will HCH control costs?  The critical mass challenge?

Challenges: Certification  Are the standards too hard to achieve?  Are the standards rigorous enough for transformation and improvements in “triple aim” outcomes?  Will payers and clinics have confidence in the statewide certification process?  How many clinics will seek certification. Is it manageable?  How will annual recertification look like as it is tied to outcomes?

Minnesota’s Vision for Health Care Homes: Opportunities and Challenges  Transformational change in care delivery Changes in clinic / community infrastructure and culture Creation of a patient- and family- centered health care system  Measurement must evaluate all three goals of the IHI Triple Aim and evaluate progress  Payment must blend payments for services and coordination of care This is just one example of what having a “ Medical Home” has done for Amanda and us as a Family!!” Marion (Amanda’s mom)

Minnesota’s Vision: Health Care Homes Marie Maes-Voreis RN, MA Health Care Homes, Program Manger