Advancing Health Care Reform in Maine: Why, What, & How? Aging Advocacy Summit November 2012 Lisa M. Letourneau MD, MPH

Objectives Identify factors contributing to the urgent case for transforming US health care system Introduce key components of Maine’s emerging model for change – Patient Centered Medical Home (PCMH) – Community Care Teams (CCTs) – Accountable Care Organizations (ACOs) Describe the role of consumers in supporting, driving this change 2

3 : Who We Are Independent, multi-stakeholder alliance in Maine working to transform health and healthcare by leading, collaborating, and aligning improvement efforts Only organization working to improve quality of care for all Maine people Members include consumers, doctors, nurses, hospitals, health systems, payers, employers, government, policy makers, and others working to improve health and healthcare

4 : What We Do Align health care quality improvement efforts Engage consumers meaningfully in improving health and health care Establish sustainable system of quality improvement support for providers Improve integration of behavioral and physical healthcare

: Major Programs Aligning Forces for Quality Maine Patient Centered Medical Home Pilot Improving Behavioral Health Integration Transforming Care at the Bedside QC Learning Community QC Annual Conference (“Best Practice College”) 5 5

A Compelling Case for Action 6

Healthy, productive, connected people & families …receiving healthcare from a highly functioning “accountable care organization ” Vision for a Transformed Health Care System … supported by a robust & well-supported system of primary care providers

What We Want from Our Health Care Relationship with our providers that crosses settings, time, & place Caring, compassionate interactions Coordination & integration of care across providers Ability to access care 24/7 – when & where we need it Time, time, time… 8

But What Do We Get? The 15 minute visit! 9

The Result: The Current Medical Home

Why? Follow the Money! What we want: Relationship, time with our providers Caring, compassionate interactions Coordination & integration of care Ability to access care 24/7 What we pay for: Visits Tests Procedures 11

The Stalemate That Blocks Change Providers unable to transform practice without viable & sustainable payment for desired services Employers & payers unwilling to pay for desired services unless providers demonstrate value AND show potential to save money BUTBUT 12

A Recipe for Change? Consumer Engagement Transparent Cost & Quality Data Help for Providers to Change Care Systems Alternative Payment Models that Reward Value (vs. Volume) Community Leadership for Change 13

Community Leadership for Change Maine Quality Counts DHA’s Maine Quality Forum Maine Health Management Coalition 14 MaineCare

The Medical Home & ACOs: Models for Change! Providers change practice, create value with viable & sustainable payment for desired services = Delivery System Change Employers & payers pay for desired services if providers can demonstrate value AND reduce spending = Payment Reform ANDAND 15

Defining Medical Home “A medical home is not a building, house, or hospital, but rather an approach to providing comprehensive primary care. A medical home is defined as primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective.” American Academy Pediatrics 16

Maine PCMH Pilot Practices 17

Maine PCMH Pilot “Core Expectations” for Practices 1.Demonstrated physician leadership for improvement 2.Team-based approach 3.Population risk-stratification and management 4.Practice-integrated care management 5.Same-day access to care 6.Behavioral-physical health integration 7.Inclusion of patients & families 8.Connection to community / local HMP 9.Commitment to reducing avoidable spending & waste 10.Integration of health IT 18

Community Care Teams Multi-disciplinary, community-based, practice- integrated care teams Build on successful models (NC, VT, NJ) Support patients & practices in Pilot sites, help most high-needs patients overcome barriers – esp. social needs - to care, improve outcomes Key element of cost-reduction strategy, targeting high-needs, high-cost patients to reduce avoidable costs (ED use, admits) 19

PCMH Practice High-need Individual Maine PCMH Pilot Community Care Teams Transportation Workplace Environment Food Systems Shopping Income Heat Faith Community Literacy Coaching Physical Therapy Hospital Services Specialists Outpatient Services Med Mgt Housing Care Mgt Behav. Health & Sub Abuse Family Schools 20

Maine’s Medical Home Movement ~ 540 Maine Primary Care Practices 26 Maine PCMH Pilot Practices 50 Pilot Phase 2 Practices 14 FQHCs CMS APC Demo 100+ NCQA PCMH Recognized Practices ~130+ MaineCare HH Practices? Payers: Medicare Medicaid Commercial (Anthem, Aetna, HPHC) Self-insured employers Payer: Medicare Payer: Medicaid 21

So…What About ACOs? “Accountable Care Organizations (ACOs) will constitute groups of providers - physicians, other clinicians, hospitals or other providers - that together provide care and share accountability for the cost and quality of care for a population of patients” T. Lake et al, “Lessons from the Field: Making Accountable Care Organizations Real “, NIHCR Research Brief, Jan

PCMH: Hub of Wider Delivery & Payment Reform Models (ACOs!) Patient Centered Medical Home Primary Care Providers Employers Hospitals/ Hospitalists/ Care Managers Home Health Nursing Homes Specialists Health Mane Parterships Home CarePharmaciesPayers 23 ACO

ACOs in Maine – What’s Happening? Employer-Provider ACO Pilots – Maine Health Management Coalition leadership – MaineGeneral-SEHC, EMMC, other pilots Medicare – multiple ACO options – Pioneer ACO – EMHS – Shared Savings programs – MH, CMMC, MePCA Medicaid: Value-Based Purchasing strategy – Seeking “Accountable Communities” proposals 24

Engaging Consumers, Partnering with Patients Untapped “force” for improving health care Need to shift from provider-centered to patient-centered approaches (think banking!) Need patients to better understand their role – To improve their health, and – To change health care system Changing patient role requires changing culture of US health care 25

26 Patient Engagement What We Say: We want patients to take active role in making decisions about their health We want patients to ask questions We want patients to express values & preferences What We know: Patients – even well educated, are reluctant to ask questions Patients are fearful of challenging provider recommendations Many patients feel physicians are authoritarian (vs. “authoritative”)

27 “Better Health. Better ME!” Consumer Engagement Campaign Take Charge of Your Health: Step ONE: VISIT your Primary Care Provider Step TWO: ASK Questions Step THREE: KNOW your numbers Step FOUR: FIND and use community resources and programs to support health 27

28 Partnering for Improvement 28

Physician-led effort to identify opportunities to improve care and decrease use of wasteful services Have created lists: “5 Things Physicians & Patients Should Question” Appeals to professionalism Promotes partnership with patients Have engaged multiple specialty physician groups ABIM “Choosing Wisely” Campaign 29

Patient Tools 30

Consumer Reports “Best Buy Drugs ” 31

32 Managed Care All Over Again? ‘Old-School’ Managed Care Focus on reducing costs Global capitation PCP at full financial risk PCP as gatekeeper Very limited information and tools vs. PCMH + ACOs Focus on demonstrating value New care management fees (plus performance payments?) Limited financial risk to PCP Primary care team coordinates care & supports patient needs across “med neighborhood” Improved information and tools (EMR, registries) 32

Change is Hard 33 Hard to repair the plane in flight Hard to practice while practicing! People fear change (loss) - any change

QC 2013 – Save the Date! Aligning Maine’s Forces To Achieve the Triple Aim of Improvement Wed, Apr 3, 2013 Augusta Civic Center Dr. Donald Berwick Join us! 34

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Contact Info / Questions  Lisa Letourneau MD, MPH  Maine Quality Counts  Maine PCMH Pilot (See “Programs”  PCMH) 36