Title Title Page Content Health System Innovation and Reform in Montana: Insights from MHCF’s first year in the field Montana Healthcare Forum December 3, 2015 Aaron Wernham, MD, MS CEO, Montana Healthcare Foundation

Title Title Page Content Montana Healthcare Foundation Strategic investments to improve the health of all Montanans Formed in 2013 through the sale of Blue Cross and Blue Shield of MT, pursuant to Montana’s health care conversion law Largest health-focused foundation in Montana (started with $40m, now up to $100m) Permanent—planned expenditures of ~5%/year Grants, research, professional expertise, convening discussions, strategic resources Learn more at:

Title Title Page Content Montana Healthcare Foundation Timeline 2013-early 2014: Board formed; CEO hired Oct, 2014 First grant in 2014: supporting county and tribal public health— community health assessments, strategic planning, board of health training, collaboration with critical access hospitals, and health improvement initiatives. Strategic planning, research, and partnership development in First open Call for Proposals in 2015

Title Title Page Content Developing a strategic plan Data analysis: State health improvement plan DPHHS epidemiology reports Vital statistics BRFSS Stakeholder meetings: County, state, and tribal health officials Elected officials Providers: hospitals, MHCs, CHCs Associations (MPCA, MHA, MMA, AMPHO, etc) Review similar conversion foundations: Programming Strategy Staffing County health dept. Community Health Assessments Hospital Community Health Needs Assessments Non-profits: NAMI, MHA, tribal orgs, housing, community development IHS Universities, local and national subject area experts Foundations active in MT Available at:

Title Title Page Content Montana Healthcare Foundation Three broad areas of focus Behavioral health—prevalent, serious problems (both mental illness and substance use disorders); workforce shortages; delivery system fragmented and not integrated with clinical care American Indian health—health disparities; administrative capacity (coding & billing), tribal design and control of services, partnerships to address workforce and administrative issues Partnerships for Better Health—focus on value-based approaches, and on using scarce resources in rural communities more wisely through collaboration)

Title Title Page Content 2015 Call for Proposals Within the 3 focus areas, were responsive, not prescriptive: What ideas do MT-based organizations have for ways to address these broad issues? Lots, as it turns out! 154 letters of interest submitted by nonprofits, government agencies, and universities. Total $7 million requested Behavioral health—62 proposals American Indian Health—24 proposals Partnerships for Better Health—68 proposals

Title Title Page Content Montana Healthcare Foundation Funding Criteria Places and people with the greatest burden of illness & unmet need Innovations with a potential to improve outcomes and reduce costs Focus on projects with a sustainable business model: we’ll fund startup costs, not ongoing programmatic budget. (Emphasis on 3 rd party reimbursable services and shared savings approaches) Partnerships to strengthen health systems and use scarce resources more efficiently and effectively Practical, applied, Montana-focused projects Statewide focus—large and small organizations, large and small communities Learn more at:

*Some applicants listed more than one geographic region WESTERN : 54 Submitted (26%) 9 Funded (21%) NORTH CENTRAL: 24 Submitted (12%) 7 Funded (16%) NORTH EASTERN: 9 Submitted (4%) 3 Funded (7%) STATEWIDE: 45 Submitted (22%) 7 Funded (16%) SOUTH CENTRAL: 40 Submitted (19%) 10 Funded (23%) EASTERN: 34 Submitted (17%) 7 Funded (16%)

Title Title Page Content Context for the 2015 CFP: Value-based care (Change: coming soon to a health system near you…!) HELP Act: o “Provide greater value for tax dollars spent” o “Reduce healthcare costs” through, for eg, care coordination, outcome incentives for providers, reducing readmissions SIM Grant: design health system reforms to improve performance (i.e. health outcomes) and control costs Medicare: 50% alternative payment models by 2018 Montana Patient Centered Medical Home Initiative

Title Title Page Content Value-based care A couple of key challenges (among many): Integrated care—Improving outcomes for people with co- occurring mental illness, addiction, chronic illness -Mental illness is the leading cause of medical disability -50% of population will develop a mental illness -Costs of addiction and mental illness? Think beyond direct care for these problems: DUIs and trauma; Hep. C; poorly controlled chronic illnesses; behavioral health diagnoses present in high percentage of “super utilizers” Social determinants of health—Influence of income, education, housing, etc. on health outcomes

Title Title Page Content Social determinants of health: What is a health system to do?

Title Title Page Content 2015 Grantees Partnerships for Better Health 12 grants. Examples: Community paramedicine (Glacier EMS): piloting home obs, ED and hospital follow-up Promotoras (Community Health Partners): lay health education and outreach to isolated vulnerable population Rural ACO (Barrett Hospital): establish a value-based payment model in rural MT. Integrated legal services for CHC patients (MT Legal Service Corp): address unsafe housing, family violence, denial of senior benefits, and so on. Manufactured housing rehabilitation and replacement (Neighborworks MT): partnership with local hospitals to address health risks of substandard housing RSVP program (RMDC): senior volunteers to reduce hospital readmissions Neonatal Abstinence Syndrome (KRMC): Standardizing screening and care for drug-exposed newborns.

Title Title Page Content 2015 Grantees Behavioral Health 15 grants. For example: Integrated Behavioral Health (IBH) Implementation: Holy Rosary (Miles City) collab. with EMCMHC IBH planning & training: WMMHC, Beaverhead County, CMH School-based services and trauma-informed education: Intermountain (mental health and substance abuse treatment for students in Helena alternative schools); Bighorn Valley CHC (school-based clinics in St. Labre schools) Comprehensive treatment for drug use in pregnancy: St. Luke, St. Vincent Planning for a Psychiatric Residency: Billings Clinic Tele-psychiatry: North Valley Hospital

Title Title Page Content 2015 grantees American Indian Health 9 grants. For example: Improving coding, billing, revenue capture—Rocky Boy Health Board. Injury prevention program —Northern Cheyenne. Health insurance enrollment and utilization–CSKT Establishing school-based health services; trauma-informed schools— Blackfeet Recruitment, partnerships within MT, and tele-medicine—Fort Peck HP/DP Needle exchange—Fort Peck

Title Title Page Content Conclusions: Medical care is expensive, the costs are rising, and social & environmental factors can impact its effectiveness We can’t get it all done in a 15 minute office visit… Value-based approaches are new, evolving fast, and there are many unknowns MHCF provides Montana’s health system with opportunities to develop, pilot, and evaluate value-based solutions 2016 grants will be more than double what we funded in 2015— stay tuned

Title Title Page Content Thank you! Join our mailing list: Aaron Wernham, MD, MS Montana Healthcare Foundation 777 E. Main St Bozeman, MT (406)