1. The Search for Innovations to Improve Health Care Delivery for Underserved Populations UC Irvine Health Care Forecast Margaret Laws, Director, Innovations for the Underserved California HealthCare Foundation February 20, 2009

2. C ALIFORNIA H EALTH C ARE F OUNDATION Overview  CHCF and the Innovations for the Underserved Program  Strategies we’re pursuing  Examples – retail clinics, virtual visits, scope of practice in oral health  Questions and issues

3. C ALIFORNIA H EALTH C ARE F OUNDATION CHCF- Who we are and what we do  Private, non-profit foundation, in operation since 1996  Approximately $35m per year in projects and grants - almost all “strategic” rather than unsolicited grants  Three major areas of work:  Innovations for the Underserved  Better Chronic Disease Care  Market and Policy Monitor  Launched “Innovations for the Underserved” program in 2006

4. C ALIFORNIA H EALTH C ARE F OUNDATION Innovations for the Underserved Program  Encourage, test and promote lower cost models of care  Improve the availability of specialty and dental services for underserved Californians  Improve enrollment and retention in publicly- sponsored insurance programs  Increase the operational efficiency of safety net institutions

5. C ALIFORNIA H EALTH C ARE F OUNDATION  More than 20% of Californians are uninsured  Workers at private sector businesses of all sizes are experiencing an increased likelihood of being uninsured, although it is most pronounced in businesses with fewer than ten employees.  Twenty-seven percent of families with incomes between $25,000 and $50,000 are uninsured  More than a third of the uninsured have family incomes of more than $50,000 per year  Seventy percent of uninsured children are in families where the head of the household has a year round, full-time job  Nearly 60% of the state's uninsured are Latino “Underserved” is a growing category… Source: CHCF Uninsured Snapshot, 2008: http://www.chcf.org/documents/insurance/UninsuredSnapshot08.pdf: http://www.chcf.org/documents/insurance/UninsuredSnapshot08.pdf

6. C ALIFORNIA H EALTH C ARE F OUNDATION Options for low income people seeking care  No great options for people in the “affordability gap” between public coverage and commercial insurance  FQHCs hit top of sliding scale at 200% of FPL  Commercial insurance for a family of four represents 80- 100% of minimum wage earnings  Well-documented problems with access among those with insurance  Don’t have a PCP  Can’t get in to see their PCP  Can’t afford the co-pays and deductibles

7. C ALIFORNIA H EALTH C ARE F OUNDATION What types of innovation can lower cost or provide better value to underserved consumers?  Strategies we’re pursuing  Stimulate development of service delivery models that offer quality care at lower cost  Promote adoption of services for the underserved that meet their health care needs with better value propositions  Promote regulation and reimbursement that encourage delivery of quality care by more cost-effective providers  Examples of areas of work to date  Retail or express clinics  Use of kiosks for basic acute care  Telehealth and “virtual visits”  “Fuel efficient” providers  Exploring scope of practice changes in oral health

8. C ALIFORNIA H EALTH C ARE F OUNDATION E XAMPLE 1: RETAIL CLINICS

9. C ALIFORNIA H EALTH C ARE F OUNDATION CHCF work on retail clinics  Two landscape reports: 2006 and 2007  Health Affairs partnership – issue on innovative care delivery models  Roundtable on retail clinics and primary care  NASHP report on regulation of retail clinics across the states  “Retail Clinic Toolkit” for safety net providers  Exploration of retail dental clinic model

10. C ALIFORNIA H EALTH C ARE F OUNDATION 10 Retail clinics in grocery, drug and mass merchandise stores

11. C ALIFORNIA H EALTH C ARE F OUNDATION Who is operating retail-based clinics? Retailer-Owned Operators  Retailers purchased clinics to have control over the brand and the rollout  See the clinics as core to their business expansion across the whole pharmacy value chain  70-75% of all clinic sites Independent “Pure Play” Operators  Largely owned by investors  Creating business to sell or operate at a profit  Some work with hospitals (or others) and create co-branded or joint venture clinics  8-10% of all clinic sites HealthCare System-Owned Operators  15-20% of all clinic sites

12. C ALIFORNIA H EALTH C ARE F OUNDATION Seven conditions account for 75-90% of retail clinic visits These visits make up ~17% of PCP visits or ~80m visits (and ~15-30% of ED visits) 12 Sinusitis URI Pharyngitis Otitis Media/Externa Bronchitis UTI Immunization Current retail clinic visits are for a limited number of conditions

13. C ALIFORNIA H EALTH C ARE F OUNDATION Number of clinics ~1100 December 2008 13 Clinics continue to open at a rapid pace around the country Forecast

14. C ALIFORNIA H EALTH C ARE F OUNDATION WSJ/Harris Poll Results – who’s using retail clinics, and for what? Surveyed 4937 U.S. adults – seven percent had visited a retail clinic 40 percent visited for a vaccination, 39 percent wanted treatment for common conditions like ear infections or colds, Just over 20 percent wanted preventive screenings or school/sports physicals 30 percent indicated that they have no primary care provider Of those with coverage, 62 percent said that their insurer covered some or all of the cost Source: WSJ.com/Harris Interactive, 2008

15. C ALIFORNIA H EALTH C ARE F OUNDATION WSJ.com/Harris survey - satisfaction  93 percent were “very” or “somewhat” satisfied with convenience  90 percent with the quality of care,  88 percent with the staff qualifications, and  86 percent with the cost Source: WSJ.com/Harris Interactive, 2008

16. C ALIFORNIA H EALTH C ARE F OUNDATION 16 Studies documenting quality are published

17. C ALIFORNIA H EALTH C ARE F OUNDATION The central tenet behind retail clinics is their limited scope of service. By limiting scope of service to simple routine acute care, these clinics: streamline operations improve customer experience maintain quality through the use of technology and reduce costs In essence they divert the less complex patients to a streamlined operation. The clinics are not trying to serve all patients in the same way with the same level of care. 17 Community health centers can adopt retail clinic principles in their own operations

18. C ALIFORNIA H EALTH C ARE F OUNDATION Current/potential roles for retail clinics or retail clinic principles in the safety net  Basic, acute care at posted, affordable rates (for everyone, regardless of insurance status, citizenship, etc)  Potential role in coverage expansion schemes  Contractor with Medicaid agencies or managed care plans  ED diversion sites for public (and other) hospitals  Access extension sites for integrated networks or community health centers

19. C ALIFORNIA H EALTH C ARE F OUNDATION E XAMPLE 2: TELEHEALTH/VIRTUAL VISITS

20. C ALIFORNIA H EALTH C ARE F OUNDATION

21. From telehealth pilots to more widespread virtual visits…  Telehealth technologies have been in broad “pilot” testing in the commercial sector and safety net for more than a decade  CHCF sponsoring several safety net demonstrations, focused on improving access to primary, specialty and dental care  Recent launch of “California Center for Connected Health” – focus on strategy, coordination and development of new business and care models

22. C ALIFORNIA H EALTH C ARE F OUNDATION Safety net applications currently or soon to be tested  Telemedicine to improve access in clinics  Kiosk for uncomplicated UTI  Virtual practice

23. C ALIFORNIA H EALTH C ARE F OUNDATION Virtual visits go mainstream?  Dixon and Stahl, Partners/Mass General, three broad aims of the study were: oto compare the physician’s ability to make diagnoses in both settings, oto compare the physician’s ability to provide therapy in both settings, and oto examine both patient and physician satisfaction with both modalities  American Well launches virtual visit program in Hawaii Major policy/reimbursement question:  How will a “visit” be defined in the future, and how will we develop the appropriate payment incentives?

24. C ALIFORNIA H EALTH C ARE F OUNDATION E XAMPLE 3: SCOPE OF PRACTICE IN ORAL HEALTH

25. C ALIFORNIA H EALTH C ARE F OUNDATION

27. The impact of unmet dental needs in CA  In 2007, California hospitals had 80,000 Emergency Department visits per year for preventable dental conditions  In some counties, these visits were more frequent than preventable visits for asthma and diabetes

28. C ALIFORNIA H EALTH C ARE F OUNDATION Significant supply/demand mismatch: dentists and safety net patients  Dentists not practicing in rural or urban underserved markets oOnly 40% of CA dentists accept Medi-Cal oMany only work part time  Scope of practice significantly limits what “mid-level” providers can do  Other states/countries have implemented effective programs to extend access through use of hygienists or dental therapists oAlaska has had a dental therapist program for four years; therapists now being trained at University of Washington oAustralia and NZ have used dental therapists for 40 years oHolland has decided to train no more dentists, only mid- level providers

29. C ALIFORNIA H EALTH C ARE F OUNDATION The path to a new scope/care model  Is not without roadblocks…scope of practice issues are notoriously contentious  But there is significant activity in states in advancing scope of practice in oral health oSeveral models for better access at lower cost to the system being tested  CA law allows for waivers to demonstrate scope of practice innovations  “Virtual dental home” project: CHCF pursuing waiver project using dental hygienists supported by remote dentists in six sites across the state

30. C ALIFORNIA H EALTH C ARE F OUNDATION Some closing questions – two practical and one more philosophical  What will encourage regulators and providers to embrace some of the more “disruptive” innovations?  Virtual visits  Routine care delivered by mid-levels  Truly patient-centered care models or even…  Medical tourism  How do we work to create incentives for lower-cost models?  Can we let the easy, cheap stuff be easy and cheap (so that we can focus expensive resources on more complex problems)?

31. C ALIFORNIA H EALTH C ARE F OUNDATION A perspective on “shopping for price in medical care” “ When services are less complex, shopping will be more effective because consumers have a better idea of what they are shopping for, they are less concerned about variation in clinical quality, and there may be less need to customize the information to meet a patient’s unique needs. Examples include immunizations, dental cleaning, and cholesterol tests. The current phenomenon of major investments in "mini-clinics" in department stores might reflect a bet on consumers’ willingness to emphasize price and convenience more in areas where they do not perceive much variation in clinical quality.” Source: Ginsburg, Shopping for Price in Medical Care, HA 26, no. 2 (2007)

32. C ALIFORNIA H EALTH C ARE F OUNDATION Contact Information Margaret Laws Director, Innovations for the Underserved California HealthCare Foundation mlaws@chcf.org www.chcf.org