Minnesota’s Vision: Health Care Homes ( aka Patient-Centered Medical Homes)

1. 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.

2. 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

3. 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)

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

5. 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.

6. 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

7. 2008 Health Reform Law: Minnesota’s Vision

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

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

10. 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

11. Primary Care Coordination: PCCHealth 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

12. 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

13. 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

14. 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%)

15. 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

16. 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.

17. 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

18. 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.

19. 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

20. Health Care Homes:Certification and Measurement

21. 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.

22. 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?

23. 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

24. 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?

25. 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?

26. 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 andevaluate progress Payment must blend payments for services and coordination of care Minnesota’s Vision for Health Care Homes: Opportunities and Challenges This is just one example of what having a “ Medical Home” has done for Amanda and us as a Family!!” Marion (Amanda’s mom)

27. Minnesota’s Vision: Health Care Homes Marie Maes-Voreis RN, MA Health Care Homes, Program Manger marie.maes-voreis@state.mn.us 651-201-3626 www.health.state.mn.us/healthreform/homes health.healthcarehomes@state.mn.us