Advancing Health Care Reform in Maine: Why, What, & How?

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

2. 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

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

5. : 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

6. A Compelling Case for Action

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

8. 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…

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

10. The Result: The Current Medical Home

11. 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 • Procedures • Procedures

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

13. A Recipe for Change?

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

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

16. 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

17. Maine PCMH Pilot Practices 17

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

19. 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

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

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

22. 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 2011 22

23. PCMH: Hub of Wider Delivery & Payment Reform Models (ACOs!) ACO

24. 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 24

25. 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

29. ABIM “Choosing Wisely” Campaign • 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 29

30. Patient Tools 30

31. Consumer Reports “Best Buy Drugs” 31

32. ‘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) Managed Care All Over Again? 32

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

34. 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

35. www.mainequalitycounts.org

36. Contact Info / Questions • Lisa Letourneau MD, MPH • LLetourneau@mainequalitycounts.org • 207.415.4043 • Maine Quality Counts • www.mainequalitycounts.org • Maine PCMH Pilot • www.mainequalitycounts.org (See “Programs”  PCMH)