Payment Reform for Primary Care – Minnesota DHS efforts

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Information about Payment Reform for Primary Care – Minnesota DHS efforts

Published on October 19, 2007

Author: nashp

Source: slideshare.net

Description

Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Author: Jeff Schiff

Payment Reform for Primary Care – Minnesota DHS efforts Jeff Schiff, MD MBA Medical Director Minnesota Health Care Programs Minnesota Department of Human Services

Current payment reform efforts in Minnesota Payment for Performance Q care Diabetes and Cardiovascular goals Care Coordination Intensive Care Coordination Provider Directed Care Coordination DIAMOND – depression care in primary care

Payment for Performance

Q care Diabetes and Cardiovascular goals

Care Coordination

Intensive Care Coordination

Provider Directed Care Coordination

DIAMOND – depression care in primary care

Today Rationale History Current legislation Implementation plans and issues

Rationale

History

Current legislation

Implementation plans and issues

Primary Care Orientation 13 industrialized countries characterized on strength of primary care health system More primary care orientation associated with better early childhood outcomes – Low birth weight Post neonatal mortality Infant mortality Starfield, Health Policy 2002; 603:201-218

13 industrialized countries characterized on strength of primary care health system

More primary care orientation associated with better early childhood outcomes –

Low birth weight

Post neonatal mortality

Infant mortality

Starfield, Health Policy 2002; 603:201-218

Primary Care Orientation In the US, the number of primary care physicians per population was the only characteristic consistently related to better outcomes, including overall mortality rates, mortality rates from heart disease and cancer, neonatal mortality, life span, and low birth weight. [i] In contrast, the number of specialty physicians per population was related to worse [or no change in] outcomes in all these areas [i]Shi L. Primary care, specialty care, and life chances. Int J Health Serv. 1994; 24 :431 –458

In the US, the number of primary care physicians per population was the only characteristic consistently related to better outcomes, including overall mortality rates, mortality rates from heart disease and cancer, neonatal mortality, life span, and low birth weight. [i]

In contrast, the number of specialty physicians per population was related to worse [or no change in] outcomes in all these areas [i]Shi L. Primary care, specialty care, and life chances. Int J Health Serv. 1994; 24 :431 –458

Primary Care Reimbursement based primarily on the quantity of services delivered, rather than on quality forces primary care physicians onto a treadmill, devaluing their professional work life. The short, rushed visits with overfilled agendas that cause patients dissatisfaction simultaneously breed frustration in physicians….Public policy on primary care does not exist…A covenant is needed between those who pay for health care and those who deliver primary care: primary care must promise to improve itself, and in return, payer must invest in primary care. -Bodenheimer, NEJM 355:861-864

Reimbursement based primarily on the quantity of services delivered, rather than on quality forces primary care physicians onto a treadmill, devaluing their professional work life. The short, rushed visits with overfilled agendas that cause patients dissatisfaction simultaneously breed frustration in physicians….Public policy on primary care does not exist…A covenant is needed between those who pay for health care and those who deliver primary care: primary care must promise to improve itself, and in return, payer must invest in primary care.

-Bodenheimer, NEJM 355:861-864

Primary Care Ultimately, the payment of primary care physicians might be a blend of fee for service, monthly fees for practices serving as patient-centered medical homes, and additional bonuses for meeting quality and efficiency performance goals. Goroll, AH J Gen Internal Med referenced by K Davis NEJM 356:1167

Ultimately, the payment of primary care physicians might be a blend of fee for service, monthly fees for practices serving as patient-centered medical homes, and additional bonuses for meeting quality and efficiency performance goals.

Goroll, AH J Gen Internal Med referenced by K Davis NEJM 356:1167

Minnesota history from 2004 Medical home learning collaborative Pediatric practices 10 sites MCHB funding Improvement collaborative Parent/provider teams Measure improvement over time Triennial meetings to support practice teams

Medical home learning collaborative

Pediatric practices

10 sites

MCHB funding

Improvement collaborative

Parent/provider teams

Measure improvement over time

Triennial meetings to support practice teams

Medical home now 21 sites Over 5000 children Second grant cycle and state funding Minimal payment to practices Major study of public patients in MH underway

21 sites

Over 5000 children

Second grant cycle and state funding

Minimal payment to practices

Major study of public patients in MH underway

Breakthrough learning collaborative Teams of Pediatrician Care coordinator Parents of two families

Teams of

Pediatrician

Care coordinator

Parents of two families

Breakthrough learning collaborative 21 teams Triennial state meetings – learn about Medical home and components Change management Meet every two weeks in the intervals to plan and implement change at the practice level PDSA experts

21 teams

Triennial state meetings – learn about

Medical home and components

Change management

Meet every two weeks in the intervals to plan and implement change at the practice level

PDSA experts

Breakthrough Series (9-12 month time frame) Select Topic Planning Group Develop Framework & Changes Participants Prework Supports E-mail Visits Phone Assessments Senior Leader Reports LS 1 LS 3 LS 2 Summits, Guides, Publications, etc. A D P S A D P S

Which system is the unit of health care practice, intervention, measurement, focus? (Batalden) Self-care system Geopolitical, market system Macrosystem Mesosystem Microsystem Individual care-giver & patient system

Clinical microsystem A small group of people who work together in a defined setting on a regular basis to provide care and the individuals who receive that care. It has clinical and business aims , linked processes , a shared information environment and produces services and care which can be measured as performance outcomes . These systems evolve over time and are (often) embedded in larger systems/organizations. As any living adaptive system, the microsystem must: (1) do the work, (2) meet staff needs, (3) maintain themselves as a clinical unit. Batalden, P, at St. Thomas 9 05

A small group of people who work together in a defined setting on a regular basis to provide care and the individuals who receive that care.

It has clinical and business aims , linked processes , a shared information environment and produces services and care which can be measured as performance outcomes . These systems evolve over time and are (often) embedded in larger systems/organizations.

As any living adaptive system, the microsystem must: (1) do the work, (2) meet staff needs, (3) maintain themselves as a clinical unit.

Batalden, P, at St. Thomas 9 05

Possible implications relevant for leading health care redesign & improvement Patients and professionals will increasingly realize they are part of the same systems…and to do well, their microsystems must thrive. Clinicians and health professional educators will place new priority on experiential learning and discovery. Authority and authenticity can meet in the new, increasingly transparent and lifelong efforts to develop and form health professionals. Batalden, P, at St. Thomas 9 05

Patients and professionals will increasingly realize they are part of the same systems…and to do well, their microsystems must thrive.

Clinicians and health professional educators will place new priority on experiential learning and discovery.

Authority and authenticity can meet in the new, increasingly transparent and lifelong efforts to develop and form health professionals.

Batalden, P, at St. Thomas 9 05

Dovetails with national attention to Medical Home Requires definition More than primary care Disparity reduction

Requires definition

More than primary care

Disparity reduction

Primary Care Orientation What is Primary Care? accessibility for first-contact care for each new problem or health need, long-term person-focused care ("longitudinality"), comprehensiveness of care in the sense that care is provided for all health needs except those that are too uncommon for the primary care practitioner to maintain competence in dealing with them, and coordination of care in instances in which patients do have to go elsewhere. I ] [i] B Starfield and L Shi. The Medical Home, Access to Care, and Insurance: A Review of Evidence.” Pediatrics 113(5):1493-1498.

accessibility for first-contact care for each new problem or health need,

long-term person-focused care ("longitudinality"),

comprehensiveness of care in the sense that care is provided for all health needs except those that are too uncommon for the primary care practitioner to maintain competence in dealing with them, and

coordination of care in instances in which patients do have to go elsewhere. I ]

[i] B Starfield and L Shi. The Medical Home, Access to Care, and Insurance: A Review of Evidence.” Pediatrics 113(5):1493-1498.

What is a medical home? Primary care based care coordination Partnership with parents Linkages to community resources And…

Primary care based care coordination

Partnership with parents

Linkages to community resources

And…

And… Continuous improvement process Improved office systems to Track and monitor progress Evaluate outcomes

Continuous improvement process

Improved office systems to

Track and monitor progress

Evaluate outcomes

PDCC legislative proposal Care coordination components defined by the DHS Patients selected by DHS to benefit from care coordination Average of $50 per month payment

Care coordination components defined by the DHS

Patients selected by DHS to benefit from care coordination

Average of $50 per month payment

Model development ~ 200,000 of 670,000 clients in our Fee for service population ~106,000 disabled Calculation of 5% savings per client per year compared to similar clients (patients would have annual health care costs over $12,000) For a clinic seeing 100 patients with this level of care coordination need - $50x12monthsX100 patients= $60,000 Initial budget page based on serving 2500 patients after two years

~ 200,000 of 670,000 clients in our Fee for service population

~106,000 disabled

Calculation of 5% savings per client per year compared to similar clients (patients would have annual health care costs over $12,000)

For a clinic seeing 100 patients with this level of care coordination need - $50x12monthsX100 patients= $60,000

Initial budget page based on serving 2500 patients after two years

Legislation passed

Pick your moral hazard This model –compliance with care coordination requirements, diagnosis inflation Current system- overuse of the visit/ procedures, lack of care coordination Global primary care capitation – under use of services/ specialists referrals, primary care physician as gatekeeper Pay for performance – teach for the test

This model –compliance with care coordination requirements, diagnosis inflation

Current system- overuse of the visit/ procedures, lack of care coordination

Global primary care capitation – under use of services/ specialists referrals, primary care physician as gatekeeper

Pay for performance – teach for the test

Implementation challenges Defining clinics capable of providing PDCC Defining client pool Stratifying payment rates Evaluation of outcomes

Defining clinics capable of providing PDCC

Defining client pool

Stratifying payment rates

Evaluation of outcomes

Defining clinics Creating care coordination criteria beyond a payment for primary care Examples: Care plan components and distribution Dedicated care coordinator time and access Community fair process Different service than waiver case management, county case management, etc.

Creating care coordination criteria beyond a payment for primary care

Examples:

Care plan components and distribution

Dedicated care coordinator time and access

Community fair process

Different service than waiver case management, county case management, etc.

Where does care coordination live? Provider Provider Directed Care Coordination Community based Case management Negotiated coordination

Community Fair Process – current work PDCC steering committee PDCC interest group PDCC criteria workgroup

PDCC steering committee

PDCC interest group

PDCC criteria workgroup

PDCC clinic criteria workgroup Positions defined by steering committee/ department Facilitated discussion Create specific criteria for care coordination to objectively verify clinics Report out and receive input from the interest group Ultimate decision rests with Commissioner

Positions defined by steering committee/ department

Facilitated discussion

Create specific criteria for care coordination to objectively verify clinics

Report out and receive input from the interest group

Ultimate decision rests with Commissioner

Workgroup membership Providers Patients and advocates Health systems Plans Disability and Mental health sections Tight, but representative group

Providers

Patients and advocates

Health systems

Plans

Disability and Mental health sections

Tight, but representative group

Patient selection Initial cohort- patients with high use of avoidable costs Future efforts Risk adjusted predictive modeling stratification around $50 average Avoidance of penalization for utilization improvement Patient selection for likelihood of impact

Initial cohort- patients with high use of avoidable costs

Future efforts

Risk adjusted predictive modeling stratification around $50 average

Avoidance of penalization for utilization improvement

Patient selection for likelihood of impact

Evaluation Quality goals (Q care) Patient engagement Service utilization

Quality goals (Q care)

Patient engagement

Service utilization

Additional tools and products CAPS grant – MTG I ICC predictive modeling group Value Exchange- MN HIVE (Health Information Value Exchange) DIAMOND

CAPS grant – MTG I

ICC predictive modeling group

Value Exchange- MN HIVE (Health Information Value Exchange)

DIAMOND

Medicaid Transformation Grant Communication and Accountability for Primary Care Systems Two way communication tool between the DHS and providers Submit care plan information- criteria to be determined and prioritized on advise from PDCC/ CAPS workgroup Receive claims based patient information Submit care coordination claims Augmented prior authorization Begin to track clinical information across the FFS system (Value exchange)

Communication and Accountability for Primary Care Systems

Two way communication tool between the DHS and providers

Submit care plan information- criteria to be determined and prioritized on advise from PDCC/ CAPS workgroup

Receive claims based patient information

Submit care coordination claims

Augmented prior authorization

Begin to track clinical information across the FFS system (Value exchange)

ICC predictive modeling Intensive care coordination pilot care model Patient selection based on CDPS and ACG and additional components Care delivery via disability service provider Incrementally increase ability to stratify care coordination payment by patient complexity Improve evaluation of care coordination based on stratified measures

Intensive care coordination pilot care model

Patient selection based on CDPS and ACG and additional components

Care delivery via disability service provider

Incrementally increase ability to stratify care coordination payment by patient complexity

Improve evaluation of care coordination based on stratified measures

MN HIVE – Minnesota’s development of a value exchange Medicaid Transformation Grant II cycle Support the four cornerstones in Minnesota Community wide health information exchange Community quality metrics – Minnesota Community Measurement/ Stratis/ ICSI

Medicaid Transformation Grant II cycle

Support the four cornerstones in Minnesota

Community wide health information exchange

Community quality metrics – Minnesota Community Measurement/ Stratis/ ICSI

DIAMOND project ICSI lead Differential care coordination payment for primary care based depression care Based on IMPACT model of defined care coordination, screening, treatment, and referral Community wide effort including plans, providers, purchasers

ICSI lead

Differential care coordination payment for primary care based depression care

Based on IMPACT model of defined care coordination, screening, treatment, and referral

Community wide effort including plans, providers, purchasers

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