Health Care Homes Community Meeting - December 12, 2008
Transcript
“Welcome”
Commissioner of Health Dr. Sanne Magnan
Minnesota Department of Health
Thank you Carol. And welcome to everyone who’s come out on this cold Minnesota morning to join us to listen and to engage with us in thinking about “health care homes.” For background I just want to put it in perspective that health care homes is part of the 2008 health care reform legislation. You’re here also today about how health care homes was in 2007 legislation also. For with the legislation that was passed in 2008 it was a comprehensive, beginning comprehensive, I should say, approach to what we’re going to need for health care reform.
As Senator Berglin likes to say, “We are paving a road.” And we’ve paved part of the road and we are going to need more to pave in the future and I say that the destination is quality, affordable, accessible health care for all Minnesotans. So what we passed in 2008 first started with an investment in public health. …An investment in working on a statewide health improvement program that addresses tobacco and obesity. So we said let’s get upstream from health care and do some investment in prevention to help people stay healthy so they won’t need as much health care.
Then there is work in the legislation around transparency; visibility of quality, and cost issues. There’s some payment reform in there with quality incentive programs with looking at care coordination payments for health care homes; redesign of care; looking at some insurance informs and access. And then to move us further into the 21st century is some legislation about e-prescribing for all providers by 2011. So as you can see in that list, there are a number of things that are being done to get us towards quality, affordable, accessible health care. So there’s not one silver bullet here. There’s a package of things.
And health care homes is part in that package.
Now, notice I’m talking about and will use words of evolution, part, package, starting down the road, as part of what I am discussing. So even today as I speak, things will be continuing to change about health care homes and what we are doing in the legislation and in redesign. But in fact, if you don’t see it in that way, then we’re probably not pushing far enough, and trying to do things really differently.
When the legislation was passed, it was envisioned that there was going to be a commission that would be designated, would be developed to enact all of this legislation, but Governor Pawlenty said, you know, “We don’t need more bureaucracy. We don’t need more administrative functions, and so the focus or the implementation of the legislation was assigned to the Commissioners of Health and Human Services. So Cal Ludeman sends his regards today, but he wanted me to share with you some draft principles, not draft, principles we drafted, around the legislation.
And we do have a Web site out there on the MDH Web site/health care reform that you can go out and see these principles, so don’t feel like you have to take them all down, but let me share them with you.
The first principle is that the purpose of health reform legislation is to improve the health of all Minnesotans and to redesign care to improve value ...with value being very simplistically right now, quality over cost. Now there’s a corollary to this principal that Commissioner Ludeman said that the success of health care reform is not when the first care coordination payment goes out the door. …That success is really when we’ve improved health, and we’ve redesigned care to improve value.
The second principle is “We must start with the end in mind.” So we need to always be focusing on what are we trying to accomplish, and what will success look like? And you’ll hear that later as I talk about outcomes. And how will we know when we’ve been successful with health care reform?
The third principle is to ensure that all Minnesotans benefit from the reforms: We should be aiming for market-wide implementation of health care reform processes. These are not just government processes, or for people who are on Minnesota Care or Medicaid. This is being planned to be redesign that goes throughout the entire state.
The fourth principal is that we will seek and expect unprecedented collaboration in the public and private environment. That’s the only way we’re going to get to transformation of health care, and better health for Minnesotans. So those principals have been guideposts along the way as we’ve been going. Another thing that has also been a guidepost for us as we are thinking about health care homes and thinking about the health care reform is something that the Quality Institute helped us put together. …Now the Quality Institute was sponsored by Commonwealth Fund. And actually, Minnesota applied to participate in that Institute, as a backup plan, actually in case legislation had not passed. Commonwealth was binging states together to talk about health care reform. Well when our health care reform legislation did pass, we subsequently had been awarded one of the awards by Commonwealth to work with other states, we decided that since the health care legislation had lots of things in it, but didn’t have overarching goals, that we would use that opportunity as we brought private people together -- public, consumers, purchasers -- together to think about, so what would overarching goals be? And from that we decided that the Triple Aim, which is often talked about throughout the country, were good overarching goals. And let me share that Triple Aim with you: First, it’s to improve the patient or consumer experience;
second, improve population health; and third, improve affordability through decreasing per capita costs. Now the triple aim says, and we agree here in the state of Minnesota, that you need to do all three simultaneously. Now some people like to work just on the health part; some people like to work on the experience, some people just like to work on the cost. In actuality to get good value we’ve got to work on all three.
And in these budget times, in these economic times, that last one about affordability is even more urgent, and more important, so that we continue to provide health care to people in Minnesota and actually expand our reach to all Minnesotans.
So, we have legislation, we have principles, we have some overarching goals. So what about health care homes? Well, first off notice that I didn’t call them “medical homes.”
Now that’s a commonly used term. If I had my druthers I’d actually have called them “health homes.”
I think “medical homes” puts the emphasis on medical models; puts the emphasis on doctors in people’s mindset; puts the emphasis on illness. And actually, health care homes is trying to be upstream from that. And to actually get the emphasis on health, the emphasis on the patient; and their thoughts and their views and their approach to how they want to stay healthy.
So I am not also going to give you a definition of what a health care home is, because that is evolving. And so, If you think, you know, or there are lots of people who want to say, “Here’s exactly what it is,” that’s going to be the wrong approach in Minnesota, Because we have got to evolve, look at what we are doing, measure, listen, talk to consumers, talk to our purchasers, talk to people who the health care system is there to serve, and figure out how to do it better, and continuously have it evolving with the focus on outcome.
So think about …what you are going to hear about what happened in the 2007 legislation about health care homes and what ‘s been happening with that. Think about that as a phase. Phase one. Think about this as the next phase of what health care homes will be. But it should not be the same thing two years from now, or three years from now. We have to continue to evolve. That’s just a principle of quality improvement and how you make something better.
So what you’ll hear today should in some sense have “draft” typed all over it. Because it’s going to evolve as we go on, but today is another way to kind of tell you what people are thinking and where things are, and to elicit your input …to elicit your involvement, and to continue to do this in a transparent and open way.
Now I know, being a healthcare person myself, and a physician, we don’t necessarily like messy stuff like that. But I can tell you, if you’re not feeling uncomfortable with where health care is right now …it’s as Eleanor Roosevelt said, “If you’re not confused, you’re not thinking clearly.”
I mean, this is very trying times. We have the most expensive health care system in the world. And in developed countries, have the worst infant mortality. So we have created a system that’s not working, and that’s just one example and I’m sure you could give many more examples of how the system is not working.
Now, some of what’s going to make you uncomfortable is the aggressive timelines. And for those of you who have complained about that, and Senator Berglin has heard about that, she has said, “You can change the timelines. You can move them up.” She’s sitting there looking at being able to provide care for all Minnesotans, and as cost goes up, access goes down. And she sees poor value being delivered. She’s concerned about it.
So she actually said at a conference …I was with her this week, that, and I’ll find my quote here from her, that she’s believed that what we should be doing now is focusing on implementation. …That the payment reforms that were put in place in legislation must change how care is delivered. So if you are sitting there thinking, “I am already doing a health care home. Just give me the money,” that’s not how Senator Berglin is thinking about it. And she said, “We must get more benefit out of paying differently.” We must get more benefit.
So the aggressive timelines mean, that we’re looking at outcomes for health care homes; capacity assessment for health care homes; skills that are needed for health care homes; criteria that are needed. Normally, you would have done that in some sequential linear fashion. We’re doing it simultaneously. So that can make some of us feel uncomfortable. It’s going to make some of you feel uncomfortable. But in order to get this redesign going, to actually be able to do the kind of work to improve value, we need to be doing these things all at the same time. And that’s why it’s even more important that we are being open about what’s happening, getting input. And as we continue to get that input, it will become clearer what we need to do for the first phase.
Now we must keep an eye on the Triple Aim as I said earlier to define how we will know success. And then we have to build toward that success. One of the key elements that
I didn’t even mention that we’re going to need to decide is what patients will qualify for the care coordination payments. But I would say to you that this redesign that is
being thinked (thought) about in health care homes should apply to the whole system and to all patients.
There are some who will get care coordination payments, but this redesign for value given the current crisis in our system needs to be for all patients in how we think about it, period.
We must measure success. I believe success will breed some success, but failure will also teach us success. I am often reminded of that quote, “Good judgment comes from experience, and experience comes from bad judgment.” So we are going to have to have enough models being tested that there’ll be success in some cases, there’ll be failure in some cases, but the patient needs to stay at the center, and what’s best for them, not what success looks like for us as the health care industry, but what looks like success for patients. And how can we learn to change care to make it better for them, and so we can afford to give that care for them.
Two examples I’ll give you that I just heard that were encouraging to me, about thinking about health care homes and the health care reform.
First was the health care system that’s building a different clinic. And their clinic is going to have one doctor, multiple nurse practitioners, and multiple coaches for their patients. I thought, that’s a remarkable way to be thinking about it, and then when I heard what they were going to do about measurement, cause they’re actually at the top of the game in Minnesota in working on a chronic disease, and actually have been leading the way in getting outcomes. And what they said is, they’re not resting on their laurels, one of the things sometimes we’re guilty of in Minnesota is resting on our laurels. They are not.
They are saying how can we take care of patients to a different level, and getting very patient-centered. So their next measures of success is going to be, does the patient have the knowledge that they need? Second one …how self-confident is the patient in managing their disease and managing their health? Now self-confidence as you know from tobacco work, that that’s probably one of the best predictors of whether someone can quit smoking is how self-confident, or what their self-efficacy is.
So this health care system is going to measure knowledge that patients have. Do they have the knowledge that they need? Do they have the self-confidence they need to manage their own health? And third, do they have goals that they have set about their own health and have the coaching to actually meet those goals.
So that’s a very exciting development of saying how can we take what we’ve done in Minnesota and go even further. And the whole concept of being patient-centered. They had patients on the design teams to redesign the clinic. So really looking at what will work for patients.
The second one that I heard is that we need to design in different ways. We need to think in different ways. And it was advanced practice nurse who said she had just seen a patient in clinic and the patient had depressed mood. And they talked about a number of things, and what would work and what would help her, and I think there was psychotherapy going on through that conversation, she said “I thought about putting the person on a medication, but was worried about the side effects and whether the person might fall from the medication, and the patient and I decided that the goals” …cause she said music was therapeutic for her. “that music was therapeutic for her.” …That the goal for her would be for her to play her piano twice a week. That was the prescription that the nurse gave her.
I sat there and thought, as a doctor, “Would I have ever gotten there?” Would I have ever gotten to that kind of prescription for that patient? I don’t know that I would have in my medical model. But that’s the kind of patient-centered thinking that we need within health care homes, and we need within the health care system period. Now as we create these outcomes, we need to create enough outcomes that leads to flexibility. That nurse, advanced practice nurse, or me as a doctor would have to know, does that person’s PHQ-9 actually get better, as a measure of depression? Do they actually get less depressed, as they played the piano, or in medication if I might have given them? Which one is actually getting the outcome that we need? So we’re going to need to focus on the outcomes, but have enough flexibility, and whatever criteria is set, or how we redesign care, enough flexibility for innovation.
That’s what this is really about is creating an environment where people in Minnesota can innovate to get better value. And health care homes is one of those vehicles to think about how can we focus on outcomes of what needs to occur; and then how can we innovate underneath with all the health care professionals we have and a team approach to get a better outcome. So today you’re going to hear a number of people speak and hopefully that will be helpful to you as we think about where we are and where we are going together. Dr. Schiff is going to talk about health care homes kind of in a deeper sense than I have, Carolyn Allshouse is going to talk about the first phase of health care homes and the work that was done in 2007 in Minnesota, and work that laid the foundation for the 2008 legislation and what has happened with their work that began with special needs kids. And then Marie Maes-Voreis will talk about some next steps in the process here as we continue along this journey, and evolving towards the destination of quality, affordable, accessible health care for all Minnesotans.
You know the times are really critical here, particularly with our economic crisis and budget crisis and things that make it troubling to many of us as we look towards the future. And yet as I saw a senator yesterday and he was echoing some of those same responses or same thoughts, he said, “You know, I believe that out of these crises and out of these troubling times come opportunity.” And he said, “That’s the only thing that can allow me to get up in the morning, and keep going.” And I truly believe that too. And I think the development of the health care reform legislation and the development of health care homes are opportunities for us, and opportunities to head towards quality, affordable, accessible health care for all Minnesotans. It’s your innovative ideas, it’s your commitment, your redesign, your being some of those examples I just shared with you that will help us get to a different place here in Minnesota, and continue to be one of the healthiest states in the nation. So thank you for coming and giving of your time and expertise today.
