Health Care Homes Community Meeting - December 12, 2008
Transcript
“Health Care Homes, Background and Legislation”
Dr. Jeff Schiff, MBA
Medical Director
Department of Human Services
I think I now know what those C-Span guys feel like. And I have to say the advantage of being on the Web is that my parents who live in Pennsylvania will be able to watch me, maybe later today, and I was to thank them for the home that I came from so I could get this done.
Before I start my slides, I just want to say some things I think dovetail with some things I think Commissioner Magnan had to say. I have to leave this meeting a little bit early because we have to deal at the Department of Human Services with the state budget. The state budget as you know isn’t very much fun right now. But I am also proud to say that I still get some clinical time in, and I actually worked in the ER last night. And two patients came in …There were a bunch, but two patients came in from other folks, wanting, or seemingly wanting, or being told that they needed high-tech diagnostic imaging. And it’s easy in the ER to not have a conversation about that; it’s actually much simpler to order a test than to not order a test. But in looking at these kids, and looking at what was wrong with them, it seemed like what they really needed was a little more time, and a little different kind of exam. And I was thinking I did really well last night because I was two for two in getting folks to not inappropriately not get a test, but appropriately not get a test. Now there’s lots of times I’ll tell you that we do these things, and there’s always reasons to, but I think that last night I thought, “Oh, this is really interesting.” And as I was coming over here today I thought, I think it’s really relevant, because one of the things that I realize now as I am both on the provider side now and on the government side, is that last night, I might have been able to buy access for somebody for a few months of care.
And I think that we have to really…one of the things I really want to challenge everyone about is, we have to really see ourselves as providers at the same time as we see ourselves as stewards of resources. I’ll often ask my colleagues who are providing care more actively, “Do you think there is waste in the system that you could find?” And almost universally they say yes.
So as I go back to the Department of Human Services today, and we have to talk about this balance between quality, cost and access, I think we all have to put ourselves in that position and think about how we steward resources.
When I was in graduate school to learn something about business, there’s this concept that comes up that in health care you can’t get improved quality, improved access and decreased costs at the same time, and that you could get great access and low quality at a high cost. But you can’t get all three of those to go in the right direction.
But I think that the contention that the Commissioner has, and that I have, is that that’s not right. That we can get all three of those to go in the right directions at the same time. And I keep on thinking about the dilemma our car manufacturers are in, or the reason why the iPod I bought five years ago is not the same product as the iPod that you can get for much less money now. Because we can if we get the right incentives in place and we get everybody moving in the same direction, improve quality for patients, and improve the cost structure and help with access.
So this whole thing with health care home is really about fundamental, transformational change in the health care system. And the last thing I want to say about that is, I want to talk about the home part of health care home. I think one of the things that’s been rather interesting as we’ve had this debate about whether “home” is the right word or not is that I’m going to suggest is that, that actually may be the right word. That one of the things that we really want, and one of the things that I think all of us feel when we’ve talked about our homes, is this palpable sense of safety, of trust, of mutual well being and of a place where we can all be together. That we’re all going in the same direction. And a couple things to say about that is that it needs to be defined by the patients, by the people who are actually receiving the services. But that sense of well-being – and that sense of trust – leads to a different conversation about health, leads to better value for our patients, leads to better health outcomes, and I think that’s where we want to go.
This whole thing about the legislation as I have learned being at the state is that legislation and its relationship to the citizens of the state is a dynamic and organic process. And what’s happened in health care home in Minnesota is the result of hard work that people have put in defining this model and to working collaboratively in Minnesota. I think what we have to be really proud of is that history, and I think what we are really challenged to do now is to keep moving that forward.
So I would like to say that our goal is not just about business and value, but about how do we combine the business and the stewardship of state resources with the quality and the compassion and all of those things that we want to get for all of our citizens in Minnesota.
So with those comments I am going to move to some more formal things about the legislation.
This is a short history of medical home in Minnesota. In the mid-90s, the MCSHN (Minnesota Children with Special Health Needs) staff at the Department of Health made a commitment to medical homes. In 2003 the medical home learning collaborative, which is the pediatric model for children’s special health care needs, started, and I am proud that some of the people who have worked so hard on that are here today and are still actively involved.
In 2005 the medical association came up with “Healthy Minnesota,” and it was the medical association that brought in a lot of folks beyond the medical association to talk about how to improve health in Minnesota, and came up with medical home as one of the key components.
In 2007 we introduced and passed what was really the first medical home legislation, which was called provider directed care coordination. Sort of to contrast it from disease management care coordination that was not involved with the providers, but I think we learned very quickly and appropriately that most patients don’t want to be directed by providers, so we changed the name, to primary care coordination.
In the summer of 2007, two groups met virtually all summer. The Governor’s Health Care Transformation Task Force, and the Legislature’s Health Care Access Commission, and they both endorsed medical home as a mechanism to improve the quality and the value of our health care system.
And then in 2008, why we’re all here, is that the health care home legislation was endorsed for virtually everyone who can be touched by the Minnesota Legislature, the Medicaid population that is our MinnesotaCare, state employees, and those who are privately insured in Minnesota. So I am going to go back to 2007 for a little bit to talk about that legislation. That was the legislation that we passed to look at primary care coordination, it was for complex patients in the Medicaid fee-for-service world.
Last year around this time we were sort of right in the middle of developing criteria for the primary care coordination, and the criteria came up with these broad categories. Access, care coordination, through dedicated care coordination staff, not necessarily a specific person, but actually the staff in a clinic that’s committed to care coordination. Electronic registry, and we could talk about the debates about electronic records, but that’s the only electronic thing we came up with. A care plan that includes care goals, addresses chronic disease, preventative disease, transitions, emergencies and end-of-life issues and assigns responsibilities for care. Ongoing monitoring of care, the real work of coordinating care, quality improvement, and learning collaborative thinks so that we actually get done what we want to get done, and that includes, most importantly I believe, including patients and families in the quality improvement cycles, and I think one of the things we have learned from experience is that including patients and families in that makes a strong and dynamic difference in the way we address our health care system. And most importantly, as we talk about a lot, is that this won’t work unless we really measure results. And we really measure results around the triple aim that Commissioner Magnan talked about.
We also wanted to say something else, and that’s that work is functionally defined, and not limited by professional role. So we are not talking about everyone expanding the scope of their license and everyone working at the top of their license. One the things that I think is a challenge and I suspect is a challenge for everyone who works in the health care system, is to think about the time you spend doing things that could be more efficiently done somewhere else. And I want to say something about that. It’s not about not having the relationships with the patients. It’s about having a team or a group of people who can work very efficiently from the cost effective point of view, but very much like a home from the trust and the relationship point of view, to work as a team to help folks actually improve their health care.
Our criteria that we developed in the 2007 legislation differs a little bit from the national models, and we’ve had a great relationship with the national folks talking about this. We put some greater emphasis on patient-centered components and quality improvement and a little less emphasis on electronic medical records that we see as perhaps more of a tool to get there, not an insignificant tool or an unimportant tool by any means, but a tool to get to health care home.
This is a little bit more now about the nuts and bolts of what we are working on for the 2007 legislation, which is really DHS legislation for a fee-for-service population, I’ll say again. And we hope it informs the conversation that’s going forward, but as Commissioner Magnan said this will be a dynamic process, and what we start off with in 2007 will probably change, as well as what we do in 2008 will evolve over time.
A couple of things: We had to figure out how to select patients. We had to say that the patients will be identified by the providers. That they are based on the medical complexity, and that we know that social complexity and functional status are important components, but are actually things that are poorly measured in the claim stream that we have available to us. And I want to talk about this without getting into too much detail, but to say that when we started to run our numbers and look at patients with chronic illnesses in the Medicaid fee-for-service population, what we found is that the patients who we identified through a relatively easy definition for chronic illnesses, but who had five or more chronic illnesses, represented one-eighth of the total fee for service population, but represented one-half of all the spending in the fee-for-service population.
And I think that’s an important thing, because one of the challenges we are going to have as we develop health care homes for everyone, is figuring out that dynamic relationship between those folks who need a lot of intensive care and coordination, and those folks who need to make sure that get in for their screening tests. And I am going to posit that they are not dichotomous populations where one population just needs screening and one population just needs intensive care, but there’s actually a spectrum, and we have to create a system where folks who need more care can flex into more complex care, and then flex down over time, and that’s going to be one the challenges we have.
But I think a lot of time people say, “Is this panel management? Do you just want to make sure that guys like me get their colonoscopy? Or is this complex care management where we really take care of those complex folks?” And what I think we really have to say is, we need to do both. And we need everyone in this room and everyone in the Minnesota communities work on making sure that we figure out how to create that continuum.
Keeping going with this 2007 legislation that we have been working on: It’s really based on complexity of the patients. We actually identified three tiers of payments, which I won’t get into the details of today. And then we actually had to figure out a rate, which is actually one of the challenges that we have, and then we have to make sure that rate is consistent with the rates in our Medicaid program and then put that rate based on existing services.
We altered that rate two ways and without getting into details, we expected, and we still expect, that as health care homes mature, that more of the work will be done by different members of the team, and in that respect we know that the rate will reflect the fact that what we are really encouraging, is for clinics to develop teams that can efficiently and appropriately create that warm home structure, but also create the quality outcomes.
We also realize that we have to pay proportionally higher for complex patients. In the Medicaid population there was a very interesting study done that was released about a year and a half ago that looked at chronic disease and the burden of chronic disease in the Medicaid population. And it looked at it in relation to shift of cost. And what it really showed is that as patients had more and more chronic diseases, their complexity and their cost increased, and not in a linear fashion. So we tried to reflect that in the rate structure to basically say that patients who are very complex, who have had the misfortune of having a lot of different problems, really require more coordination, and we tried to reflect that in the rates we were developing.
The other thing I was very pleased about is that as we were developing our model in the spring and summer and fall, Medicare has come out with a national model that they want to try out as a test in eight states, and our model landed very similar to theirs. So I thought, “Oh, I feel better.” …Because if we were in different worlds we wouldn’t be very happy.
And our model was based on legislation that said, on a fiscal note, that we would spend an average of $50 per member per month coordinating care and expect to see the return on that in decreased utilization of high-cost services on the other end. The Medicare model landed very similar to that for the Medicare demo.
So we have a lot of implementation work to do on the 2007 legislation. It includes working on clinic verification, working on patient identification, just the logistics of these processes. And then since, just because DHS is not without its bureaucracy, we have to make sure we get all the systems work in place.
And then the last thing that’s not on this list right now, is we as the Medicaid program have to make sure that all of what we have we are doing is compatible with what the federal government sees, and we have an application in to the federal government to allow for payment for what we are saying is a new service, and is a new service, and so we are waiting to hear from these folks about that. That can take several iterations and can take many months to do, but I am an eternal optimist, so I am hoping to know in February where we are at with that.
That was the base, that 2007 legislation for the fee-for-service Medicaid program and the work that was done through the Minnesota medical home learning collaborative, and a lot of other work that was done by other groups around, a lot of conversation that really led to the 2008 legislation. And the 2008 legislation really calls for the development of the health care home, as I said, for a broad, broad group of the Minnesota population.
And what it calls for first is the development of standards for criteria for certification of health care homes, and it calls for the development of those with a broad range of stakeholders. I am happy to say we used these same stakeholders in 2007. And Marie will spend some time later talking about how we’re how we’re using the same groups and getting input from all these groups as we develop the 2008 legislation.
As Commissioner Magnan said, we have the option of getting these done before July first, but we don’t have the option of getting them done after. So there’s a very aggressive timeline of meetings, and some of you, I bet a fair number of you, will be attending these with us and working on the criteria that will be used to certify health care homes for the 2008 legislation.
We hope, and we would expect that as the criteria for 2008 are developed that we will look at those internally, see if they meet the needs of the chronic patients who are served by the 2007 legislation. And our goal of course would be not to create two different verification processes, but to make sure that they work well together. We do want to make sure that we take care of the complexity of the patients in the fee-for-service program.
The next thing that the legislation calls for is payment restructuring, and it calls for DHS in coordination with MDH to develop a per-person care coordination payment rates for health care home services that are based on patient care complexity, diagnoses, social and cultural determinants and predictive modeling. And these have to be developed by January 2010. We feel almost like it’s a walk in the park to have a year to do this compared to the other stuff, but it’s not going to be, and we expect that we will start this process very early in 2009 to make sure that we again do this with a collaborative process.
A couple of things to say. One is that that second bullet there under, “The fee will be paid through developing social and cultural determinants of care.” I’ll just say this, that we are out on the edge in some ways because there are no good models of determining social and cultural determinants of care that are being used consistently in a structure like this.
And so we have to work both on developing them as we work on figuring out how to incorporate them into the fee and into this whole process, and we will need all of your input working on those processes.
By January 2010, all health plans must include health care homes in their networks. And by July 2010, all health care plans must pay a coordination fee to certified health care homes. And that includes state employees, which is the last bullet, for those of us who are working for the state.
Well these are the tasks that are involved, and I think Marie will talk more about these. Identification of outcomes is an ongoing process, and ICSI (Institute for Clinical Systems Improvement) Has been charged with developing and synthesizing a group of outcomes that we will be looking at in health care home, which is identification of outcomes that we will be looking at in health care home. This fulfills a very important point of looking at where we want to go to get there. Criteria I talked about, verification process, payment methodology, and collaborative learning and measurement of results.
A couple things I want to say just fundamentally as we talk about development. We want to learn from local and national experiences with health care homes, and I think we’ve done a very good job about that so far.
I’ll stop here to put a little pitch in for you to write down January 13th on your calendar. Tentatively we’ll have a few, or three hopefully, national experts on the development of the health care home in that evening. We’ll have another session like this, which will be a day more than a month from now, and we’ll have the opportunity in that session to really find out where we are compared to what’s happening around the country. And I think that will be a great discussion as those of you who are involved in the criteria go to those meetings and those of you who are not at those meetings still track what’s going on, so stay tuned.
The second bullet is that this will be a collaborative process with broad stakeholder input that it will be flexible, as we talked about within the parameters of the legislation creating opportunities to test different models. That we want to have meaningful measures focused on desired outcomes. That we want those to be, we need to move as much as possible from meaningful outcomes around health, and around quality, and around value, more than process. We know that will not happen immediately, but that it will take time to evolve.
The last couple of things about this process is the Department of Health and the Department of Human Services have worked together on this. It would be better if we were on the same phone system, but I do know all seven digits for everybody sitting at the table in front of me, and they probably know all seven of mine. We are doing this through a combination of state grants, and a state organized process. And I think one of the other things I’ll say is …health care home is one part of this health care reform process, and we are working as hard as we can to integrate this with all the parts of the health care reform legislation so we have as much as possible an integrated process.
Marie will talk more about these. I classify our work right now into foundational work around outcome recommendations, around the capacity assessment grant that’s been issued and awarded to look at the capacity of the system and the understanding of patients around health care homes really our chance to make sure we put in the center of what we are doing. And the criteria development we spent some time on.
I’ll finish talking about this a little bit. We want this to be transformational change in care delivery. If this just becomes a change in payment mechanism, we will have done very little. We want to make sure that we measure and evaluate these aims at the same time we create what I think, and I really said at the beginning of this is a palpable change in the way we feel about the way care gets delivered. We know that in order to do that we need to blend payments for services as we do now, with payments for coordination of care; with payments for improved outcome. And that that blend, the challenge that we have is really trying to figure out to get the right blend to make that happen so that we can support the transformational change in health care that I think both patients and providers are very hungry to do.
I’ll finish with this because I think it’s important that we as a community know where we’re at. This is actually from some folks in the National Family Practice Academy, although I think they stole it from someone else. This is the hype cycle I think this is fascinating. …Waves of irrational exuberance. And if you have early adolescent children, you can apply this. (laughter) …Which is really where my kids are at.
But here’s what I’ll tell you …is the line that has the big camel peak in it is expectations. “This is the best thing since sliced bread, nothing can be better than this.” And then somewhere on there, I don’t think I have a pointer, but as the slope starts to change you start to say, “Maybe it’s not the best thing since sliced bread.” And then people come down the other side and say, “This won’t ever work.” I think that depending on where you are, how much you’ve heard about health care home, you’re either climbing the slope, going down the other side, or in the “trough of disillusionment,” as it’s called.
And I think the reality of this is that we need to get real here. And that is that this is really hard work, and if it’s really hard work, it’s going to take us to move steadily forward, and we need to help each other so that when somebody is on that peak going up we say, “Don’t get your hopes up.” And when somebody’s going down the other side, we say, “You’re in the wrong part of this curve, we need to work on this together.” And we need to make slow and steady progress. And I think one of the things the Commissioner alluded to, and I’ll close saying this, is that this is something that’s going to transform over time if we do this right. And we will create slow and steady progress. One of the gifts I think that we have in Minnesota is that we have the ability to have conversations like this, and we have the ability to say that this is going to evolve over time. We …the Legislature and through the input that they get from groups like this, I think will give us time to develop this. As long as we continue to make steady progress in the right direction. To be able to prove what we are doing, and this won’t be a flash in the pan if we get it right when we do that, so. So I challenge all of you, if you’re going up, or going down or in the trough, to think about slow and steady progress.
I’ll stop there. I am going to turn this over to Carolyn Allshouse. I’ll introduce Carolyn briefly by saying that Carolyn and I have known each other for I’m sure over a decade. Carolyn is both the lead on the medical home learning collaborative in the Minnesota Department of Health, but also a state and nationally known patient and family advocate. And it’s her passion I think that has driven a lot of the progress in Minnesota. So, thank you very much. (Applause)
