Minnesota

1
Minnesotas VisionHealth 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 nations 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 Minnesotas Vision
8
Framework for Minnesotas Vision IHIs Triple
Aim

• Improve population health
• Improve the patient/consumer experience
• Improve the affordability of health care

9
Care Delivery Payment RedesignA 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 PaymentsLegislative
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 PaymentsThe 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 HomesProgram 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 HomesStandards and Criteria

• facilitates consistent and ongoing communication
  among the HCH and the patient and family, and
  provides the patient with continuous access to
  the patients 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 patients family in the
  care planning process and
• reflects continuous improvement in the quality of
  the patients experience, the patients health
  outcomes, and the
  cost-effectiveness of services.

17
What Makes Minnesotas 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
  patients 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 clinics 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 HomesCertification and Measurement
21
Outcomes Measurement Requirements

• HCHs must submit data to the statewide
  measurement reporting system
• Outcomes measures are based on the clinics 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

N688 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
Minnesotas Vision for Health Care Homes
Opportunities and Challenges

• 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 and evaluate progress
• Payment must blend payments for services and
  coordination of care

This is just one example of what having a
Medical Home has done for Amanda and us as a
Family!! Marion (Amandas mom)
27
Minnesotas Vision Health Care Homes

• Marie Maes-Voreis RN, MA
• Health Care Homes, Program Manger
• marie.maes-voreis_at_state.mn.us
• 651-201-3626
• www.health.state.mn.us/healthreform/homes
• health.healthcarehomes_at_state.mn.us