Primary Care in Minnesota

Innovations in Primary Care

Jeff Schiff, MD MBA Medical Director Minnesota Department of Human Services 13 December 2010

What’s so different up there?

• Low rate of uninsured • Collaborative non-profit culture • Highly integrated delivery systems • Strong primary care base

And …

2008 percent of GDP in healthcare National 15.1% Minnesota 13.4% Relatively healthy population

Underpinnings of Primary Care Delivery Reform • Patient and Family Centered Care • “Agency” role of providers • Advocate vs. steward • Creating and regulating the right market in health care

“That a power imbalance exists between doctors and patients has been readily acknowledged…. However the effects of this asymmetry can be mitigated through the establishment of trust between doctor and patient” - Loree K Kallianinen,MD

Primary Care in Minnesota – Health Care Home • 2003 –HRSA grant to provide medical home for children with special health care needs • 2007- first Minnesota legislation to pay for care coordination • 2008- major Minnesota health care reform legislation including Health Care Home

Minnesota Health Care Home Program

• • • • • 2008 Enabling legislation Designation of criteria in state rule Active clinic certification process Complexity-adjusted multi-payer payment methodology Learning collaborative Outcomes reporting and results required for recertification

Services required of certified Health Care Homes • Access and communication standards – Availability of patient registry information – Appointment availability/ triage capacity • Registry functionality • Care planning • Care coordination – Transition coordination – Coordination with community agencies – Dedicated care coordination capacity • Practice based quality improvement – Patient and family centered care

Complexity adjusted payment methodology • Provider determined tier assignment • Based on the number of conditions groups (e.g. endocrine, cardiovascular) that are chronic, severe, and requiring a care team for optimal management • Two supplemental complexity factors added (non English as primary language and significant mental illness) • Work of providing a HCH (and payment rate) estimated based on this complexity • Modeling estimation of provider tier assignment derived from claims based risk adjustment software (also to be used to audit provider tier assignment)

Estimated Distribution: MHCP FFS

Figure 2: Distribution of Member Months by Count of Major Condition Groups - Fee-for-Service MHCP Population

State Fiscal Year 2008 12% 9% 50% Count of M ajor Condition Groups 0 (Tier 0) 1-3 (Tier 1) 4-6 (Tier 2) 7-9 (Tier 3) 10+ (Tier 4) 17% 12%

HCH payment

• Payment rates range from $10-$60 PMPM • All Medicaid, state employees and privately insured included in a “manner consistent with…” that developed by DHS • ~2% of the total health care spend on patients • Cost neutrality assumed by the legislature

Minnesota and federal health care reform------Health Care Home • Multipayer Advanced Primary Care Practice (MAPCP) Demonstration • ACA section 2703 – expanded federal Medicaid match

MAPCP

• Cost neutrality $14.43 PMPM • Medicare FFS to join state efforts • Effect in the state • Critical mass • Credibility of program • Common expectations for evaluation

Key Design Feature #1 (contd.):

Statewide Scope and “Critical Mass” of Payment SOURCE: Adapted from MDH Health Economics Program, Medicare enrollment data and SEGIP enrollment data

ACO components – our program as the logical bridge • Build on primary care/ care coordination • Attribution • Risk • Total cost of care methodology/ Gain sharing • Measurement • Our complex population

ACO in the ACA

ACO ≠ capitation • Center for Medicare and Medicaid Innovation • Medicare shared savings • Pediatric ACO • Safety net hospital ACO

Key Program Information:

Minnesota Department of Health (MDH) http://www.health.state.mn.us/healthreform/homes/index.html

Minnesota Department of Human Services (DHS) http://www.dhs.state.mn.us/healthcarehomes