Advancing Health Care Reform in Maine: Why, What, & How?

Aging Advocacy Summit November 2012 Lisa M. Letourneau MD, MPH

• • •

Objectives

Identify factors contributing to the urgent case for transforming US health care system Introduce key components of Maine’s emerging model for change – Patient Centered Medical Home (PCMH) – Community Care Teams (CCTs) – Accountable Care Organizations (ACOs) Describe the role of consumers in supporting , driving this change 2

: Who We Are

• • • Independent, multi-stakeholder alliance in Maine working to transform health and healthcare by leading, collaborating, and aligning improvement efforts Only organization working to improve quality of care for all Maine people Members include consumers, doctors, nurses, hospitals, health systems, payers, employers, government, policy makers, and others working to improve health and healthcare 3

: What We Do

• • • • Align health care quality improvement efforts Engage consumers meaningfully in improving health and health care Establish sustainable system of quality improvement support for providers Improve integration of behavioral and physical healthcare 4

:

Major Programs

• • • • • • Aligning Forces for Quality Maine Patient Centered Medical Home Pilot Improving Behavioral Health Integration Transforming Care at the Bedside QC Learning Community QC Annual Conference (“Best Practice College”) 5 5

A Compelling Case for Action

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Vision for a Transformed Health Care System Healthy, productive, connected people & families …receiving healthcare from a highly functioning “accountable care organization ” … supported by a robust & well-supported system of primary care providers

What We Want from Our Health Care

• • • • • Relationship with our providers that crosses settings, time, & place Caring, compassionate interactions Coordination & integration of care across providers Ability to access care 24/7 – when & where we need it Time, time, time… 8

But What Do We Get?

The 15 minute visit!

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The Result: The Current Medical Home

Why? Follow the Money!

What we want: • Relationship, time with our providers • Caring, compassionate interactions • Coordination & integration of care • Ability to access care 24/7 What we pay for: • Visits • Tests • Procedures • Procedures • Procedures 11

The Stalemate That Blocks Change

Providers unable to transform practice without viable & sustainable payment for desired services B U T Employers & payers unwilling to pay for desired services unless providers demonstrate value AND show potential to save money 12

A Recipe for Change?

Consumer Engagement Transparent Cost & Quality Data Community Leadership for Change Help for Providers to Change Care Systems Alternative Payment Models that Reward Value (vs. Volume) 13

Community Leadership for Change

Maine Quality Counts Maine Health Management Coalition MaineCare DHA’s Maine Quality Forum 14

The Medical Home & ACOs: Models for Change!

Providers change practice, create value with viable & sustainable payment for desired services = Delivery System Change A N D Employers & payers pay for desired services if providers can demonstrate value AND reduce spending = Payment Reform 15

Defining Medical Home

“A medical home is not a building, house, or hospital, but rather an approach to providing comprehensive primary care. A medical home is defined as primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective.” American Academy Pediatrics 16

Maine PCMH Pilot Practices

Maine PCMH Pilot “Core Expectations” for Practices

1. Demonstrated physician leadership for improvement 2. Team-based approach 3. Population risk-stratification and management 4. Practice-integrated care management 5. Same-day access to care 6. Behavioral-physical health integration 7. Inclusion of patients & families 8. Connection to community / local HMP 9. Commitment to reducing avoidable spending & waste 10. Integration of health IT 18

Community Care Teams

• • • • Multi-disciplinary, community-based, practice integrated care teams Build on successful models (NC, VT, NJ) Support patients & practices in Pilot sites, help most high-needs patients overcome barriers – esp. social needs - to care, improve outcomes Key element of cost-reduction strategy, targeting high-needs, high-cost patients to reduce avoidable costs (ED use, admits) 19

Maine PCMH Pilot Community Care Teams Workplace Food Systems Shopping Environment Schools Housing Transportation Care Mgt Outpatient Services Family High-need Individual PCMH Practice Med Mgt Coaching Specialists Behav. Health & Sub Abuse Hospital Services Income Heat Faith Community Physical Therapy

Literacy 20

Payers: •Medicare •Medicaid •Commercial (Anthem, Aetna, HPHC) •Self-insured employers

Maine’s Medical Home Movement ~ 540 Maine Primary Care Practices 100+ NCQA PCMH Recognized Practices ~130+ MaineCare HH Practices?

26 Maine PCMH Pilot Practices 50 Pilot Phase 2 Practices 14 FQHCs CMS APC Demo

Payer: Medicaid Payer: Medicare 21

So…What About ACOs?

“Accountable Care Organizations (ACOs) will constitute groups of providers - physicians, other clinicians, hospitals or other providers that together provide care and share accountability for the cost and quality of care for a population of patients” T. Lake et al, “Lessons from the Field: Making Accountable Care Organizations Real “, NIHCR Research Brief, Jan 2011 22

PCMH: Hub of Wider Delivery & Payment Reform Models (ACOs!)

Pharmacies Home Care Payers Primary Care Providers Patient Centered Medical Home Employers Hospitals/ Hospitalists/ Care Managers Home Health Health Mane Parterships Specialists Nursing Homes ACO 23

ACOs in Maine – What’s Happening?

• • • Employer-Provider ACO Pilots – Maine Health Management Coalition leadership – MaineGeneral-SEHC, EMMC, other pilots Medicare – multiple ACO options – Pioneer ACO – EMHS 24 – Shared Savings programs – MH, CMMC, MePCA Medicaid: Value-Based Purchasing strategy – Seeking “Accountable Communities” proposals 24

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Engaging Consumers, Partnering with Patients

Untapped “force” for improving health care Need to shift from provider-centered to patient-centered approaches (think banking!) Need patients to better understand their role – To improve their health, and – To change health care system Changing patient role requires changing culture of US health care 25

Patient Engagement

What We Say:

• We want patients to take active role in making decisions about their health • We want patients to ask questions • We want patients to express values & preferences

What We know:

• Patients – even well educated, are reluctant to ask questions • Patients are fearful of challenging provider recommendations • Many patients feel physicians are authoritarian (vs. “authoritative”) 26

“Better Health. Better ME!” Consumer Engagement Campaign

• • • •

Take Charge of Your Health: Step ONE: VISIT

your Primary Care Provider

Step TWO

:

ASK

Questions

Step THREE

:

KNOW

your numbers

Step FOUR: FIND

and use community resources and programs to support health 27 27

Partnering for Improvement

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ABIM “Choosing Wisely” Campaign

• Physician-led effort to identify opportunities to improve care and decrease use of wasteful services • Have created lists: “5 Things Physicians & Patients Should Question” • Appeals to professionalism • Promotes partnership with patients • Have engaged multiple specialty physician groups 29

Patient Tools

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Consumer Reports “Best Buy Drugs

” 31

Managed Care All Over Again?

• • • • •

‘Old-School’ Managed Care

Focus on reducing costs Global capitation PCP at full financial risk PCP as gatekeeper Very limited information and tools • • • • •

vs. PCMH + ACOs

Focus on demonstrating value New care management fees (plus performance payments?) Limited financial risk to PCP Primary care team coordinates care & supports patient needs across “med neighborhood” Improved information and tools (EMR, registries) 32 32

Change is Hard

• • • Hard to repair the plane in flight Hard to practice while practicing!

People fear change (loss) - any change 33

QC 2013 – Save the Date!

Aligning Maine’s Forces To Achieve the Triple Aim of Improvement

• • • • Wed, Apr 3, 2013 Augusta Civic Center Dr. Donald Berwick Join us!

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www.mainequalitycounts.org

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Contact Info / Questions

 Lisa Letourneau MD, MPH • [email protected]

• 207.415.4043

 • Maine Quality Counts www.mainequalitycounts.org

 Maine PCMH Pilot • www.mainequalitycounts.org

(See “Programs”  PCMH) 36