Primary Care in MinnesotaInnovations in Primary Care

Jeff Schiff, MD MBAMedical Director

Minnesota Department of Human Services13 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 healthcareNational 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 FFSFigure 2: Distribution of Member Months by Count of Major

Condition Groups - Fee-for-Service MHCP PopulationState Fiscal Year 2008

50%

9%

12%

17%

12%

0 (Tier 0)

1-3 (Tier 1)

4-6 (Tier 2)

7-9 (Tier 3)

10+ (Tier 4)

Count of Major Condition

Groups

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