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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