Journey Back to Your Island Health Care Home

Richard Bettini, President and Chief Executive Officer Waianae Coast Comprehensive Health Center

Ihilani Resort and Spa ~ Ko Olina, Hawaii November 28-30, 2012

Today’s Conference has its “ROOTS” HERE:

Keynote Address: The History of the Medical Home Concept: Dr. Calvin Sia Speakers (Onsite) Sarah Scholle, Assistant Vice President for Research and Analysis, National Committee for Quality Assurance Jim Hunt, Chief Executive Officer, Massachusetts League of Community Health Centers Georganne Chapin, Chief Executive Officer, Hudson Health Plan Paul Gallese, Acting Chief Executive Officer, Community Health Plan of Washington Anita Monoian, Chair Elect, National Association of Community Health Centers Dr. Winston F. Wong, Medical Director, Community Benefit Disparities Improvement and Quality Initiatives, Kaiser Permanente Ed Phippen, Program Director, Health Work Force Institute Graduated Competencies – A Funded Program of the Robert Wood Johnson Foundation Gary Cloud, Assistant Provost, Associate Dean for Financial Resources, A.T. Still University Dr. Karen DeSalvo, MD, Vice Dean of Community Affairs Tulane University – Chair Louisiana Health Care Home Committee Dr. Samir Patel, Kaiser Permanente Care Management and Patient Self Management Support Speakers (Via Teleconference) Dr. David Stevens, Director, National Association of Community Health Centers Quality Centers Melinda Abrams, Assistant Vice President, The Commonwealth Fund

AGENDA from our 2008 Journey to an Island Healthcare Home Conference included speakers:

And Even Back to Here:

And Way Back to Here The AHA Concept

1. Accessible – Community-based, Universal

2. Family-centered – Family as partners in care

3. Coordinated – Context of both family and community

4. Comprehensive – Treats the whole patient

5. Continuum – 24/7

6. Culturally Effective

7. Compassionate

Founding Principles of Medical Home

Our Healthcare Home Model May Be Different Than Others Based on Unique Needs of Our Community

“The most reliable predictor of population health is the zip code lived in” Income – Schools – Crime – Unemployment – Stress – Access Barriers

Consensus Report From “First Game” Delegates Decided on a Collective ‘Team’ Name

MALAMA OLA HUI

The following is recommended by Malama Ola Hui:

Malama Ola Hui recognizes there are standards set that define the patient-centered medical home.

However, Malama Ola Hui feels the current NCQA medical home standards would be more reflective of community

health values if we expanded to a patient-centered healthcare home.

We suggest the following additional standards be included

in the definition of a patient-centered healthcare home.

4 New Supplemental Competencies (with standards to be developed)

for Medical Home in MUA or when Saving MUP’s

• ECONOMIC/WORKFORCE DEVELOPMENT

• CULTURAL EFFECTIVENESS

• ENABLING/SUPPORTIVE SERVICES

• COMMUNITY ENGAGEMENT

MUA: Medically Underserved Areas

MUP: Medically Underserved Populations

The Journey Continues…Consumer Leadership in Health Care Transformation

August 25 – 26, 2011 San Diego, California

THE GAME

Outcome of 3 Game Series – (If patients could pick PCMH Scoring)

OUR COMMUNITY’S HEALTHCARE PROBLEMS

YEARS OF LIFE – LOST!

• Early onset of chronic disease – diabetes

• High risk pregnancy

• Depression & lack of hope – substance abuse

• What do you see?

• How can we better address these needs?

IF NO JOB SKILLS (WHICH PATH)

COMMUNITY BASED

INNOVATIVE JOB TRAINING

CONTINUING LACK OF JOB

SKILLS

SUCCESS/HOPE

STRESS/ HOPELESSNESS

MOTIVATED FOR WELLNESS

DISEASE & RISK TAKING BEHAVIOR

The original concept of a Medical Home extends care into community networks that impact on well being

Link between Employment & Health

Graduated 57 students as Community Health Workers, Substance Abuse Counselors, Medical Reimbursement Specialists and Pharmacy Technicians

August 9, 2012 Waianae Health Academy Graduation

What do you see in this picture that suggests we take a unique view of healthcare? What is represented here?

What Are Care Enabling Services? The Function of Reducing Access Barriers to Care

12 month visit count by procedure code at one AHA-RO Center

REQUIRED BY FEDERAL WAIVER – NOT BEING SUPPORTED TO ALL PLANS What Are Care Enabling Services?

The Function of Reducing Access Barriers to Care

12 month visit count by procedure code at one AHA-RO Center

In Addition to care Enabling Services there are other Value Added Services Some Plans Pay for and Some Don’t and That Are

Responsive to Special Population Needs

• Medical Nutrition Therapy

• Supervised Exercise by Certified Trainers

• CSAC Substance Abuse Counseling

• “Humbug Adjudication” (Ask us)

• Integrative & Traditional Practice – State Certified

• Pharmacy Counseling

Transitioning

From Game Format Virtual Reality

• MUA Communities have different healthcare needs.

• Integration of services beyond medical model.

• Advocating from consumer base.

• Community engagement as well as patient engagement.

• Payment and incentives reflecting value provided.

• New models for assessing complexity of patient served and predicting how preventable costs can be found.

• Shared Savings or a Virtual ACO.

Waimanalo Health Center: Unduplicated Patients: 4,195 Total Patient Visits: 20,760 Uninsured Patients: 1,321 Medicaid Patients: 2,033 Top two ethnic groups served: Native Hawaiian = 46.4% and Other Pacific Islanders = 15.7% Incorporation: January 25, 1989 1st patient seen: January 1992

Waianae Coast Comprehensive Health Center: Unduplicated Patients: 28, 912 Total Patient Visits: 164,852 Uninsured Patients: 13% Medicaid Patients: 55% Top two ethnic groups served: Hawaiian/Part Hawaiian = 52% and Caucasian = 16% Incorporation: 1972

Ko’olauloa Community Health & Wellness Center Unduplicated Patients: 5,766 Total Patient Visits: 18,490 Uninsured Patients: 1,279 Top two ethnic groups served: Native Hawaiian = 49.2% and Asian = 13.2% Incorporation: October 10, 2003 1st patient seen: May 2004

Our 3 Health Centers

Recognizing we must be constructive partners in containing healthcare costs and creating better value for our patients and payers.

WHAT IS AHARO?

Promoting access, quality, and cost effectiveness in healthcare by empowering consumers to evaluate the performance of healthcare agencies that serve them.

AHA-RO Background Information AHA-RO Mission

What have AHARO staff done to facilitate payment reform?

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We discussed where are the savings in healthcare: • Met with plans • Looked at data • Discussed with health professionals

We have learned so far that savings can be found: Facility Costs • Decrease Hospitalizations • Decrease Hospital Days • Decrease 30-day Hospital Re-Admissions • Decreased ER Use Drug Costs • Increased Generic Dispensing Rate (GDR) • Improve Medication Adherence (Diabetes Mellitus and

Medication Possession Ratio (MPR) for Chronic Medications) Other • Increase Advanced Directives on File

STEP ONE:

We have developed the AHARO Payment Reform Model – From

Medical Home to Healthcare Home in High Poverty Communities

• Maintain health center blended fee for service rate

taking into account Integrated Primary Care Services and

Medical Complexity. (PPS)

• Adds capitation for non-care primary care services.

(Value added services – non-PPS)

• Establishes bonus payments for Medical Home (NCQA)

and Healthcare Home (MUA) Standards

• Creates a Shared Savings formula based on dynamic

performance of 360 evaluation of health plan standards

as well as healthcare home performance on financial

performance metrics.

STEP TWO:

STEP THREE: Engaged Two Medicaid Health Plans (To implement the model in 2012)

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1. The Plan agrees to provide matching funds for a prospective investment in care coordination and HIT system development.

2. The Plan agrees to support supplemental PCMH (non-PPS) services in centers that meet tiered supplemental standards (consumer developed) and become “Patient Centered Healthcare Homes”.

3. Partners agree to exchange data and establish performance dashboards including transparent risk pool accrual dashboard.

4. Plans agrees to support non-blended rate covered services with capitation for additional care enabling services.

5. Risk pool savings are shared based on financial performance metrics and a 360° evaluation of the plan of health care home.

MORE CLUES TO REDUCING HEALTHCARE

COSTS IN MEDICAID PATIENTS

• A small % of patients generate a high % of preventable

costs.

• These patients often have complex problems involving

access issues, social/behavioral issues, as well as chronic

disease.

• Lack of access to primary care in evening hours

contributes to increase in preventable cost.

• Lack of hope leads to risk taking behavior that leads to

increase in preventable costs.

• Using providers outside our network may reduce revenue

while also increasing preventable costs.

Healthcare Reimbursement Is Changing

Bonus Payments – Shared Savings and Risk Pools

Up to 30% of our revenue may come from bonuses

Health Home Based Risk Pool Jointly Managed By

Plans & Health Home

Payments to Health Home

• Primary Care • Some Specialists • Lab/Radiology • Evening Hours • Pharmacy • Behavioral Health • Care Enabling

Payments to Hospitals

Payments to Specialists

State pays Medicaid Capitation to plans with bonus based incentives withheld

Payments to Pharmacy

Benefit Manager

Plans set up Risk Pools & create bonuses for Health Homes

$175 PMPM

Outside Pharmacy

$200 PMPM

Will system be fair? Who picks measures? Who shares savings?

SAVINGS COME FROM WHAT IS LEFT IN POOL

Cooperation and the Kuleana Question

How far along do you

push the needle?

HEALTH PLAN $$$

HEALTHCARE HOME

(The Comp)

Risk Management

(& assumption) &

Claims Processing

NO THANKS

Vertical Network

Formation including

Secondary & Tertiary Care

SOME

Care Coordination

or *(CCN)

HIT System Development

SOME

Care Enabling Social Services & Community Engagement

WE DO IT

Pharmacy, Specialty & Behavioral

Health Services

WE DO IT

Primary Care Medicine &

Ancillary Services

WE DO IT

How much do we do: Form specialty networks, build our own HIT

systems, use our own care coordinators.

(We already integrate our own pharmacy and

behavioral health services into primary care.)

* *

*

WE HAVE AN OPPORTUNITY!

THE EMERGING HEALTHCARE ENVIRONMENT

New Healthcare Technology will lead to: The measurement of the relative value

healthcare providers offer payers and patients

(Reimbursement will then be associated with this measured value)

o Medical Home: Primarily Measures Capabilities (NCQA)

o Accountable Care: Share the Savings

Key Questions:

Will we be fairly valued? Who picks the measures? Who shares the savings?

AHA-RO MCO Partnerships

MUA/MUP Based Healthcare Home – Measuring

Performance and Performing Value

Flow of Services and Data

AHA-Rural Oahu Dashboards – Tools for Measuring Performance

Clinical Process & Outcome Measures

Community Selected & Utilized

(Currently being used as PIC dashboard)

• Being developed by

Consumers

• Community Outcomes

• Community

Transformation Project

Direct Risk Pool Financial Data – To Repository

• Monthly update risk

pool expenditures

• Targets and metrics

on costs:

o Pharmacy

o Hospital

o Primary Care

o Specialty

Comparative Dashboard

Risk Pool Dashboard

Community Dashboard

Consumer Satisfaction Summary View

“360° Evaluation” Healthcare Home Concept Medicaid/MUA Environment

The Patient Healthcare

Home Plan

Intermediary Payers

CMS

State

“Currently we over-emphasize linking performance payments to the quality of services provided at Healthcare Homes.”

“We should recognize that the optimum value from the healthcare dollar comes from measuring and incentivizing performance throughout the continuum of the healthcare deliver system.”

AHARO begins by incentivizing and holding accountable plans as well as providers. We may also ask these questions in future games:

•How does the proficiency of Medicaid agencies to act as a wise purchaser affect the value that the whole Medicaid system can realize?

•To what extent should patients be incentivized to contribute to outcomes?

Turning the 360° Healthcare Home into a 3D Healthcare Home

Beyond HEDIS - Competitively Bidding Value Added Services

Being Active in Setting Healthcare Exchange Criteria

The Basic Health Plan Concept

Responding to Meaningful Use

Incentivizing the Extra Effort

Telemetry and Remote Tracking Complex Patients

Patient Engagement Partnerships

Value Added Benefits

State Medicaid Agency

Plan

Provider Net

Patient

Want a free iPhone?

OUR HEALTHCARE HOME MODEL-IN SUMMARY

• Triple Aim – Quality (including patient experience), Community Health &

Addressing Preventable Costs

• Performance based – we must prove our value – and share savings

• Consumer & Community Driven – 4 Supplemental Health Home Standards

• Preserves Prospective Payment System

As a blended rate capturing extended hours, some enabling, ancillary and

specialty services

Assures no distinctive to outreach to highly complex and “expensive

patient”

Does not conflict with value based models if scope and complexity is

documented and value component added

• We will add Aged, Blind & Disabled to our Healthcare Home Model (Kupuna

Care & Severely Mentally Ill)

MOVING FORWARD FROM HERE???

1. Where are the preventable cost in Aged, Blind and Disabled population

and how can FQHCs address them?

1. Where there are extraordinary health disparities in the early onset of

chronic disease in certain populations (like Native Hawaiians) how can

health plans be risk adjusted for assuming greater share of this

population?

1. Will the benefit package provided to the gap group under the health

exchange, basic health plan, or Medicaid expansion reflect the actual

needs of patients in this economic category and which of these insurance

options continue to utilize the Prospective Payment System?

1. Can we develop Integrated Care Coordination and HIT Systems at the

community health level?

1. Do conferences like this help by raising questions like ones above and

should they continue?