The document discusses Minnesota's payment reform efforts in primary care, focusing on various models and strategies for improving care coordination and patient outcomes. It emphasizes the need for a blend of payment structures that incentivize quality rather than quantity in primary care, highlighting historical challenges and current initiatives like the medical home concept. Key goals include better patient engagement, reduced healthcare costs, and the establishment of effective care coordination systems through collaboration between healthcare providers and policymakers.

1. Payment Reform for Primary Care – Minnesota DHS efforts Jeff Schiff, MD MBA Medical Director Minnesota Health Care Programs Minnesota Department of Human Services

2. Current payment reform efforts in Minnesota Payment for Performance Q care Diabetes and Cardiovascular goals Care Coordination Intensive Care Coordination Provider Directed Care Coordination DIAMOND – depression care in primary care

3. Today Rationale History Current legislation Implementation plans and issues

4. Primary Care Orientation 13 industrialized countries characterized on strength of primary care health system More primary care orientation associated with better early childhood outcomes – Low birth weight Post neonatal mortality Infant mortality Starfield, Health Policy 2002; 603:201-218

5. Primary Care Orientation In the US, the number of primary care physicians per population was the only characteristic consistently related to better outcomes, including overall mortality rates, mortality rates from heart disease and cancer, neonatal mortality, life span, and low birth weight. [i] In contrast, the number of specialty physicians per population was related to worse [or no change in] outcomes in all these areas [i]Shi L. Primary care, specialty care, and life chances. Int J Health Serv. 1994; 24 :431 –458

6. Primary Care Reimbursement based primarily on the quantity of services delivered, rather than on quality forces primary care physicians onto a treadmill, devaluing their professional work life. The short, rushed visits with overfilled agendas that cause patients dissatisfaction simultaneously breed frustration in physicians….Public policy on primary care does not exist…A covenant is needed between those who pay for health care and those who deliver primary care: primary care must promise to improve itself, and in return, payer must invest in primary care. -Bodenheimer, NEJM 355:861-864

7. Primary Care Ultimately, the payment of primary care physicians might be a blend of fee for service, monthly fees for practices serving as patient-centered medical homes, and additional bonuses for meeting quality and efficiency performance goals. Goroll, AH J Gen Internal Med referenced by K Davis NEJM 356:1167

8. Minnesota history from 2004 Medical home learning collaborative Pediatric practices 10 sites MCHB funding Improvement collaborative Parent/provider teams Measure improvement over time Triennial meetings to support practice teams

9. Medical home now 21 sites Over 5000 children Second grant cycle and state funding Minimal payment to practices Major study of public patients in MH underway

10. Breakthrough learning collaborative Teams of Pediatrician Care coordinator Parents of two families

11. Breakthrough learning collaborative 21 teams Triennial state meetings – learn about Medical home and components Change management Meet every two weeks in the intervals to plan and implement change at the practice level PDSA experts

12. Breakthrough Series (9-12 month time frame) Select Topic Planning Group Develop Framework & Changes Participants Prework Supports E-mail Visits Phone Assessments Senior Leader Reports LS 1 LS 3 LS 2 Summits, Guides, Publications, etc. A D P S A D P S

13. Which system is the unit of health care practice, intervention, measurement, focus? (Batalden) Self-care system Geopolitical, market system Macrosystem Mesosystem Microsystem Individual care-giver & patient system

14. Clinical microsystem A small group of people who work together in a defined setting on a regular basis to provide care and the individuals who receive that care. It has clinical and business aims , linked processes , a shared information environment and produces services and care which can be measured as performance outcomes . These systems evolve over time and are (often) embedded in larger systems/organizations. As any living adaptive system, the microsystem must: (1) do the work, (2) meet staff needs, (3) maintain themselves as a clinical unit. Batalden, P, at St. Thomas 9 05

15. Possible implications relevant for leading health care redesign & improvement Patients and professionals will increasingly realize they are part of the same systems…and to do well, their microsystems must thrive. Clinicians and health professional educators will place new priority on experiential learning and discovery. Authority and authenticity can meet in the new, increasingly transparent and lifelong efforts to develop and form health professionals. Batalden, P, at St. Thomas 9 05

16. Dovetails with national attention to Medical Home Requires definition More than primary care Disparity reduction

17. Primary Care Orientation What is Primary Care? accessibility for first-contact care for each new problem or health need, long-term person-focused care ("longitudinality"), comprehensiveness of care in the sense that care is provided for all health needs except those that are too uncommon for the primary care practitioner to maintain competence in dealing with them, and coordination of care in instances in which patients do have to go elsewhere. I ] [i] B Starfield and L Shi. The Medical Home, Access to Care, and Insurance: A Review of Evidence.” Pediatrics 113(5):1493-1498.

18. What is a medical home? Primary care based care coordination Partnership with parents Linkages to community resources And…

19. And… Continuous improvement process Improved office systems to Track and monitor progress Evaluate outcomes

20. PDCC legislative proposal Care coordination components defined by the DHS Patients selected by DHS to benefit from care coordination Average of $50 per month payment

21. Model development ~ 200,000 of 670,000 clients in our Fee for service population ~106,000 disabled Calculation of 5% savings per client per year compared to similar clients (patients would have annual health care costs over $12,000) For a clinic seeing 100 patients with this level of care coordination need - $50x12monthsX100 patients= $60,000 Initial budget page based on serving 2500 patients after two years

22. Legislation passed

23. Pick your moral hazard This model –compliance with care coordination requirements, diagnosis inflation Current system- overuse of the visit/ procedures, lack of care coordination Global primary care capitation – under use of services/ specialists referrals, primary care physician as gatekeeper Pay for performance – teach for the test

24. Implementation challenges Defining clinics capable of providing PDCC Defining client pool Stratifying payment rates Evaluation of outcomes

25. Defining clinics Creating care coordination criteria beyond a payment for primary care Examples: Care plan components and distribution Dedicated care coordinator time and access Community fair process Different service than waiver case management, county case management, etc.

26. Where does care coordination live? Provider Provider Directed Care Coordination Community based Case management Negotiated coordination

27. Community Fair Process – current work PDCC steering committee PDCC interest group PDCC criteria workgroup

28. PDCC clinic criteria workgroup Positions defined by steering committee/ department Facilitated discussion Create specific criteria for care coordination to objectively verify clinics Report out and receive input from the interest group Ultimate decision rests with Commissioner

29. Workgroup membership Providers Patients and advocates Health systems Plans Disability and Mental health sections Tight, but representative group

30. Patient selection Initial cohort- patients with high use of avoidable costs Future efforts Risk adjusted predictive modeling stratification around $50 average Avoidance of penalization for utilization improvement Patient selection for likelihood of impact

31. Evaluation Quality goals (Q care) Patient engagement Service utilization

32. Additional tools and products CAPS grant – MTG I ICC predictive modeling group Value Exchange- MN HIVE (Health Information Value Exchange) DIAMOND

33. Medicaid Transformation Grant Communication and Accountability for Primary Care Systems Two way communication tool between the DHS and providers Submit care plan information- criteria to be determined and prioritized on advise from PDCC/ CAPS workgroup Receive claims based patient information Submit care coordination claims Augmented prior authorization Begin to track clinical information across the FFS system (Value exchange)

34. ICC predictive modeling Intensive care coordination pilot care model Patient selection based on CDPS and ACG and additional components Care delivery via disability service provider Incrementally increase ability to stratify care coordination payment by patient complexity Improve evaluation of care coordination based on stratified measures

35. MN HIVE – Minnesota’s development of a value exchange Medicaid Transformation Grant II cycle Support the four cornerstones in Minnesota Community wide health information exchange Community quality metrics – Minnesota Community Measurement/ Stratis/ ICSI

36. DIAMOND project ICSI lead Differential care coordination payment for primary care based depression care Based on IMPACT model of defined care coordination, screening, treatment, and referral Community wide effort including plans, providers, purchasers