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A Great Health Care Home …


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									Minnesota’s Vision:
Health Care Homes
(aka Patient-Centered Medical Homes)

                      State Name: “Minnesota” comes
                       from Dakota Indian words
                       meaning “sky-tinted waters,” or
                       “sky-blue waters.” Often
                       nicknamed “land of 10,000

                      Statehood: Minnesota became
                       a state in 1858 and was the
                       32nd state in the union.

                      Size: 12th largest state in the
                       United States.
Minnesota Starts from a Good Place:
Health Care Delivery

 Ranked as one of the top 2 or 3 healthiest states
 History of collaboration and innovation in the
  health care delivery system
   • Largely non-profit environment
   • High concentration of large, integrated, multi-
     specialty group medical practices in urban and
     rural practices
   • Institute for Clinical Systems Improvement
   • Minnesota Community Measurement
   • Active large purchasers
 Minnesota Starts from a Good Place:

 Among the nation’s lowest uninsurance rates
 Strong employer base
 Significant presence of local health plans
 Health plans are required to be non-profit to
  participate in Medicaid managed care, contracts with
  public employee insurance programs or workers’
 MN has MinnesotaCare a subsidized insurance
  program (since 1992, pre-SCHIP)
Minnesota Starts from a Good Place:
Primary Care

                        MN HCH Capacity
                          707 primary care
Minnesota Still Faces Challenges

 Rising health care costs in the state are
 Our health care system creates poor value and has
  misaligned incentives.
 Private insurance continues to erode, and the
  number of uninsured is rising.
 Health care quality is low relative to the amount
  spent, and unevenly distributed across the
 The way we pay for health care services leads to
  distortions in the types of health care that gets
Cumulative Health Care Cost Growth
vs. Other Economic Indicators

Note: Health care cost is MN privately insured spending on health care services per person, and does not include enrollee
out of pocket spending for deductibles, copayments/coinsurance, and services not covered by insurance.

 Sources: Minnesota Department of Health, Health Economics Program; U.S. Department
 of Commerce, Bureau of Economic Analysis; U.S. Bureau of Labor Statistics, Minnesota
 Department of Employment and Economic Development
2008 Health Reform Law:
Minnesota’s Vision
Framework for Minnesota’s Vision:
IHI’s Triple Aim

 Improve population health
 Improve the patient/consumer
 Improve the affordability of health
Care Delivery & Payment Redesign:
A Great Health Care Home…

Is satisfying
   and clinic
Two Foundational Pieces of Legislation

 2007: First “medical home” legislation.
  Provider Directed Care Coordination for
  patients with complex illness in the Medicaid
  FFS population (now Primary Care
  Coordination, or PCC)
 2008: Health care reform legislation requires
  health care homes (HCH) for all Medicaid /
  SCHIP / state employees / privately insured
  in Minnesota
Primary Care Coordination: PCC
Health Care Homes: HCH

 Both programs promote care coordination
  and focus on achievement of outcomes.
  – PCC: focuses on most chronically ill fee-for-
    service Medicaid patients
  – HCH: focuses on all patients who have or are at
    risk of chronic or complex conditions, can benefit
    from the services of a HCH and are interested in

 Both have new payment options for per-
  person care coordination
2008 HCH Legislation… the standards
developed by the commissioners must
meet the following criteria:
 use of primary care
 focus on high-quality, efficient, and effective health
  care services
 use of health information technology and systematic
  follow-up, including the use of patient registries
 provide consistent, ongoing contact with a personal
  clinician or team of clinical professionals
 ensure appropriate comprehensive care plans for
  their patients with complex or chronic conditions
 measure quality, resource use, cost of care, and
  patient experience;
 use of scientifically based health care, patient
  decision-making aids
 encourage patient-centered care
Care Coordination Payments:
Legislative Requirements

 DHS / MDH develop a system of per-person care
  coordination payments to certified HCHs by
  1/1/2010, MN [256B.073] and MN [62U.03]
 Health plans include HCHs in their provider
  networks by 1/1/2010
 Fees vary by thresholds of patient complexity
 Development considers the feasibility of including
  non-medical complexity information.
 Payment conditions and terms for health plans shall
  be developed “in a manner that is consistent with”
  the system for public enrollees.
 Health Plans and DHS make care
  coordination payments by 7/1/2010
Care Coordination Payments:
The Goal of Critical Mass

Included (~40% of Minnesotans):
   • Medicaid/State-funded Public Programs
   • State Employees
   • Fully-Insured Private Insurance (small
     employer groups and individual policies)
Not Included (~60% of Minnesotans):
   • Medicare (14%)
   • Self-Insured Private Insurance (large
     employer groups) (40%)
   • Uninsured (7%)
Health Care Homes:
Program Development Tasks

Identification of outcomes
Criteria for participation
Verification process
Common payment methodology
Incorporation of collaborative learning
Measurement of results
Community-wide communication
 Health Care Homes:
 Standards and Criteria
 facilitates consistent and ongoing communication among the
   HCH and the patient and family, and provides the patient with
   continuous access to the patient’s HCH;
 uses an electronic, searchable patient registry that enables the
   HCH to manage health care services, provide appropriate
   follow-up and identify gaps in patient care;
 includes care coordination that focuses on patient and
   family-centered care;
 includes a care plan for selected patients with a chronic or
   complex condition, involve the patient and, if appropriate, the
   patient’s family in the care planning process; and
 reflects continuous improvement in the quality of the
   patient’s experience, the patient’s health outcomes, and
   the cost-effectiveness of services.
 What Makes Minnesota’s Vision for
 Health Care Homes Unique?

 Statewide approach, public / private partnership
 Rule with HCH standards for certification, with an
    onsite verification process.
   Development of a payment methodology, per-person
    care coordination payment
   Integration of community partnerships with the HCH
   Outcomes measurement with accountability
   Required participation in a state-sponsored HCH
    learning collaborative
   Statewide health information technology plan in place
   Integration of patient and family
    centered care concepts
Who Can Apply for HCH Certification?

An eligible provider is a physician, nurse practitioner or
physician assistant that works as part of a team that
takes responsibility for the patient’s care and provides
the full range of primary care services including:

first point of contact acute care
preventive care
chronic care

Providers are certified. A clinic is certified when all the
clinic’s providers meet the requirements for
 Certification as HCH is Voluntary

 Certification requirements are met at
 Recertification at the end of year one and
  annually thereafter
 A variance may be granted for good cause or
  when failure to grant a variance would result
  in hardship
Health Care Homes:
Certification and Measurement
Outcomes Measurement Requirements

 HCHs must submit data to the statewide
  measurement reporting system
 Outcomes measures are based on the
  clinic’s total population
 The commissioner announces annually:
  – HCH outcome measures
  – Benchmarks to determine whether a HCH has
    demonstrated sufficient progress
 These are determined through a community
  work group process.
Challenges: Clinic Readiness to Begin
HCH Implementation?

 Two studies over the past few months:
  – 72% and 83% of primary care clinics self-
    identified they are working on health care home
    and they plan to seek certification. N = 375 / 400

 In one study 15% of clinics replied that they
  did not know about the certification.
 Do clinics really understand the
  transformation required?
 Challenges: Consumer Gaps in
 Understanding HCH Concepts

 Only 50% of patients agreed or strongly agreed that
they understood the meaning of Health Care Home

 N=688 consumers, MDH HCH Capacity Assessment Report
Challenges: Payment Methodology for Care
Coordination Payments

 Is the per person care coordination fee the
  right billing model?
 Can we design a billing process for types of
 What about cost neutrality for clinics, payers
  and patients?
 Skepticism: Will HCH control costs?
 The critical mass challenge?
Challenges: Certification

 Are the standards too hard to achieve?
 Are the standards rigorous enough for
  transformation and improvements in “triple
  aim” outcomes?
 Will payers and clinics have confidence in
  the statewide certification process?
 How many clinics will seek certification. Is it
 How will annual recertification look like as it
  is tied to outcomes?
Minnesota’s Vision for Health Care
Homes: Opportunities and Challenges

                             Transformational change in
                              care delivery
                              • Changes in clinic / community
                                infrastructure and culture
                              • Creation of a patient- and family-
                                centered health care system
                             Measurement must evaluate
                              all three goals of the IHI Triple
                              Aim and evaluate progress
                                Payment must blend payments
                                 for services and coordination
This is just one example of what of care
having a “ Medical Home” has
done for Amanda and us as a
Family!!” Marion (Amanda’s mom)
Minnesota’s Vision:
Health Care Homes

 Marie Maes-Voreis RN, MA
 Health Care Homes, Program Manger


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