All Healthcare is Local: Working Together to Prepare for Healthcare - - PDF document

9/30/2010 1

Dale Jarvis, CPA MCPP Healthcare Consulting, Inc. Seattle, Washington dale@mcpp.net

All Healthcare is Local: Working Together to Prepare for Healthcare Reform in Colorado

1

Overview

• Colorado is embarking on a Medicaid Healthcare Reform experiment

(Regional Care Collaborative Organizations) that will surely disrupt the status quo and may or may not work.

• In order to support Coloradans in the safety net, Community Health

Centers and Community Behavioral Healthcare Organizations need to: – Obtain a deep understanding of how healthcare reform should unfold in the U.S. and Colorado; – Build on work already underway by Colorado’s CHCs and CBHOs; and – Plan and implement a set of local and statewide strategies to promote a Next Generation Safety Net Healthcare System, leveraging the

• pportunities (and working within the limitations) of the Accountable

Care Act and the RCCO RFP.

2

9/30/2010 2

But wait, I live in Seattle…and

• All Healthcare is Local
• We are moving into a new era in

how the US Healthcare System is

• rganized and funded
• So we are going to have to figure this
• ut together…

3

Three Discussion Topics

• The Safety Net Delivery System in the

Context of the Overall US Healthcare System

• Redesigning the US Healthcare System –

Opportunities in the Accountable Care Act and Lessons from the Field

• Designing the Next Generation Colorado

Safety Net Healthcare System

4

9/30/2010 3

The Safety Net Delivery System in the Context

• f the Overall US

Healthcare System

5

A Tale of 2 Siblings

This session is partly a story of two siblings that were separated when they were children: CHCs and CMHCs

6

9/30/2010 4

CHCs: Federal Program Managed by HRSA

1960s Migrant Health Act of 1962 for farm workers/families Economic Opportunity Act of 1964 funds CHCs 1970s Section 330 of the Public Health Services Act

• Community Health Center Program – Section 330(e)
• Migrant Health Center Program – Section 330(g)

National Health Service Corps begins 1980s Health Care for the Homeless Program – Section 330(h) The 3 Types of CHCs become known as FQHCs FQHC Cost-Based Payments for Medicare & Medicaid 1990s Free Federal Tort Protection (Malpractice Insurance) Public Housing Primary Care Program – Section 330(i) 2000s Prospective Payment System States Required to Cover Difference between Rates & PPS Expansion of Funding and Capacity, adding BH Services

7

CMHCs: De-Federalized Program Managed by the States

Sister of CHCs in the 1960s and 1970s Part of the Shift and Shaft strategy that began in 1981 Leaving success or failure up to each state’s leadership and funding levels and the ability of local CBHOs to succeed (or not) in a highly regulated and underfunded environment.

8

9/30/2010 5

SMHA-Controlled Mental Health Revenue by State, FY 2006

State Total State Mental Health Revenue Target # of Persons to Serve/Year Revenue per Target Client Rank $ Over (Under) Top 10 Average % Over (Under) Top 10 Average Pennsylvania $3,332,904,698 544,949 $6,116 1 $1,644 37% Maine $464,300,000 76,362 $6,080 2 $1,608 36% District of Columbia $229,400,000 38,093 $6,022 3 $1,550 35% Alaska $183,200,000 33,512 $5,467 4 $995 22% New Hampshire $166,100,000 38,394 $4,326 5

• $146
• 3%

Maryland $810,000,000 233,097 $3,475 6

• $997
• 22%

New Jersey $1,241,600,000 365,082 $3,401 7

• $1,071
• 24%

Minnesota $721,100,000 213,635 $3,375 8

• $1,096
• 25%

Vermont $122,500,000 36,426 $3,363 9

• $1,109
• 25%

New York $3,982,300,000 1,287,434 $3,093 10

• $1,379
• 31%

Top 10 Average $4,472 Wyoming $52,600,000 22,248 $2,364 13

• $2,108
• 47%

Arizona $977,900,000 447,063 $2,187 15

• $2,284
• 51%

Kansas $248,700,000 125,940 $1,975 22

• $2,497
• 56%

South Dakota $57,800,000 31,047 $1,862 25

• $2,610
• 58%

Colorado $340,000,000 221,881 $1,532 29

• $2,940
• 66%

Nebraska $108,700,000 71,758 $1,515 31

• $2,957
• 66%

Utah $150,000,000 116,070 $1,292 33

• $3,180
• 71%

Nevada $151,000,000 118,765 $1,271 34

• $3,200
• 72%

Idaho $67,100,000 69,246 $969 38

• $3,503
• 78%

9

Meanwhile…

• The dysfunction of the rest of the American Healthcare System has

been creating a huge sucking sound in the American Economy

• And funding for the safety net has taken a back seat to centers of

power: insurance companies, pharmaceutical companies, hospitals, specialty physicians, etc…

10

Billions % FQHC Funding $9.1 0.3% CMHC Funding $19.7 0.7% Combined Funding $28.8 1.0% US Healthcare Funding $2,776 100% Millions % Medicaid or Indigent/Uninsured 69 22% Total US Residents 307 100% Sources: HRSA, NASMHPD, SAMHSA, Kaiser, Commonwealth Fund

9/30/2010 6

Which has created an upside down Resource Allocation Triangle

Acute Care

Specialty Care

Prevention Primary Care

11

Acute Care

Specialty

Care

Prevention Primary Care

Results: Healthcare Cost

The Cost Growth of

the current American Healthcare System is unsustainable Growing at a rate much higher than the rest of the Economy

12

9/30/2010 7

Results: Healthcare Quality

The U.S. Healthcare System is both the Best and the Worst Healthcare System in the Industrialized World

13

60 70 80 90 100 110 65 71 71 74 74 77 80 82 82 84 84 90 93 96 101 103 103 104 110

Preventable Deaths* per 100,000 Population in 2002-2003 (19 Industrialized Nations, Commonwealth Fund)

(* by conditions such as diabetes, epilepsy, stroke, influenza, ulcers, pneumonia, infant mortality and appendicitis)

• The 53 year lifespan for Americans with a Serious Mental Illness is comparable with

Sub-Saharan Africa

• Americans with a Co-Occurring Disorder are dying, on average, at age 45

(Oregon Department of Human Services Addiction and Mental Health Division, June, 2008)

14

Results: Americans with a SMI and a COD

9/30/2010 8

The Consequences for the Overall Healthcare System

15

Total Healthcare Expenditures

• f Americans

with a Serious Mental Illness are 2 to 3 times higher

The Consequences for the Overall Healthcare System

Mental Health, Substance Use, and Co-Occurring Disorders: an inseparable part of the equation

16

GA-U: General Assistance Unemployable

9/30/2010 9

The Challenge for Americans in the Safety Net and the Organizations that Serve Them

• Nationally, CHCs, CMHCs and other Safety Net Providers need

to find new ways to work together to plan for and deliver quality and cost-effective services through the development of a Next- Generation Safety Net Healthcare System.

17

Safety Net Healthcare System Accountable Care Organization

Person Centered Health Care Homes Hospitals

Food Mart

Specialty Clinics

Food Mart

Specialty Clinics Person Centered Health Care Homes Hospitals Clinic Clinic Social Service Agencies Schools Child Care Etc.

Redesigning the US Healthcare System – Opportunities in the Accountable Care Act and Lessons from the Field

18

9/30/2010 10

Four Strategies in the Accountable Care Act...

19

Atul Gawande: Testing, Testing

• Insurance Reform and Coverage

Expansion are “technical fixes”

• Service Delivery Redesign and

Payment Reform will require pilots to test ideas and models

20

9/30/2010 11

Strategy: Insurance Reform Addresses Many Problems

• Many New Protections, including:

– Insurance Companies can’t Deny Coverage – Bans Pre-Existing Condition Exclusions – Prohibits all Annual and Lifetime Limits – Provide Dependent Coverage for Children up to Age 26 in Individual and Group Policies

21

Strategy: Coverage Expansion

• Expands Coverage to most Americans

– Expands Medicaid for all Under 133% of the Federal Poverty Level – Creates State Health Insurance Exchanges to help Newly Insured and those with Individual and Small Group Coverage to Purchase Affordable Policies (large buying club) – Provides Credits & Subsidies up to 400% of the Federal Poverty Level to help Individuals and Families Purchase Insurance Important Note: The majority of low income, uninsured Americans with behavioral health disorders will obtain coverage by 2014

22

9/30/2010 12

Coverage Expansion: BIG NUMBERS

Insurance Coverage of Nonelderly Coloradans (0-64) with Incomes up to 133% Federal Poverty Level (2007-2008) CO # CO % Employer 150,400 18.9% Individual 62,700 7.9% Medicaid 222,900 28.0% Other Public 35,300 4.4% Uninsured 324,100 40.7% Total 795,400 100.0%

http://www.statehealthfacts.org/profileind.jsp?cmprgn=1&cat=3&rgn=7&ind=849&sub=177

23 24

Commonwealth Fund Report The Path to a High Performance U.S. Health System "Near" Universal Coverage Net Savings from Insurance Expansion Reduced Administative Costs Payment Reforms Enhanced Payment for Primary Care Adoption of the Medical Home Bundled Payment for Acute Care Correcting Medicare Rates Improving Quality and Outcomes Accellerating Spread and Use of IT Center for Comparative Effectiveness Reducing Tobacco Use Reducing Obesity Net Impact 2010 - 2020 (-$2,998 Billion)

Identified 10 Health Care Reform Policies that can save $3 trillion

• ver 10 years (Commonwealth Fund 2009)

Service Delivery Redesign and Payment Reform

9/30/2010 13

And the Policies CAN WORK "In Denmark, over the last few decades, the number of hospitals has dropped from 155 to 21 today”, according to Grundy.”

(excerpt from the Providence Business News 5/27/2010)

And in the US: “Pilots in the U.S. include Geisinger's, which Grundy says has been remarkably successful, yielding … a 12% reduction in ER utilization, a 20% reduction in hospitalization, and a 48% reduction in

• rehospitalization. (excerpt from David Harlow’s Health Care Law Blog 9/15/2009)

25

Four Key Innovations Encompass Most of the Commonwealth Fund’s Policy Changes

• Patient Centered Medical Homes with

new Payment Mechanisms

• Bi-Directional Primary Care/

Behavioral Health Integration

• Bundled Payments

for Conditions that Require Inpatient Admission

• Accountable Care

Organizations

26

Patient Centered Medical Homes

Person-Centered Healthcare Home Development Fully Integrated or Focused Partnership Healthcare Home Supporting Mental Health and Substance Use Services in Primary Care

CBHO CBHO with Embedded Medical Clinic Providing Primary Care Services in Community Behavioral Healthcare Organizations Food Mart CBHO

9/30/2010 14

Medical Homes: The Promise…

The Group Health Cooperative Story

2002-2006: Move towards Medical Home

– Email your Doctor – Online Medical Records – Same Day/Next Day Appointment

(Increased patient access but also saw provider burn-out and decline in quality scores)

2007: More robust Healthcare Home Pilot

– Added more staff (15% more docs; 44% more mid-levels; 17% more RNs; 18% more MAs/LPNs; 72% more pharmacists) – Shifted to 30 minute PCP slots

(Reduced burnout, increased quality scores, broke even in the first year)

27

What Group Health is Trying to Accomplish: Medical Home Principles

Everyone has...

• An Ongoing Relationship with a PCP
• A Care Team who collectively takes

responsibility for ongoing care and

• Provides all Healthcare or makes

Appropriate Referrals

• Helping ensure that Care is Coordinated and/or Integrated

Where...

• Quality and Safety are hallmarks
• Enhanced Access to care is available (evenings & weekends)
• And Payment appropriately recognizes the Added Value

(Joint Principles of the Patient-Centered Medical Home: www.pcpcc.net)

28

9/30/2010 15

• Fee for Service is headed towards extinction
• Healthcare Home models are beginning with a 3-layer funding design with

the goal of the FFS layer shrinking over time

• Being replaced with case rate or capitation with a pay for performance layer

29

New Payment Mechanisms for Patient Centered Medical Homes

Person Centered Healthcare Homes

Case Rate Fee for Service/ PPS Bonus

· Prevention, Early Intervention, Care Management for Chronic Medical Conditions · Per Service Payment · Prospective Payment System (PPS) Settlement (FQHC model) to cover shortfalls · Share in Savings from Reduced Total Healthcare Expenditures (bending the curve)

Payment Reform: Bundled Payments

Bundled Payments for Conditions that Require Inpatient Admission – the “sleeper strategy” that will dramatically affect the centers of power in healthcare

• Payment for inpatient care will bundle hospital and physician services that
• nly pay for part of Potentially Avoidable Complications (PACs)
• Bundled payments

may include all costs in the 30 days post an inpatient stay, including any return to the hospital

Think of DRGs on steroids…

30

9/30/2010 16

Accountable Care Organizations (ACOs) – the homes for medical homes

• Accountable Care Organization (ACO) Model

Medical Homes Hospitals Medical Homes

Food Mart

Specialty Clinics

Food Mart

Specialty Clinics Medical Homes Hospitals Clinic Clinic Accountable Care Organization Health Plan

31

ACO’s dual purpose:

• Organization structure to support coordination of care and

payments between Healthcare Homes, Specialists and Hospitals

• Way for small to mid-sized primary care practices to
• btain the infrastructure of larger practices as they work

to become Person-Centered Healthcare Homes

Harold Miller, How to Create Accountable Care Organizations, www.chqpr.org

32

9/30/2010 17

Bi-Directional Primary Care/ Behavioral Health Integration

• A growing awareness of the prevalence of

MH/SU disorders and the cost of not providing effective treatment and supports

• Combined with the an awareness that

– Behavioral Health is necessary for Health – Prevention is Effective – Treatment Works – People Recover

• Results in increasing recognition that we

can’t bend the cost curve without addressing the healthcare needs of persons with a SMI and the MH/SU needs of all Americans

33

Bi-Directional Primary Care/ Behavioral Health Integration

Bi-Directional Care: Behavioral Health in Primary Care and Primary Care in Behavioral Health

34

Clinical Design for Adults with Low to Moderate and Youth with Low to High BH Risk and Complexity Primary Care Clinic with Behavioral Health Clinicians embedded, providing assessment, PCP consultation, care management and direct service Partnership/ Linkage with Specialty CBHO for persons who need their care stepped up to address increased risk and complexity with ability to step back to Primary Care Clinical Design for Adults with Moderate to High BH Risk and Complexity Community Behavioral Healthcare Organization with an embedded Primary Care Medical Clinic with ability to address the full range of primary healthcare needs of persons with moderate to high behavioral health risk and complexity Food Mart CBHO

Food Mart

CBHO

9/30/2010 18

Service Delivery Redesign and Payment Reform

• $700 Billion Question: Will the current healthcare reform law

and accompanying payment reform & delivery system redesign tools be enough to improve quality and bend the cost curve before healthcare costs bankrupt us?

• Our Prediction: Not unless a robust Safety Net Healthcare

System is successfully created and widely deployed

35

Designing the Next Generation Colorado Safety Net Healthcare System

36

9/30/2010 19

Designing the Next Generation Colorado Safety Net Healthcare System

• Supporters of a Next Generation Safety Net System in

Colorado must focus on four areas:

• 1. Creating a Vision of what’s needed
• 2. Deploying a best practice Service Delivery Design

throughout Colorado

• 3. Building a best practice Management System throughout

Colorado that supports the new Service Delivery Design

• 4. Developing a Financing Design that supports the new

Service Delivery Design and pushing for State and Federal Financing Design changes

37

• 1. Creating a Vision for the Next

Generation Colorado Safety Net Healthcare System

• Robust Medical Homes are critical
• We also need to expand the available services in Medical Homes to

include a focus on the behavioral health, housing, social and personal supports needed to achieve and maintain health

• And “flip” the

Resource Allocation Triangle to adequately fund needed services and supports

Safety Net Healthcare System Accountable Care Organization

Person Centered Health Care Homes Hospitals

Food Mart

Specialty Clinics

Food Mart

Specialty Clinics Person Centered Health Care Homes Hospitals Clinic Clinic Social Service Agencies Schools Child Care Etc. 38

9/30/2010 20

• 2. Deploying a best practice

Service Delivery Design throughout Colorado

• Will Colorado’s healthcare reform efforts (the

Regional Care Collaborative Organizations):

– Successfully integrate Care Management into Medical Homes?

39

RCCOs and Research on External versus Integrated Care Management

40

9/30/2010 21

• 2. Deploying a best practice

Service Delivery Design throughout Colorado

• Will Colorado’s healthcare reform efforts (the

Regional Care Collaborative Organizations):

– Build on the efforts of the CHC/CBHO primary care/behavioral integration work?

41

The Colorado Safety Net System is several steps ahead of many other states… The Integration Mapping Project identifies nearly 100 local initiatives

42

http://maps.google.com/maps/ms?ie=UTF8&hl=en&msa=0&msid=111864582520065243892.000 476516d22ca18503a5&z=7

9/30/2010 22

• 2. Deploying a best practice

Service Delivery Design throughout Colorado

• Do Colorado’s safety net clinics meet

standards for NCQA PCMH certification?

• And if “not quite”, what kind of support is

needed (financial and technical) to close any existing gaps? (next slide)

43

NCQA Certification Standards for PCMH

(revised and posted for comment, * indicates reference to MH/SU conditions)

• PCMH 1: Access and Continuity

– Access During Office Hours – Access After Hours – Electronic Access – Continuity – Patient/Family Partnership – Culturally and Linguistically Appropriate Services – Practice Organization

• PCMH 2: Identify and Manage Patient

Populations – Basic Data – Searchable Clinical Data – Comprehensive Health Assessment* – Using Data for Population Management

• PCMH 3: Plan and Manage Care

– Guidelines for Important Conditions – Care Management* – Medication Management – Electronic Prescribing

• PCMH 4: Self-Care Process
• PCMH 5: Track and Coordinate Care

– Test Tracking and Follow-up – Referral Tracking and Follow-up* – Coordination with Facilities/Care Transitions – Referrals to Community Resources

• PCMH 6 Performance Measurement and

Quality Improvement – Measures of Performances – Patient/Family Feedback – Quality Improvement – Reporting Performance Measures

44

9/30/2010 23

• 2. Deploying a best practice

Service Delivery Design throughout Colorado

• Do all of the primary care/behavioral health

integration efforts have clear clinical designs and care processes that support/align with the clinical designs? (next slide)

45

Well Defined PC/BH Integration Clinical Designs? (WA State Clinical Model)

46

New Patient’s first Visit to PCP includes behavioral health screening

Possible BH Issues?

Behavioral Health Assessment by BH Professional working in primary care

Need BH Svcs?

Clients with Low to Moderate BH need enrolled in Level 1; to be case managed and served in primary care by PCP and BH Care Coordinator with support from Consulting Psychiatrist and

• ther clinic-based Mental Health Providers

Clients with Hi Moderate to High need referred to Level 2 specialty care; PCP continues to provide medical services and BH Care Coordinator maintains linkage; this is a time- limited referral with expectation that care will be stepped back to primary care

YES YES

Person Centered Healthcare Home Clinical Design based on IMPACT Model

• Systematic outcomes tracking (e.g., PHQ-9 for depression, GAD-7 for anxiety)
• Treatment adjustment as needed including stepped care (e.g. up to specialty BH)

(based on clinical outcomes, evidence-based algorithm; in consultation with team psychiatrist)

• Relapse prevention

Referrals to other needed services and supports (e.g. CSO, Vocational Rehabilitation)

9/30/2010 24

• 2. Deploying a best practice

Service Delivery Design throughout Colorado

• How close is the existing delivery system to

Group Health, Intermountain and Geisinger?

• What internal redesign efforts and external

regulatory and financing changes are needed to support closing any gaps?

47

• 3. Building a best practice

Management System throughout Colorado

• How do the existing safety net systems

throughout the state leverage existing resources to create greater synergy and impact? (Central Oregon project)

48

9/30/2010 25

The Central Oregon Regional Health Authority Experiment

49

9/30/2010 26

• 3. Building a best practice

Management System throughout Colorado

• How do the existing safety net systems

throughout the state move further up the food chain to manage the full continuum of care settings and services similar to the Accountable Care Organization and Integrated Health System (e.g. Group Health) models? (next slide)

52

9/30/2010 27

Community Health Plan of Washington

53

• 3. Building a best practice

Management System throughout Colorado

• Is the Regional Care Collaborative Organizations ACO RFP an
• pening or black hole for moving to the next level?

54

9/30/2010 28

• 4. Financial System Design

Developing a Financing Design that supports the New System – Can the funding braiding and blending unfolding in the Central Regional Health Authority be applied to Colorado?

55

• 4. Financial System Design

Developing a Financing Design that supports the New System – Is there any room in the market to create a statewide safety net health plan like CHPW?

56

9/30/2010 29

• 4. Financial System Design

Pushing for State and Federal Financing Design changes: – Is it possible to change the FQHC funding model in Colorado to support a bonus/shared savings layer in the framework of the Prospective Payment System? – What other Colorado regulatory issues hinder the ability to get paid for important integration-related clinical work?

57

Conclusion

• Colorado is embarking on a Medicaid Healthcare Reform experiment

(Regional Care Collaborative Organizations) that will surely disrupt the status quo and may or may not work.

• In order to support Coloradans in the safety net, Community Health

Centers and Community Behavioral Healthcare Organizations need to: – Obtain a deep understanding of how healthcare reform should unfold in the U.S. and Colorado; – Build on work already underway by Colorado’s CHCs and CBHOs; and – Plan and implement a set of local and statewide strategies to promote a next generation Safety Net Healthcare System leveraging the

• pportunities (and working within the limitations) of the Accountable

Care Act and the RCCO RFP.

58