Advancing Health Care Reform in Maine:
Why, What, & How?
Aging Advocacy Summit
November 2012
Lisa M. Letourneau MD, MPH
Objectives
• Identify factors contributing to the urgent case
for transforming US health care system
• Introduce key components of Maine’s
emerging model for change
– Patient Centered Medical Home (PCMH)
– Community Care Teams (CCTs)
– Accountable Care Organizations (ACOs)
• Describe the role of consumers in supporting ,
driving this change
2
: Who We Are
•
•
•
Independent, multi-stakeholder alliance in Maine
working to transform health and healthcare by leading,
collaborating, and aligning improvement efforts
Only organization working to improve quality of care
for all Maine people
Members include consumers, doctors, nurses,
hospitals, health systems, payers, employers,
government, policy makers, and others working to
improve health and healthcare
3
: What We Do
• Align health care quality improvement efforts
• Engage consumers meaningfully in improving
health and health care
• Establish sustainable system of quality
improvement support for providers
• Improve integration of behavioral and
physical healthcare
4
: Major Programs
•
•
•
•
•
•
Aligning Forces for Quality
Maine Patient Centered Medical Home Pilot
Improving Behavioral Health Integration
Transforming Care at the Bedside
QC Learning Community
QC Annual Conference (“Best Practice College”)
5
5
A Compelling Case for Action
6
Vision for a Transformed Health Care System
Healthy, productive,
connected people &
families
…receiving
healthcare
from a highly
functioning
“accountable
care
organization”
… supported by a robust & well-supported system of primary care providers
What We Want from Our Health Care
• Relationship with our providers that crosses
settings, time, & place
• Caring, compassionate interactions
• Coordination & integration of care across
providers
• Ability to access care 24/7 – when & where
we need it
• Time, time, time…
8
But What Do We Get?
The 15 minute visit!
9
The Result: The Current Medical Home
Why? Follow the Money!
What we want:
• Relationship, time with
our providers
• Caring, compassionate
interactions
• Coordination &
integration of care
• Ability to access care
24/7
What we pay for:
• Visits
• Tests
• Procedures
• Procedures
• Procedures
11
The Stalemate That Blocks Change
Providers unable to
transform practice without
viable & sustainable
payment for desired
services
B
U
T
Employers & payers
unwilling to pay for desired
services unless providers
demonstrate value AND
show potential to save
money
12
A Recipe for Change?
Consumer Engagement
Transparent Cost &
Quality Data
Community
Leadership for Change
Help for Providers to
Change Care Systems
Alternative Payment
Models that Reward Value
(vs. Volume)
13
Community Leadership for Change
Maine
Quality
Counts
Maine Health
Management
Coalition
DHA’s
Maine
Quality
Forum
MaineCare
14
The Medical Home & ACOs:
Models for Change!
Providers change practice,
create value with viable &
sustainable payment for
desired services
= Delivery System Change
A
N
D
Employers & payers
pay for desired services
if providers can
demonstrate value AND
reduce spending
= Payment Reform
15
Defining Medical Home
“A medical home is not a building, house, or hospital,
but rather an approach to providing comprehensive
primary care. A medical home is defined as primary
care that is accessible, continuous, comprehensive,
family centered, coordinated, compassionate, and
culturally effective.”
American Academy Pediatrics
16
Maine PCMH Pilot Practices
17
17
Maine PCMH Pilot
“Core Expectations” for Practices
1. Demonstrated physician leadership for improvement
2. Team-based approach
3. Population risk-stratification and management
4. Practice-integrated care management
5. Same-day access to care
6. Behavioral-physical health integration
7. Inclusion of patients & families
8. Connection to community / local HMP
9. Commitment to reducing avoidable spending & waste
10. Integration of health IT
18
Community Care Teams
• Multi-disciplinary, community-based, practiceintegrated care teams
• Build on successful models (NC, VT, NJ)
• Support patients & practices in Pilot sites, help
most high-needs patients overcome barriers –
esp. social needs - to care, improve outcomes
• Key element of cost-reduction strategy,
targeting high-needs, high-cost patients to
reduce avoidable costs (ED use, admits)
19
Maine PCMH Pilot Community Care Teams
Environment
Schools
Transportation
Housing
Workplace
Outpatient
Services
Care Mgt
Family
Food Systems
High-need
Individual
Shopping
PCMH Med Mgt
Practice
Specialists
Coaching
Behav. Health
& Sub Abuse
Income
Hospital
Services
Physical
Therapy
Heat
Faith
Community
Literacy
20
Maine’s Medical Home Movement
~ 540 Maine Primary Care
Practices
Payers:
•Medicare
•Medicaid
•Commercial
(Anthem,
Aetna,
HPHC)
•Self-insured
employers
100+ NCQA PCMH
Recognized
Practices
26 Maine
PCMH Pilot
Practices
~130+ MaineCare
HH Practices?
50 Pilot
Phase 2
Practices
14 FQHCs
CMS APC
Demo
Payer:
Medicaid
Payer:
Medicare
21
So…What About ACOs?
“Accountable Care Organizations (ACOs) will
constitute groups of providers - physicians,
other clinicians, hospitals or other providers that together provide care and share
accountability for the cost and quality of care for
a population of patients”
T. Lake et al, “Lessons from the Field: Making Accountable Care
Organizations Real “, NIHCR Research Brief, Jan 2011
22
PCMH: Hub of Wider Delivery &
Payment Reform Models (ACOs!)
Primary Care
Providers
Employers
Payers
Hospitals/
Hospitalists/
Care
Managers
Pharmacies
Patient
Centered
Medical
Home
Home
Health
Home Care
Health
Mane
Parterships
Nursing
Homes
Specialists
ACO
23
ACOs in Maine – What’s Happening?
• Employer-Provider ACO Pilots
– Maine Health Management Coalition leadership
– MaineGeneral-SEHC, EMMC, other pilots
• Medicare – multiple ACO options
24
– Pioneer ACO – EMHS
– Shared Savings programs – MH, CMMC, MePCA
• Medicaid: Value-Based Purchasing strategy
– Seeking “Accountable Communities” proposals
24
Engaging Consumers,
Partnering with Patients
• Untapped “force” for improving health care
• Need to shift from provider-centered to
patient-centered approaches (think banking!)
• Need patients to better understand their role
– To improve their health, and
– To change health care system
• Changing patient role requires changing
culture of US health care
25
Patient Engagement
What We Say:
• We want patients to
take active role in
making decisions about
their health
What We know:
• Patients – even well
educated, are reluctant to
ask questions
• We want patients to
ask questions
• Patients are fearful of
challenging provider
recommendations
• We want patients to
express values &
preferences
• Many patients feel
physicians are authoritarian
(vs. “authoritative”)
26
“Better Health. Better ME!”
Consumer Engagement Campaign
Take Charge of Your Health:
• Step ONE: VISIT your Primary
Care Provider
• Step TWO: ASK Questions
• Step THREE: KNOW your
numbers
• Step FOUR: FIND and use
community resources and
programs to support health
27
27
Partnering for Improvement
28
28
ABIM “Choosing Wisely” Campaign
• Physician-led effort to identify
opportunities to improve care
and decrease use of wasteful
services
• Have created lists: “5 Things
Physicians & Patients Should
Question”
• Appeals to professionalism
• Promotes partnership with
patients
• Have engaged multiple
specialty physician groups
29
Patient Tools
30
Consumer Reports “Best Buy Drugs”
31
Managed Care All Over Again?
‘Old-School’ Managed Care
• Focus on reducing costs
• Global capitation
vs.
PCMH + ACOs
• Focus on demonstrating value
• New care management fees
(plus performance payments?)
• PCP at full financial risk
• Limited financial risk to PCP
• PCP as gatekeeper
• Primary care team coordinates
care & supports patient needs
across “med neighborhood”
• Very limited information and • Improved information and tools
(EMR, registries)
tools
32 32
Change is Hard
• Hard to repair the plane
in flight
• Hard to practice while
practicing!
• People fear change (loss)
- any change
33
QC 2013 – Save the Date!
Aligning Maine’s Forces
To Achieve the Triple Aim of Improvement
•
•
•
•
Wed, Apr 3, 2013
Augusta Civic Center
Dr. Donald Berwick
Join us!
34
34
www.mainequalitycounts.org
35
Contact Info / Questions
 Lisa Letourneau MD, MPH
• LLetourneau@mainequalitycounts.org
• 207.415.4043
 Maine Quality Counts
• www.mainequalitycounts.org
Maine PCMH Pilot
• www.mainequalitycounts.org
(See “Programs”  PCMH)
36