Primary Care in Minnesota
Innovations in Primary Care
Jeff Schiff, MD MBA
Medical Director
Minnesota Department of Human Services
13 December 2010
What’s so different up there?
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Low rate of uninsured
Collaborative non-profit culture
Highly integrated delivery systems
Strong primary care base
And …
2008 percent of GDP in healthcare
National 15.1%
Minnesota 13.4%
Relatively healthy population
Underpinnings of Primary Care
Delivery Reform
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Patient and Family Centered Care
“Agency” role of providers
Advocate vs. steward
Creating and regulating the right market in
health care
“That a power imbalance exists between doctors and
patients has been readily acknowledged…. However the
effects of this asymmetry can be mitigated through the
establishment of trust between doctor and patient”
- Loree K Kallianinen,MD
Primary Care in Minnesota –
Health Care Home
• 2003 –HRSA grant to provide medical
home for children with special health care
needs
• 2007- first Minnesota legislation to pay for
care coordination
• 2008- major Minnesota health care reform
legislation including Health Care Home
Minnesota Health Care Home
Program
2008 Enabling legislation
• Designation of criteria in state rule
• Active clinic certification process
• Complexity-adjusted multi-payer payment
methodology
• Learning collaborative
• Outcomes reporting and results required
for recertification
Services required of certified
Health Care Homes
• Access and communication standards
– Availability of patient registry information
– Appointment availability/ triage capacity
• Registry functionality
• Care planning
• Care coordination
– Transition coordination
– Coordination with community agencies
– Dedicated care coordination capacity
• Practice based quality improvement
– Patient and family centered care
Complexity adjusted payment
methodology
• Provider determined tier assignment
• Based on the number of conditions groups (e.g.
endocrine, cardiovascular) that are chronic, severe,
and requiring a care team for optimal management
• Two supplemental complexity factors added (non
English as primary language and significant mental
illness)
• Work of providing a HCH (and payment rate)
estimated based on this complexity
• Modeling estimation of provider tier assignment
derived from claims based risk adjustment software
(also to be used to audit provider tier assignment)
Estimated Distribution: MHCP FFS
Figure 2: Distribution of Member Months by Count of Major
Condition Groups - Fee-for-Service MHCP Population
State Fiscal Year 2008
Count of M ajor
Condition
Groups
9%
12%
0 (Tier 0)
1-3 (Tier 1)
4-6 (Tier 2)
50%
7-9 (Tier 3)
10+ (Tier 4)
17%
12%
HCH payment
• Payment rates range from $10-$60 PMPM
• All Medicaid, state employees and
privately insured included in a “manner
consistent with…” that developed by DHS
• ~2% of the total health care spend on
patients
• Cost neutrality assumed by the legislature
Minnesota and federal health care
reform------Health Care Home
• Multipayer Advanced Primary Care
Practice (MAPCP) Demonstration
• ACA section 2703 – expanded federal
Medicaid match
MAPCP
• Cost neutrality $14.43 PMPM
• Medicare FFS to join state efforts
• Effect in the state
• Critical mass
• Credibility of program
• Common expectations for evaluation
Key Design Feature #1 (contd.):
Statewide Scope and “Critical Mass” of Payment
SOURCE: Adapted from MDH Health Economics Program, Medicare enrollment data and SEGIP enrollment data
ACO components – our program as
the logical bridge
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Build on primary care/ care coordination
Attribution
Risk
Total cost of care methodology/ Gain
sharing
• Measurement
• Our complex population
ACO in the ACA
ACO ≠ capitation
• Center for Medicare and Medicaid
Innovation
• Medicare shared savings
• Pediatric ACO
• Safety net hospital ACO
Key Program Information:
Minnesota Department of Health (MDH)
http://www.health.state.mn.us/healthreform/homes/index.html
Minnesota Department of Human Services (DHS)
http://www.dhs.state.mn.us/healthcarehomes