LEADING HEALTH CENTERS THROUGH CHANGE:MOVING FROM VOLUME TO VALUE THROUGH THE TRIPLE AIM

Mary Maddux-González, MD, MPH

Chief Medical Officer, Interim CEO

Redwood Community Health Coalition (RCHC)

16 Non-Profit Community Health Centers and Clinics in Sonoma, Marin, Napa and Yolo Counties

225,000 patients

Redwood Community Health Coalition

Changes• Transition to Managed Care Medi-Cal with Partnership

HealthPlan of Califorina!

• Demographics• Disease Trends• Health Care Reform• Practice Transformation• Payment Reform• PPS?

THE CURRENT HEALTH CARE SYSTEM IS UNSUSTAINABLE AND IS NOT DELIVERING THE OUTCOMES AND QUALITY THAT OUR PATIENTS, COMMUNITIES AND NATION NEED

Determinants of Health and Their Contribution to Premature Death

Social circumstances

15%

Environmental exposure

5%

Health care10%

Behavioral patterns

40%

Genetic predisposition

30%

Adapted from: McGinnis JM, Williams-Russo P, KnickmanJR. The case for more active policy attention to health promotion. Health Aff(Millwood) 2002;21(2):78-93.

Proportional Contribution to Premature Death

Sonoma County Life Expectancy

Life Expectancy

Country Life Expectancy At Birth (Years)

1 Japan 82.0

2 Singapore 81.8

3 France 80.8

4 Sweden 80.6

5 Australia 80.6

6 Switzerland 80.6

7 Canada 80.3

8 Italy 79.9

9 Spain 79.8

10 Norway 79.7

11 Israel 79.6

12 Greece 79.4

13 Austria 79.2

14 Netherlands 79.1

15 Germany 79.0

16 New Zealand 79.0

17 Belgium 78.9

18 United Kingdom 78.7

19 Finland 78.7

20 Denmark 78.0

21 United States 77.9

22 Ireland 77.9

23 Portugal 77.9

24 Mexico 75.6

25 Poland 75.2

26 China 72.9

Life Expectancy

Country Life Expectancy At Birth (Years)

1 Japan 82.0

2 Singapore 81.8

3 France 80.8

4 Sweden 80.6

5 Australia 80.6

6 Switzerland 80.6

7 Canada 80.3

8 Italy 79.9

9 Spain 79.8

10 Norway 79.7

11 Israel 79.6

12 Greece 79.4

13 Austria 79.2

14 Netherlands 79.1

15 Germany 79.0

16 New Zealand 79.0

17 Belgium 78.9

18 United Kingdom 78.7

19 Finland 78.7

20 Denmark 78.0

21 United States 77.9

22 Ireland 77.9

23 Portugal 77.9

24 Mexico 75.6

25 Poland 75.2

26 China 72.9

Infant Mortality Rate

1998

1999

2000

2001

2002

^20

03

2004

^20

0520

0620

070

4

8

12

7.2 7.0 6.9 6.8 7.0 6.8 6.8 6.9 6.7 6.8

10.311.1

10.2 9.9 9.9 9.610.1

10.810.0 9.9

5.3 5.1 5.0 4.9 4.8 4.7 4.7 5.0 5.0 5.0

U.S. average Bottom 10% states Top 10% states

Iceland

SwedenJapan

Finland

Norway

Denmark

Canada

United States

2.02.5 2.6 2.7

3.14.0

5.1

6.8

National average and state distribution

International comparison, 2007

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.

Infant deaths per 1,000 live births

^ Denotes years in 2006 and 2008 National Scorecards.Data: National and state—National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2003–2008; Mathews and MacDorman, 2011); international comparison—OECD Health Data 2011 (database), Version 06/2011.

Mortality Amenable to Health Care

76

88 8981

8899 97

109116

10697

134

115 113

127120

55 57 60 61 61 64 66 67 74 76 77 78 79 80 8396

0

50

100

150 1997–98 2006–07

Deaths per 100,000 population*

* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.See Appendix B for list of all conditions considered amenable to health care in the analysis.Data: E. Nolte, RAND Europe, and M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality files and CDC mortality data for U.S. (Nolte and McKee, 2011).

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.

The Uninsured

• United States• 50 million people

• Health Consequences of No Insurance

• 6th leading cause of death in the US

Donald Berwick: NY Times Dec. 3, 2011

• US health system - “extremely high level of waste”

• 20-30 % of health spending is waste and yields no benefit to patients

• Five reasons• Overtreatment of patient• Failure to coordinate care• Administrative complexity of the health care system• Burdensome rules• Fraud

High Degree of Fragmentation and Misaligned Payment Systems

• High degree of fragmentation in insurance system leads to cost-shifting, inefficient administration and rewards for avoiding sick, high-risk patients

• Rewards for specialty care greater than those for primary care

• Payment incentives within fragmented delivery structure encourage the provision of more, and progressively more fragmented care, especially for chronically ill patients

Framework for a High Performance Health System in the United States, The Commonwealth Club, 2006

“We spend more on health care than any other country. But we allocate our resources inefficiently and wastefully, failing to provide universal access to

care and failing to achieve value commensurate with the money spent.”

WE CAN DO BETTER AND WE KNOW HOW.

In March 2010, President Obama signed into law theAffordable Care Act.

Health Care Reform

 

ACA STRATEGIES

Three Dimensions of Value

PopulationHealth

Experienceof Care

Per CapitaCost

ALL MODELS ARE WRONG…

28

ALL MODELS ARE WRONG…BUT SOME ARE USEFUL

29

System designs that simultaneously improve three dimensions: Improving the health of the populations; Improving the patient experience of care (including quality and satisfaction); and

Reducing the per capita cost of health care.

Triple Aim

‘Simplicity’ of the conceptIHI reputationModel forces us to go beyond our limited roles within our

fragmented system and look across continuum of systemStrong primary care emphasis Goes beyond the US experience to include that of other

countriesApplies a rationale construct to our irrational system

Drivers of Low Value Health Care

Primary Drivers

“More Is Better” Culture

Supply Driven Demand

No Mechanism to ControlCost at the Population Level

Over-Reliance on Doctors

Lack of Appreciation fora System

Low Value Health Care

Where are the ‘Triple Aim’ opportunities to improve care, get better outcomes and control per capita costs?

• Primary Care

• Chronic Disease Care Management

• Reducing Preventable Hospitalizations

• Reducing Hospital Readmissions

• Improving End of Life Care

• “The pursuit of the Triple Aim is not congruent with the current business models of an but a tiny number of US health care organizations...Thus we face a paradox with respect to …Triple Aim. From the perspective of the United States as a whole it is essential, yet from the viewpoint of individual actors responding to current market forces, pursuing the three aims is not in their immediate self-interest.”

Berwick, DM et al Health Affairs, 27,no. 3 (2008)

RCHC Strategic Priorities

• Demonstrate Triple Aim Value of our Community Health Centers

• Achieve Patient-Centered Health Home Transformation and Recognition

• Develop Capacity to Maximize Positive Impact of Health Care Reform

• Develop ACO• Strengthen Data Capacity and Infrastructure• Strengthen RCHC Relationship with Partnership and other

Health Care Delivery System Partners

Value of Health Centers Study

• Adult FQHC patients* statistically less likely than non-FQHC patients to experience

• Multi-day admission**• Emergency visit• 30-day readmission

• *Controlling for disability status, age, gender and months enrollment• **non-pregnancy, non-mental health/substance abuse)

Value of Health Centers Study

• FQHC adult patients had 19% lower total costs compared to non-FQHC patients on average (p<.01)

Value of Health Centers Study

• “FQHCs are demonstrating value. The investment in primary care through FQHC PPS rates and enabling services, is associated with reduced inpatient utilization, lower readmission rates and fewer ED visits for their patient population.”

Achieve Patient-Centered Health Home Transformation and Recognition

• RCHC Health Home Transformation Health Home Collaborative

• Complex Care Management Pilots

Organize HH Team

Complete HH/ Organizational Assessments

Gap Analysis

Health Home Road Map

Implement/Document Health Home Elements

Complete and Submit NCQA

Application

HH Strategic Coaching

CPCA Portal

2012----APRIL -------------- MAY-------- JUNE---------------------------------------MAY 2013------

HHWC Learning Sessions: In-person and webinars

Achieve Patient-Centered Health Home Transformation and Recognition: RCHC Health Home Working Collaborative

Develop Capacity to Maximize Positive Impact of Health Care Reform

• Maximize outreach, enrollment and retention

• Position health centers for value-based reimbursement and shared risk

Coverage Expansion

• Medi-Cal Expansion

• Commercial Insurance Expansion • Exchanges- Covered California

• Individuals• Small Business (SHOP)

• Individual Mandate

Coverage Expansion

•What will happen to the current 70,000 uninsured?• 30,000 eligible for Private insurance• 20,000 eligible for Medi-Cal• 20,000 ineligible for insurance under ACA

Coverage Expansion

•What will happen to the current 70,000 uninsured?• 30,000 eligible for Private insurance• 20,000 eligible for Medi-Cal• 20,000 ineligible for insurance under ACA

Number of residual uninsured will be ???

Projected Insurance Status In California After The Affordable Care Act, 2016.

Long P , Gruber J Health Aff 2011;30:63-70

©2011 by Project HOPE - The People-to-People Health Foundation, Inc.

Expanded Coverage Initiative (ECI)

• Convened by Healthy Kids Sonoma (RCHC)

• ECI Workgroup to design and develop ongoing system of collaborative outreach, enrollment and coverage retention activities

• Involves Health Centers, Hospitals, Health Department, Social Services, CBOs, Partnership Health Plan, others

Develop ACO

• Redwood Community Care Organization (RCCO)

• Applying to CMS for ACO status in 2013

Strengthen Data Capacity & Infrastructure

• Data Plan

• Blue Shield Consortia Data Capacity Grant

• HRSA Health Center Network Grant

• Chief Medical Informatics Officer

Strengthen Relationship with Partnership & Other Health Care Partners

•Partnership Health Plan

• Collaborative Projects and Studies• Participation in Board and Committees• Quality Improvement Program• Policy Issues• Consortium Meetings• Medical Director Collaboration

Strengthen Relationship with Other Health Care Partners

•Health Action

•Committee for Health Care Improvement

Global Triple Aim Participants

Local Opportunities:1. Maximize Coverage Expansion through Outreach,

Enrollment and Retention

2. Develop and coordinate local infrastructure and expertise for delivering Value-Based Care

3. Community-based Prevention

4. Maintain a Safety Net for residual uninsured

5. Communication, Coordination and Collaboration

CONTACT INFORMATION

Mary Maddux-González, MD, MPHInterim Chief Executive Officer &

Chief Medical Officer

Redwood Community Health Coalitionmmgonzalez@rchc.net

Breakout Sessions

• 1. What are 2 ways in which you can create a sense of urgency for change in your organization.

• 2. What are 2 opportunities for short term ‘wins’ in your organization?