The Search for Innovations to Improve Health Care Delivery for Underserved Populations UC Irvine Health Care Forecast Margaret Laws, Director, Innovations

The Search for Innovations to Improve The Search for Innovations to Improve Health Care Delivery for Underserved Health Care Delivery for Underserved PopulationsPopulations

UC Irvine Health Care Forecast

Margaret Laws, Director, Innovations for the UnderservedCalifornia HealthCare FoundationFebruary 20, 2009

CALIFORNIA HEALTHCARE FOUNDATION

Overview

CHCF and the Innovations for the Underserved Program

Strategies we’re pursuing

Examples – retail clinics, virtual visits, scope of practice in oral health

Questions and issues


CHCF- Who we are and what we do

Private, non-profit foundation, in operation since 1996

Approximately $35m per year in projects and grants - almost all “strategic” rather than unsolicited grants

Three major areas of work:

Innovations for the Underserved Better Chronic Disease Care Market and Policy Monitor

Launched “Innovations for the Underserved” program in 2006


Innovations for the Underserved Program

Encourage, test and promote lower cost models of care

Improve the availability of specialty and dental services for underserved Californians

Improve enrollment and retention in publicly-sponsored insurance programs

Increase the operational efficiency of safety net institutions


More than 20% of Californians are uninsured

Workers at private sector businesses of all sizes are experiencing an increased likelihood of being uninsured, although it is most pronounced in businesses with fewer than ten employees.

Twenty-seven percent of families with incomes between $25,000 and $50,000 are uninsured

More than a third of the uninsured have family incomes of more than $50,000 per year

Seventy percent of uninsured children are in families where the head of the household has a year round, full-time job

Nearly 60% of the state's uninsured are Latino

“Underserved” is a growing category…

Source: CHCF Uninsured Snapshot, 2008: http://www.chcf.org/documents/insurance/UninsuredSnapshot08.pdf


Options for low income people seeking care

No great options for people in the “affordability gap” between public coverage and commercial insurance FQHCs hit top of sliding scale at 200% of FPL

Commercial insurance for a family of four represents 80-100% of minimum wage earnings

Well-documented problems with access among those with insurance Don’t have a PCP Can’t get in to see their PCP Can’t afford the co-pays and deductibles


What types of innovation can lower cost or provide better value to underserved consumers?

Strategies we’re pursuing Stimulate development of service delivery models that offer

quality care at lower cost Promote adoption of services for the underserved that meet

their health care needs with better value propositions Promote regulation and reimbursement that encourage

delivery of quality care by more cost-effective providers

Examples of areas of work to date Retail or express clinics Use of kiosks for basic acute care Telehealth and “virtual visits” “Fuel efficient” providers Exploring scope of practice changes in oral health


EXAMPLE 1: RETAIL CLINICS


CHCF work on retail clinics

Two landscape reports: 2006 and 2007

Health Affairs partnership – issue on innovative care delivery models

Roundtable on retail clinics and primary care

NASHP report on regulation of retail clinics across the states

“Retail Clinic Toolkit” for safety net providers

Exploration of retail dental clinic model


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Retail clinics in grocery, drug and mass Retail clinics in grocery, drug and mass merchandise storesmerchandise stores


Who is operating retail-based clinics?Who is operating retail-based clinics?

Retailer-Owned Operators Retailers purchased clinics to have control over the

brand and the rollout See the clinics as core to their business expansion

across the whole pharmacy value chain 70-75% of all clinic sites

Independent “Pure Play” Operators Largely owned by investors Creating business to sell or operate at a profit Some work with hospitals (or others) and create co-

branded or joint venture clinics 8-10% of all clinic sites

HealthCare System-Owned Operators 15-20% of all clinic sites


Seven conditions account for 75-90% of retail clinic visits

These visits make up ~17% of PCP visits or ~80m visits (and ~15-30% of ED visits)

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Sinusitis

URI

Pharyngitis

Otitis Media/Externa

Bronchitis

UTI

Immunization

Current retail clinic visits are for a limited Current retail clinic visits are for a limited number of conditionsnumber of conditions


62 255 350800

1500

4000

6000

Jan. 2006 Dec. 2006 May-07 Dec. 2007 Dec. 2008 Dec. 2010 Dec. 2012

Number of clinics

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Clinics continue to open at a rapid pace Clinics continue to open at a rapid pace around the country around the country

Forecast


WSJ/Harris Poll Results – who’s using retail clinics, and for what?

• Surveyed 4937 U.S. adults – seven percent had visited a retail clinic• 40 percent visited for a vaccination, • 39 percent wanted treatment for common conditions like

ear infections or colds,• Just over 20 percent wanted preventive screenings or

school/sports physicals

• 30 percent indicated that they have no primary care provider

• Of those with coverage, 62 percent said that their insurer covered some or all of the cost

Source: WSJ.com/Harris Interactive, 2008


WSJ.com/Harris survey - satisfaction

93 percent were “very” or “somewhat” satisfied with convenience

90 percent with the quality of care,

88 percent with the staff qualifications, and

86 percent with the cost

Source: WSJ.com/Harris Interactive, 2008

CALIFORNIA HEALTHCARE FOUNDATION 16

Studies documenting quality are publishedStudies documenting quality are published


The central tenet behind retail clinics is their limited scope of service. By limiting scope of service to simple routine acute care, these clinics:

streamline operations

improve customer experience

maintain quality through the use of technology and

reduce costs

In essence they divert the less complex patients to a streamlined operation. The clinics are not trying to serve all patients in the same way with the same level of care.

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Community health centers can adopt retail Community health centers can adopt retail clinic principles in their own operationsclinic principles in their own operations


Current/potential roles for retail clinics or retail clinic principles in the safety net

Basic, acute care at posted, affordable rates (for everyone, regardless of insurance status, citizenship, etc) Potential role in coverage expansion schemes

Contractor with Medicaid agencies or managed care plans

ED diversion sites for public (and other) hospitals

Access extension sites for integrated networks or community health centers


EXAMPLE 2: TELEHEALTH/VIRTUAL VISITS



From telehealth pilots to more widespread virtual visits…

Telehealth technologies have been in broad “pilot” testing in the commercial sector and safety net for more than a decade

CHCF sponsoring several safety net demonstrations, focused on improving access to primary, specialty and dental care

Recent launch of “California Center for Connected Health” – focus on strategy, coordination and development of new business and care models


Safety net applications currently or soon to be tested

Telemedicine to improve access in clinics

Kiosk for uncomplicated UTI

Virtual practice


Virtual visits go mainstream?

Dixon and Stahl, Partners/Mass General, three broad aims of the study were:o to compare the physician’s ability to make diagnoses in both

settings, o to compare the physician’s ability to provide therapy in both

settings, ando to examine both patient and physician satisfaction with both

modalities

American Well launches virtual visit program in Hawaii

Major policy/reimbursement question:

How will a “visit” be defined in the future, and how will we develop the appropriate payment incentives?


EXAMPLE 3: SCOPE OF PRACTICE IN ORAL HEALTH




The impact of unmet dental needs in CA

In 2007, California hospitals had 80,000 Emergency Department visits per year for preventable dental conditions

In some counties, these visits were more frequent than preventable visits for asthma and diabetes


Significant supply/demand mismatch: dentists and safety net patients Dentists not practicing in rural or urban underserved

marketso Only 40% of CA dentists accept Medi-Calo Many only work part time

Scope of practice significantly limits what “mid-level” providers can do

Other states/countries have implemented effective programs to extend access through use of hygienists or dental therapistso Alaska has had a dental therapist program for four years;

therapists now being trained at University of Washingtono Australia and NZ have used dental therapists for 40 yearso Holland has decided to train no more dentists, only mid-level

providers


The path to a new scope/care model

Is not without roadblocks…scope of practice issues are notoriously contentious

But there is significant activity in states in advancing scope of practice in oral healtho Several models for better access at lower cost to the

system being tested

CA law allows for waivers to demonstrate scope of practice innovations

“Virtual dental home” project: CHCF pursuing waiver project using dental hygienists supported by remote dentists in six sites across the state


Some closing questions – two practical and one more philosophical

What will encourage regulators and providers to embrace some of the more “disruptive” innovations? Virtual visits Routine care delivered by mid-levels Truly patient-centered care modelsor even… Medical tourism

How do we work to create incentives for lower-cost models?

Can we let the easy, cheap stuff be easy and cheap (so that we can focus expensive resources on more complex problems)?


A perspective on “shopping for price in medical care”

“When services are less complex, shopping will be more effective because consumers have a better idea of what they are shopping for, they are less concerned about variation in clinical quality, and there may be less need to customize the information to meet a patient’s unique needs. Examples include immunizations, dental cleaning, and cholesterol tests. The current phenomenon of major investments in "mini-clinics" in department stores might reflect a bet on consumers’ willingness to emphasize price and convenience more in areas where they do not perceive much variation in clinical quality.”

Source: Ginsburg, Shopping for Price in Medical Care, HA 26, no. 2 (2007)


Contact Information

Margaret Laws

Director, Innovations for the Underserved

California HealthCare Foundation

[email protected]

www.chcf.org

Documents

The Search for Innovations to Improve Health Care Delivery for Underserved Populations UC Irvine Health Care Forecast Margaret Laws, Director, Innovations