Health Care Home (HCH)
Purchaser/Employer Partnership
Final Report
August 2, 2012
Health Care Home (HCH) Purchaser/Employer Partnership
Final Report
Background
BHCAG was hired to conduct outreach, education and dialogue between state government (Minnesota
Department of Health [MDH] and Minnesota Department of Humans Services [DHS]) and self-insured
purchasers of health care regarding the statewide multi-payer Health Care Home (HCH) initiative. The HCH
initiative was enacted through state legislation that mandated public and insured, private, payer
participation. While self-insured purchasers share the goals of HCH, their participation as payers was not
mandated. The project was designed to raise awareness of, educate and engage employers in the HCH
initiative so they may realize its value, support it to their employees, and participate through their health
plans and administrators.
Goals and Objectives: The proposal included the following goals for participating purchaser/employer
organizations by the end of the project:
• Understand the main components of the HCH initiative
• Place the initiative in the context of state and national purchaser-led health reform
• Identify the opportunities and barriers to incorporating HCH into their benefits and purchasing
strategies
• Work with MDH/DHS program staff and participating organizations to craft messages and identify
next steps
Project Activities: Representatives from the State of Minnesota’s departments of Human Services and
Health, BHCAG representatives and Steering Committee representatives participated in the following:
•
•
•
•
Conference calls: Eight conference calls were conducted between MDH, DHS and BHAG personnel
on March 7, March 21st, April 4th, April 23rd, May 4th, May 16th, May 30th, June 13th. They included
initial selection of Steering Committee members (see Appendix A), planning of Steering Committee
meetings and Workshops, Tool Kit Contents (Appendix D) and updates on relevant activities of the
BHCAG and the Departments of Human Services and Health.
Steering Committee Meetings: Four Steering Committee meetings were conducted including
representatives from purchasers, providers, health plans, the State and BHCAG. They were
conducted on March 7th, March 29th, April 25th and May 31st. Agenda’s included sharing background
information on HCH activities of the State, project goals and structure, information on
implementation models by each health plan, information on models and activities of national
insurers including United HealthCare, input on Workshop agendas, logistics, and Tool Kit contents.
Work Shops: Two workshops were conducted on May 24th and June 21st. Invitations were sent
through multiple distribution channels including CEBS, consultants, agents, BHCAG and State of MN
mailing lists. A more detailed evaluation of each event follows below. Selected presentations are
available on BHCAG’s website as well as videos of selected speakers from the second workshop.
Tool Kit: A web based Tool Kit was developed and available on BHCAG’s website on June 21st. A
Table of Contents is attached.
2
Educational Workshops
The Steering Committee provided input on the logistics of the two Workshops. They were both held at the
Airport Embassy Suites from 8-10am. Preparation activities included developing agendas, preparing
materials for distribution, identifying and recruiting speakers, identifying and securing channels for
distribution of invitations, managing logistical arrangements and soliciting evaluations from attendees at
each Workshop.
May 24th Workshop
representative from the CMS Center for Innovation, national payers, Minnesota activities, an employer
perspective, and a provider perspective. BHCAG facilitated input from purchasers including their goals and
perspectives on how to fund HCHs and structure benefit plan design.
June 21st Workshop
The second workshop included a national speaker describing employers’ success stories, an overview of HCH
and Total Cost of Care (TCOC) payment models, a health plan panel that described their activities to support
HCHs and an overview of the final Tool Kit. Discussion included suggestions on how employers could
support HCHs including having active discussions with their health plans about communications, benefit plan
design, and payment models as well as acting collectively to develop new, enhanced, primary care practices.
Workshop Evaluation
Evaluation forms were distributed at each event and on the BHCAG website after the final workshop. future
activities. Results are included in the Appendices.
Recommendations and Next Steps
The following recommendations and next steps were developed in collaboration with the State of
Minnesota’s Department of Health and took into consideration, comments, questions, and feedback from
purchasers and other stakeholders in Steering Committee meetings, Workshops and related discussions.
Need for Continued Dialogue and Learning
The desire and need for continued dialogue between all parties, but especially between purchasers and
providers, was the most consistent theme from participants and members of the Steering Committee and
attendees of the workshops. It was evident, early on, and throughout the course of this project, that most
purchasers were not familiar with the concept, rationale, results, or characteristics of HCHs in Minnesota or
patient centered medical homes (PCMHs) nationally.
Explain How HCH Relates to Total Cost of Care
While Minnesota based purchasers have heard a great deal about Total Cost of Care (TCOC) contracting as a
means of payment reform, they were confused about if, and how, HCH related to this concept and payment
reform. Many felt they could “skip over” HCH and “jump’ to TCOC as a method of payment reform.
Purchasers Don’t Want to Pay More for Healthcare and Want Proof it Saves Money
Purchasers agreed with the need and desire to transform primary care but were unsure of how the
investment for its costs should be covered. They generally do not want to pay any more for healthcare. In
addition, they were told that no solid data exist showing the cost savings directly attributable to HCH, to
date. For providers, it is difficult to count on dollars from care management fees, and in some cases, shared
savings agreements, both of which are unpredictable and deferred, and represent a very small portion of
total reimbursement, to pay for care managers and finance the infrastructure necessary to transform their
practice.
3
The current payment model, mandated by State regulations, requires purchasers to pay an “upfront,
additional” fee. Until and unless cost savings can be attributed directly to HCH, it will be difficult to make the
case they should make these payments, putting both purchasers and providers in a “Catch 22.” A revised
model that doesn’t require purchasers to take make payments up front, or take a “leap of faith” that future
costs will be reduced, would be ideal.
Rushika Fernadopulle MD, the opening speaker at the second workshop, and other providers, who have
successfully demonstrated cost savings in other markets, have begun their care transformation by focusing
their efforts on the highest cost, most complex patients. While all chronic care patients may benefit from
more coordinated care, a well-managed diabetic patient, with adequate social support may not benefit as
much or yield savings for purchasers as a patient with multiple chronic conditions and little social support.
Cost savings data should show which patients and conditions yield the biggest and fastest “bang for the
buck” and care focused on these patients for purchasers to more readily adopt HCH.
Performance Based Payment to Providers
In addition, Minnesota purchasers, particularly BHCAG’s Bridges to Excellence “Champions” are accustomed
to, and expect, performance based payment for providers. They do not support “one size fits all” payment
model that doesn’t differentiate between high and low performing providers, regardless of outcomes.
Eliminate Patient Liability
Employers have been moving to High Deductible Health Plans (HDHPs) in Minnesota more aggressively than
other states and don’t see this trend changing. These plans shift up front costs to the patient. Many also
have implemented Health Savings Accounts (HSAs) or Health Reimbursement Accounts (HRAs). These
account based plans may require patients to pay for any billed services until their deductible is met. The
existing payment model requires providers to bill payers their care management fees through the traditional
claims payment system. Some providers, but not all, have chosen to bill these services and tell the patient
up front they will incur these charges. When faced with paying HCH care management fees, patients with
HDHPs have reportedly declined participation. The next iteration of the HCH payment model should include
a method that doesn’t utilize the traditional claims payment system in order to encourage, rather than
discouraged, patients’ participation in care management.
Many national payers, e.g., United HealthCare, pay care management fees outside the claims system. They
use a variety of methods to determine which patients are attributable, and how providers are compensated,
and for self-insured purchasers, these costs have been paid out of their administrative fees fund instead of
their medical expenses, circumventing this problem.
Clarify the Relationship Between HCH and Disease/Care Management Programs of Health Plans
Purchasers have also implemented disease and care management programs over the last several years. They
have invested time and energy into putting these programs in place. They questioned how these phonebased services relate, if at all, to the additional care management services offered by HCHs and feel that
paying care management fees to HCH providers is like paying twice for the same services. Also, until all
patients have the same opportunity to receive these services from all providers, e.g., all providers are
designated HCHs, they are reluctant to discontinue their existing programs.
The Steering Committee discussed this topic at length and health plans voiced a variety of perspectives
including the opinion that these programs are not duplicative but rather complementary, that purchasers
may “opt out” of specific disease management programs for specific patients, and that they are still
discussing, internally, how best to proceed. Purchasers expressed the need to be at the table during these
discussions and were frustrated by this lack of clarity.
4
What To Do Next
The following specific actions are possible next steps for BHCAG and the State of MN:
•
•
•
•
•
Conduct another Workshop that does a “deep dive” into the HCH Tool Kit
Connect specific providers and purchasers, who have a critical mass of patients and employees in a
given geography, in a dialogue related to how to enhance primary care
Connect BHCAG’s Bridges to Excellence program, that rewards high performing providers, to the
next iteration of the HCH payment model
Include participation in BHCAG’s Diabetes Prevention Program as a criteria for HCH providers
Arrange BHCAG meetings and/or workgroups focused on specific challenges
o Understanding and demonstrating cost savings
o Rationalizing disease and care management programs of health plans and HCH care
coordination
o Determining how best to eliminate patient liability due to the movement to HDHPs
o Determine how best to support virtual visits and innovative, alternative care models
o Encourage providers to master care for complex patients, those with the most need for
coordination, who, potentially, benefit the most and deliver the biggest return on
investment for purchasers
The State of Minnesota’s Department of Health and BHCAG have agreed to continue discussions on how
best to continue the dialogue and learning and plan to develop specific plans over the coming months.
5
Appendices
Appendix A – Steering Committee Members
Page 7
Appendix B - Tool Kit Table of Contents
Page 8
Appendix C – May 24th Workshop
•
•
•
•
Invitation
Agenda
Attendee Registration
Evaluation Summary
Page 9
Page 10
Page 11
Pages 12-13
Appendix D – June 21st Workshop
•
•
•
•
Invitation
Agenda
Attendee Registration
Evaluation Summary
Appendix E – Final Evaluation
Page 14
Page 15
Page 16
Page 17
Page 18
6
Appendix A – Steering Committee Members
Chuck Abrahamson
HealthPartners
Tina Armstrong
MN Commerce Dept.
Paul Beresford
Family Health Services of Minnesota (Entira)
Kathleen Butterfield Miles
Medica
Linda Davis
BHCAG Consultant
Kris Kopski
Park Nicollet
Steve Lafferty
Target
Gretchen Lennon
Wells Fargo
Marie Maes-Voreis
MN Department of Health
Nathan Moracco
State Employee Group Insurance Plan (SEGIP)
Rachel Nyenhuis
Integrity
Ross Owen
Department of Human Services
Carolyn Pare
BHCAG
Rachel Tschida
Department of Human Services
Tina Morey/Darcee Weber
PreferredOne
Eric Hoag/Steve Thompson
BCBSMN
Carrie Tichey
Target Corporation
7
Appendix B – Tool Kit Table of Contents
Surveying the Health Care Home Landscape
•
•
•
Health Plan Questions for National Employers
What to Communicate to Health Plans
Questions for disease and care management vendors
Deciding
•
•
•
Examples of Employers’ Success
Questions to Consider Before Deciding to Participate
Making the Business Case Inside Your Organization: Evidence on Savings and Productivity
Implementing
•
•
What to Consider and Tools for Implementing Health Care Homes
How to Explain HCH to Employees and Family Members
Selected YouTube Videos
Multiple videos included Information and perspectives for employers and patients from providers, health
plans, and multi-stakeholder organizations.
Helpful Websites
Agency for Healthcare Research and Quality (AHRQ
Catalyst for Payment Reform
Centers for Medicare and Medicaid Services (CMS)
Commonwealth Fund
HealthAffairs
ICSI
Medical Home for All
Minnesota’s Health Care Home (HCH) website
The National Business Coalition on Health (NBCH)
National Committee Quality Assurance (NCQA)
Patient Centered Primary Care Collaborative (PCPCC)
Robert Wood Johnson Foundation
8
Appendix C – Workshop I Invitation
9
Appendix C-Workshop #1 Agenda
SAVING DOLLARS THROUGH HEALTH CARE (AKA MEDICAL) HOMES:
AN EMPLOYERS GUIDE
BHCAG and the Minnesota Departments of health and Human Services are sponsoring two
interactive workshops designed specifically for Minnesota employers about transformation to
Health Care Homes.
Workshop One: Understanding Health Care Home
Thursday May 24, 2012
8:00 to 10:00 AM
Embassy Suites, 7901 34th Avenue, Bloomington, MN.
•
•
•
•
•
Building the case for health care homes
How they have evolved
Who’s supporting them
Results to date
What employers need to know
Workshop Two: Sharing Success and Planning for Participation
Thursday June 21, 2012
8:00 to 10:00 AM
Embassy Suites, 7901 34th Avenue, Bloomington, MN.
•
•
•
Benefits realized through Health Care Homes: a case study
How to evaluate and implement an Health Care Home support strategy
How to engage employees and their family members
No matter what the Supreme Court of the upcoming election decides, health care reform is still
happening in Minnesota. Hospitals, physicians and other providers have been working to make
care safer, more effective, and patient centered and affordable. With this in mind, please mark
your calendars and plan to join us to learn more about all the features and benefits of Health
Care Homes. This is a great opportunity to network with other Minnesota employers interested
in improving health are outcomes and the health and vitality of our workforce! For on-line
registration go to [email protected]
See you there!
10
Appendix C - Workshop #1 Attendee Registration
First Name:
Charles
Eliott
Lynn
Virginia
Ramona
Susan
Colleen
Linda
Mark
Kristi
Jeffrey
Jon
Kathleen
Marcia
Jeanne
Diane
Linda
Marshall
Carin
Paulette
Mark
Todd
Mary
Eric
Ken
Jolene
Sue
Jill
Leah
Gretchen
Melody
Beth
Marie
Eric
David
Dave
Nance Lee
Greg
Mary Alice
Ross
Carolyn
Jeff
Barry
Jeni
Kris
Rachel
Meridith
Betsy
Dan
Bobbi
Last Name:
Abrahamson
Axelrod
Balfour
Barzan
Berger
Bernardy
Bjerke
Blake
Bloom
Bohn
Bolter
Born
Butterfield-Miles
Carlson
Clay
Davies
Davis
Feller
Folk
Grausnick
Halvorson
Hanson
Hauck
Hoag
Horstman
Hunter
Jesseman
Kielblock
Larson
Lennon
Linn
Lundholm
Maes-Voreis
Mann
Martin
Moen, MD
Mosquera
Nelson
Noel
“Owen
Pare
Raymond
Rosenthal
Simon
Soegaard
Tschida
Wagner
Walton
Weir
Zirbes
Company:
HealthPartners
Allstate Benefits
MN Academy of Family Physicians Foundation
MN Academy of Family Physicians
Eide Bailly LLP
Fairview Health Services
Minnesota AIDS Project
University of Minnesota
BeneCard PBF
BCBS of MN
Aon Hewitt
SUPERVALU INC.
Medica
MN Dept. of Health
DMA
Davies and Associates
Health Care Consultant
Medica
Suburban Radiologic Consultants
BCBS of MN
BCBS of MN
CBIZ
MN Dept. of Health
BCBS of MN
Rosemount Inc.
Blue Cross
BHCAG
AFSCME Council 5
Aon Hewitt
Wells Fargo
CEBS
State of Minnesota
MN Dept. of Health
David Martin Agency, Inc.
Fairview Physician Associates
David Martin Agency
3M
Medica
MN Dept. of Human Services
BHCAG
BCBS of MN
BeneCard PBF
Aon Hewitt
BHCAG
MN Dept. of Human Services
Patient Care
CMS
Consultant
Cargill
11
Appendix C - Workshop #1 Evaluation Recap
Speakers Recap: Average score of 3.6 on a scale of 1-4 with 4 being highest
Betsy Walton
Linda Davis
Marie Maes-Voreis
Dave Moen
Gretchen Lennon
Carolyn Pare
Meeting Logistics and Content
The length of the workshop was about right
The content was appropriate and informative
The location and meeting arrangements were convenient
96% (strongly agree or agree)
100% (strongly agree or agree)
87% (strongly agree or agree)
General Feedback
What kind of tools would be helpful in an employer toolkit?
• Employee and/or exclusive representative input in the discussions
• More information on HCH
• A real focus on health
• An executive summary of what these concepts are
• Total cost of care contracting
• Thinking outside the box; how you can have conversations with new partners (e.g.
employer to clinic)
• What questions should I be asking my medical vendor?
• Shouldn’t you look to NBGH instead of reinventing the wheel?
• But … PGuarantees, SPD, plan design, parameters, RFP language, 100% coverage??
• How to begin the change the culture
• List of certified clinics and what health plan networks they are in
• Case studies; proven ROI
What did you like most about today’s workshop?
• Dialogue
• Great information that is thought provoking
• Description of what’s happening in MN; Dr. Moen’s provocative challenge; Gretchen’s
questions
• CMS presenter was way good – should have had more time, but cut short; Dr. Moen
was a good presenter and very relevant
• Betsy and Dave could cover entire session
• Broad perspective
• Interactive
• Thought provoking, good primer on Medicare and MN efforts
• CMS, MDH and Dr. Moen insights
• The different perspectives (national gov’t > national; commercial > local > providers
• Dave Moen’s talk was extremely enlightening; thanks for your willingness to be honest
• Dr. Moen’s talk
• Structure: national down to physician/ER helped clarify a confusing, amorphous
concept
12
Appendix C - Health Care Home Workshop #1 Evaluation Recap Continued
What should we be sure to include in the Workshop on June 21st?
• Employer’s stories; what they’re doing
• Identify what payers can do to help or next steps
• Discussion on total value of health care – more on the medical neighborhood
• More on health care home, disease management, and case management. Another
employer talked about both and not either or want to understand the balance
• More interactive
• Employer design and administration; implications perfect next step
• Need clear specifics on how employers can do this and what are pitfalls to look for
• More employer discussion
• The diverse representation at this session was great; please do it again
Other Comments
• Enjoyed it very much
• Looking forward to workshop #2!
• From an employer perspective, it troubles me that there does not seem to be a real
investment from the providers. In our business, we have to budget and make our own
investments, not get “subsidies” from the employers, who are already paying too much
and paying twice as much as ten years ago with worse results! I am not willing to pay
more for worse with no commitment by providers – pay less not more! Regarding the
State’s involvement in this – since they cannot manage what they already have, I see
no reason for them to lead or be involved.
• Wonderful session; thank you for all you do!
• Please distribute the presentations or links that the speakers delivered
• Thanks!
13
Appendix D – Workshop #2, June 21st, 2012 Invitation
14
Appendix D - Workshop #2 Agenda
Saving Dollars Through Health Care
(aka Medical) Homes: An Employers Guide
Workshop Two: Sharing Successes and Planning for Participation
Welcome and Introduction
Carolyn Pare, President and CEO, BHCAG
Employer Success Stories
Dr. Rushika Fernandopulle, Founder, Iora Health
Total Cost of Care and Health Care Home
Ross Owen, Former Manager of Care Delivery Reform,
Minnesota Department of Human Services
Panel Discussion – How Health Plans are Supporting Health Care Home
Charles Abrahamson, HealthPartners
Kathleen Butterfield-Miles, Medica
Rashad Buckner, Blue Cross and Blue Shield of Minnesota Department of Health
Darcee Weber, Preferred One
Employer Health Care Home Toolkit Preview
Linda Davis, Health Care Consultant
Next Steps and Wrap-Up
Carolyn Pare, President and CEO, BHCAG
15
Appendix D - Workshop #2 Attendee Registration
First Name:
Last Name:
Company
Charles
Natalie
Tina
Virginia
Barbara
Susan
Mark
Jon
Rashad
Kathleen
Jeanne
Michelle
Eric
Diane
Linda
Marshall
Dr. Rushika
Vivi-Ann
Mary Beth
Barbara
John
Paulette
Todd
Ken
Nathan
Sue
Elizabeth
Margaret
Leah
Gretchen
Paulette
Melody
Beth
Marie
David
Stephanie
Nancy Lee
Greg
Mary Alice
Jane
Ross
Carolyn
Kris
Judy
Barry
Jeff
Cherylee
Heather
Jeni
Leif
Shelly
Joe
Rachel
Barb
Clare
Bobbi
Abrahamson
Anderson
Armstrong
Barzan
Berkness
Bernardy
Bloom
Born
Buckner
Butterfield-Miles
Clay
Connor
Daniels
Davies
Davis
Feller
Fernandopulle
Fischer
Galey
Goergen
Goergen
Grausnick
Hanson
Horstman
Hunkins
Jesseman
Jones, Fnp
Kolb-Travis
Larson
Lennon
Lewis
Linn
Lundholm
Maes-Voreis
Martin
Molliconi
Mosquera
Nelson
Noel
Olson
Owen
Pare
Poppie
Reger
Rosenthal
Schiff
Sherry
Siebenaler
Simon
Solberg
Samrock
Thomas
Tschida
Vasko
Verplank
Zirbes
HealthPartners
MOM Brands
Minnesota Department of Commerce
Minnesota Academy of Family Physicians
Emerson Process Mgmt – Rosemount “Inc.
Fairview Health Services
4 Degrees, LLC
SUPERVALU INC.
BlueCross BlueShield of MN
Medica
DMA
CBIZ Benefits
BlueCross BlueShield of MN
Davies and Associates, LLC
BHCAG Consultant
Medica
Iora Health
ChiroCare of Minnesota
Medica
Medicom Health Interactive
BlueCross BlueShield of MN
CBIZ
Rosemount Inc. Emerson Process Management
MN Community Measurement
BHCAG
Southside Community Health Services, Inc
David Martin Agency
Aon Hewitt
Wells Fargo
Merck
CEBS
MN Mgmt & Budget-SEPIG
MN Dept. of Health
David Martin Agency, Inc.
BlueCross BlueShield of MN
David Martin Agency
3M
Medica
Olson and Associates
BHCAG
Lilly USA, LLC
Medica
N/A
MN Dept. of Human Services
MN Dept. of Health
BlueCross BlueShield of MN
Aon Hewitt
HealthPartners
Novartis
bswift
MN Dept. of Human Services
Aon Hewitt
Wells Fargo
Cargill
16
Appendix D
Health Care Home Workshop #2 Evaluation Recap
Speakers: Average 3.1 on a scale of 1-4 with 4 being highest
Carolyn Pare
Rushika Fernandopulle
Ross Owen
Charles Abrahamson
Kathleen Butterfield-Miles
Rashad Buckner
Linda Davis
Meeting Logistics and Content
The length of the workshop was about right
The content was appropriate and informative
The location and meeting arrangements were convenient
100% (strongly agree or agree)
100% (strongly agree or agree)
100% (strongly agree or agree)
General Feedback
What did you like most about today’s workshop?
• Rushika Fernandopulle and his presentation; great speaker; positive examples and
comments; wonderful, humorous and insightful presenter; presentation was innovative,
exciting and enlightening; sharing success stories; thanks you! (8)
• Stories of how payers and providers are taking the initiative to drive payment reform.
• Responses from each payer, but they were not really pressed about exactly how they are
paying, practices, and how they are coordinating their approaches among the plans.
• Linda’s toolkit
If you attended the first workshop, which workshop was the most useful?
• The second workshop was the most useful.
• Both were great (2).
Are there any additional tools you would suggest for inclusion in the employer toolkit?
• Not sure yet; need to review in-depth.
Would you be interested in future discussions related to Health Care Home?
• Yes (7).
• Definitely!
• Yes, impacting contracting/payment by health plans.
• Need to hear from Minnesota physicians, clinic administration and other providers.
Appendix E
HealthCare Home Workshops Final Feedback
On a scale of 1-4 with 1 being poor and 4 being excellent:
1.
2.
3.
4.
5.
6.
1
2
3
4
The workshops raised my awareness of health care home
(HCH) and patient centered medical home activities
locally and nationally.
0%
0%
0%
100%
The workshops increased my understanding of the
differences between HCH and usual primary care.
The workshops helped me understand what is going on
related to HCH nationally.
0%
0%
100%
The workshops helped me understand what is currently
taking place in Minnesota
0%
0%
0%
0%
33%
67%
The workshops helped me think through what our
organization’s next steps should be related to HCH.
The Tool Kit is/looks like it will be helpful in taking these
next steps.
0%
0%
0%
33%
33%
67%
0%
67%
67%
0%
33%
Comments:
•
•
I would love to hear some strong evidence on its success
I wish there had been time for more discussion about how people respond to the
information –what they will do next-more action oriented; I think the on-the-ground
provider or patient perspective would have been useful.
18