Community Health Centers and Health Reform: Issues and Ideas for States

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1 Community Health Centers and Health Reform: Issues and Ideas for States Ann S. Torregrossa, Esq. Deputy Director & Director of Policy Governor s Office of Health Care Reform Commonwealth of Pennsylvania WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 1

2 Prescription for Pennsylvania Prescription for Pennsylvania is a set of integrated practical strategies for improving the health care of all Pennsylvanians, making the health care system more efficient and containing its cost. Right State Right Plan Right Now WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 2

3 Community Health Centers Needed to Play an Important Role in our Reform Efforts Never going to be able to cover all the uninsured unless we had a mandate and a lot more money for subsidies than our Legislature would give us. We would need them to help provide care to those who remained uninsured despite coverage expansions. PA has the largest rural population of any state and community health centers in medically underserved areas would be critical for the insured and uninsured. We knew the FQHCs could provide leadership for improving chronic care building on the HRSA Learning Collaboratives. WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 3

4 Did a Review of Safety Net Providers 23 out of 67 counties had no FQHC or community health center. 5 counties had no hospital. 3 counties had neither an FQHC or a hospital. This may account for the fact that Pa has 14% more ER visits than the national average. Clear we need to address access problems in these counties without safety net providers. WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 4

5 The State of Insurance Coverage in Pennsylvania The survey found 9% of our population is uninsured--over 900,000 Pennsylvanians. Our uninsured are more than the total population of Alaska, Delaware, North Dakota, South Dakota, Vermont, Wyoming or D.C. 71% of uninsured adults are employed. 27.3% of uninsured adults have been without health care coverage for 5 years or more. 76% have household incomes below 300% FPL and will need help paying for coverage. 49% are in between ages years. 62% of uninsured working adults work in the service industry and 21% in retail. 56% of very small employers do not provide health care coverage. WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 5

6 Critical to address coverage, cost and quality at the same time. Difficult to add more people to publicly funded health care when costs are out of control for the other 91% who have coverage There is a huge relationship between quality issues and increasing costs. Try to find the win-win reforms that reduce costs and improve the quality of health care. Need to make the case that because of cost shifting we are already paying health care costs of the uninsured. Asked our consultants to give us a state of our state on cost and quality of our health care. WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 6

7 Pennsylvania s Employees and Pennsylvania s Businesses Cannot Keep Up with Health Care Inflation % Increase in Family Health Insurance Premiums vs. Inflation and Increase in Median Wages in PA Between 2000 and 2006 Increase in Premiums 75.5% Inflation 17.0% Increase in Median Income 13.3% WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 7

8 Every day that passes without meaningful change increases the cost to our health care system. Inefficiencies Drive Cost in Pennsylvania's Health Care System $1.4 Billion $3.5 Billion $1.7 Billion $965 Million 1 Cost of the Uninsured Health Acquired Infections Chronic Care Hospitalizations Readmissions and Errors WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 8

9 Rx for Affordability Cover all Kids-subsidizes children up to 300%FPL Cover All Pennsylvanians (now ABC) SB 1137 passed the House Filed 115 waiver with CMS Coverage for College Students and Young Adults: House Bill 1556 passed the House Community Benefit Requirements: In draft regulations Uniform Admission Criteria: In draft regulations. Fair Billing and Collection Practices: In draft regulations. Capital Expenditures: Draft Executive Order prepared. Small Group Insurance Reform: House Bill 2005 passed the House Transparency of Cost and Quality Data: Website with prices of the 200 most commonly prescribed drugs available in PA pharmacies will go live in September. WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 9

10 Rx for Access Health Care Workforce: Legislation introduced in the House passed to institutionalize the PA Center for Health Care Careers, which has been effective in increasing the number of nursing graduates from PA nursing schools. Removing Practice Barriers: Scope of practice bills passed, for CRNPs, nurse midwives and dental hygienists. Scope of practice legislation introduced in the House for pharmacists, physical therapists, nurse anesthetists and physician assistants. Working with insurers to credential and include non-physician practitioners in all networks. Cost-Effective Sites: Requirement that hospitals have cost effective primary care available for those presenting at hospital emergency rooms who do not need emergency room care is in draft regulations. Funding obtained to start up additional Federally Qualified Health Centers, nurse managed centers and mobile wellness vans for medically underserved areas. Funding for 2 mobile health clinics to serve Forest, Venango and Greene counties. Grants will be made soon for FQHCs or nurse managed centers in counties that do not have them. Working with insurers to include all cost-effective sites in networks where geographically appropriate. Co-Occurring Disorders: DPW and DOH are jointly credentialing mental health and substance abuse treatment providers who treat patients with co-occurring disorders. WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 10

11 Rx for Quality Health Care Associated Infections: Legislation passed to require infection prevention procedures and reporting of health-care associated infections by hospitals. Implementation is ongoing. Quality Outcomes: Included in legislation for hospitals for hospital-acquired infections and in draft hospital regulations for other hospital quality measures. Technology: Hired Director of Technology. Developed architecture for statewide interoperability and electronic health records. Executive Order establishing the PA Health Information Exchange (PHIX) Pay for Performance: DPW has implemented performance based contracting features in both Health Choices and ACCESS Plus contracts for primary care providers. In addition, some hospital disproportionate share funding has been used to reward quality-related activities for hospitals since Enhancements are planned for A $2 million grant program is also set up for hospitals to access for quality-related projects. ACCESS Plus has already demonstrated cost savings and better outcomes for patients for patients with chronic diseases. Chronic Care: Executive Order created a Commission to make recommendations on establishing the infrastructure to change how chronic care is delivered across Pennsylvania. Strategic plan was presented to the Governor and Legislative Leadership in February. Implementation of the chronic care model will begin in Philadelphia in May, and in other regions of the state in September WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 11

12 Rx for Quality Health Disparities Executive Order established Office of Health Equity. Funding received to provide grants to increase minority health care providers. Child Wellness: Increased funding for subsidized school breakfasts and improved health curriculums. Adult Wellness: Smoking ban has passed and signed into law Long Term Living: Assisted Living Residence licensure law passed, barriers to timely receipt of home and community waiver services eliminated, nursing home transition program established, regular meeting of the Long Term Living Cabinet and joint Deputy reporting to Aging and DPW. End of Life and Palliative Care: Advanced Directive bill enacted. DOH working on hospice regulations to include small residential hospices. Budget WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 12

13 Transforming Chronic Care in Pennsylvania For 2007, hospitals charged $4 billion for avoidable hospitalizations for those with chronic conditions. Begin regional rollouts using learning collaboratives, practice coaches and provider and consumer incentive alignment beginning with Southeast PA in May 2008 The model is an integration of Chronic Care Model and the Patient- Centered Medical Home concepts. WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 13

14 The Chronic Care Model Team-based coordinated care, with a focus on patients with chronic illness Origin: Ed Wagner, McColl Institute for Healthcare Innovation, Group Health Cooperative of Puget Sound Improved care coordination Cost reductions from averted admissions Improved quality of care Several existing state and national collaboratives, e.g., Vermont s Blueprint for Health WA state - based on the IHI Breakthrough Series Model HRSA implementation through Federally Qualified Health Centers across the U.S., including 16 in PA WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 14

15 The Patient-Centered Medical Home (PCMH) Origin: American Academy of Pediatrics Now embraced by American Academy of Family Physicians, American College of Physicians and American Osteopathic Association Several pilots in place and emerging around the country (NY, CO) Features Open access scheduling Use of a registry or EMR to manage a population Use of a team: Physician, CRNPs, case managers, health educators Improved communication (telephonic, ) Decision support WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 15

16 Requirements: Funding faculty and expenses for a year-long learning collaborative for participating primary care practices Coordinating the flow of data and funds to practices Providing ongoing project management support Funding cost of registry (first rollout excluded due to lack of appropriations) Funding data collection, evaluation and reporting activities through a contracted 3 rd party Funding the evaluation. WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 16

17 Requirements: Primary Care Practices Participate in seven days of learning collaborative meetings in year 1: initial focus on diabetes and pediatric asthma Work with an assigned practice coach between learning collaborative sessions to transform practice Use a patient registry to track patients with chronic illness Achieve Level 1 NCQA PPC-PCMH Recognition within 12 months Report data from the patient registry and other sources required for evaluation purposes Reinvest funds into the practice site, including for case management in those instances where the practice does not already have that resource in place Three-year commitment WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 17

18 Requirements: Payers Infrastructure development payments Licensing fee for registry, support for data entry to registry, cost of NCQA survey tool, NCQA application fee, and lost revenue for time to attend 7 days of learning collaborative meetings in the first year Enhanced payments to FFS/capitation For initial three years, lump sum payments aligned with stepwise achievement of the three levels of NCQA PPC-PCMH recognition Pay-for-performance Maintenance of existing program common measures across insurers by 2010 WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 18

19 Requirements: Payers Derivation of infrastructure development payments: Infrastructure Costs to Practice During the First Year NCQA PPC-PCMH survey tool $80/practice Data entry to registry $800/practice Office assistant $8,000/practice NCQA application fee $360/clinician Registry license fee $275/clinician Time to attend learning collab (7 days/year) $11,655/clinician WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 19

20 Payment Triggered by NCQA PPC PCMH Recognition Annualized revenue per full-time-equivalent practitioner from all sources for implementing the features of the PCMH recognizes economies of scale and the incremental resources to achieve full transformation of the practice to include all features, discounted by the % of practice revenue derived by Medicare FFS and insurers with low market share. NCQA PCMH Recognition Level Practice 1 FTE Practice 2-4 FTEs Practice 5-9 FTEs Practice FTEs Level 1 $40,000 $36,000 $32,000 $28,000 Level 2 $60,000 $54,000 $48,000 $42,000 Level 3 $95,000 $85,500 $76,000 $66,500 WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 20

21 SE Participants 34 practices of which 9 are FQHCs/ FQHC look a likes representing 165 clinician FTEs serving 176,000 patients internal medicine, family practice, pediatrics and NP-led practices combination of community clinics, independent practices and those affiliated with one of three academic systems almost half have or are implementing an EMR size of applicant practice sites: 3 practices of 1 physician 16 practices of 2-4 physicians 10 practices of 5-8 physicians 3 practices of physicians WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 21

22 6 payers Participants Aetna, AmeriChoice (Medicaid), CIGNA Healthcare, Health Partners (Medicaid), Independence Blue Cross, Keystone Mercy Health Plan (Medicaid) Insurers including commercial (insured and self-insured), Medicaid and Medicare Advantage business, no Medicare FFS WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 22

23 Evaluation The Commission has recommended an evaluation design utilized matched pairs of practices as a control group. The initiative will be evaluated using the following measurement domains: 1. engaged providers 2. patient self-care knowledge and skills 3. patient function and health status 4. primary care practice satisfaction 5. appropriate and efficient utilization of services 6. clinical care quality 7. cost WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 23

24 Anticipated Gains Improved quality of care within 1 year Reduced admissions and cost in 3 years Improved access to care and member satisfaction Support for the vulnerable and essential primary care professional community A robust demonstration of the impact of a farreaching, multi-payer strategy to transform care delivery Lessons learned to hopefully apply to a broader system-wide model application WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 24

25 In Conclusion Cost cutting reforms that improve quality are a win-win. Chronic care & HAI Access, cost and quality are linked and an integrated plan is needed. Need to make the case that we all pay for the uninsured through cost shifting and improving access to care for them will help reduce health care costs. Need to capitalize on FQHCs head start on Chronic Care Model. There is an important roll for community health centers to play in state health care reform. WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 25

26 Contact for Additional Information Ann S. Torregrossa WORKING TO ACHIEVE ACCESSIBLE, AFFORDABLE QUALITY HEALTH AND LONG TERM LIVING SERVICES FOR ALL PENNSYLVANIANS 26

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