Aiming Higher

1
Aiming Higher

• Karen Davis
• President, The Commonwealth Fund
• Summit on the High Cost of Health Insurance
• Oklahoma City, OK
• November 9, 2007
• kd_at_cmwf.org
• www.commonwealthfund.org

2
Oklahoma Takes Off on High Performance Health
System Journey

• Three annual summits on high cost of health
  insurance
• Assessing where Oklahoma stands
• Establishment of priorities for action,
  implementation, and taking stock
• Learning from other states what else might help
• Adult health insurance coverage
• Medical home
• Chronic care management
• Medicaid pay for performance
• National health policy context

3
Scorecard on Health System Performance
4
US Scorecard Why Not the Best?Commonwealth
Fund Commission National Scorecard

• 37 Indicators
• U.S. compared to benchmarks

Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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5
Aiming Higher Commonwealth Fund Commission
State Scorecard on Health System Performance

• State ranks
• 32 indicators

6
Uninsured Non-Elderly Adult Rate Increasedin
Oklahoma from 21.5 to 25.3 Percent in Last Six
Years
Data Two-year averages 19992000, updated with
2007 CPS correction, and 20052006 from the
Census Bureaus March 2000, 2001 and 2006, 2007
Current Population Surveys.
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State Variation Ambulatory Care Quality
Indicators
QUALITY THE RIGHT CARE
Percent
DATA Adult preventive care 2002/2004 BRFSS
Adult diabetic preventive care 2002/2004 BRFSS
Child vaccines 2005 National Immunization
Survey Child medical and dental visits 2003
National Survey of Childrens Health SOURCE
Commonwealth Fund State Scorecard on Health
System Performance, 2007
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State Variation Hospital Admissions Indicators
AVOIDABLE HOSPITAL USE AND COSTS
Percent
DATA Medicare readmissions 2003 Medicare SAF
5 Inpatient Data Nursing home admission and
readmissions 2000 Medicare enrollment records
and MedPAR file Home health admissions 2004
Outcome and Assessment Information Set SOURCE
Commonwealth Fund State Scorecard on Health
System Performance, 2007
11
Gains if Oklahoma Achieved Top State Performance

• More People Covered
• 380,000 additional adults and children insured
• More Getting the Right Care
• Nearly 167,000 additional adults (50) and 60,944
  diabetics would receive recommended care
• 13,064 children immunized
• More Getting Primary Care
• 303,000 adults and 170,000 children with primary
  care
• Less Avoidable Hospital Utilization
• More than 25,000 fewer Medicare hospital
  admissions and readmissions per year (Savings of
  140 million per year)
• Healthy Lives
• 1707 fewer premature deaths

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Summit on High Cost of Health Insurance
13
Top Ten Oklahoma Priorities

• Re-engineering healthcare coverage
• Basic benefit plan
• Health Information Organization and EMRs
• Federal Medicaid match for provider payment
• Liability reform
• Cost-effective utilization of health services
• Expand federally qualified health centers
• Evidence-based treatment
• Universal coverage for children
• Premium assistance for working poor (O-EPIC)

14
Learning from other StatesAdult insurance
coverage
15
Massachusetts Health Plan

• MassHealth expansion for children up
• to 300 FPL adults up to 100 poverty
• Individual mandate, with affordability
• provision subsidies between 100 and
• 300 of poverty
• Employer mandatory offer, employee mandatory
  take-up
• Employer assessment (295 if employer doesnt
  provide health insurance)
• Connector to organize affordable insurance
  offerings through a group pool
• Reasonable success since implementation
• 67 of MA voters view reform favorably
• Approximately 200,000 newly covered individuals
  in just over a year
• Costs in free care pool showed a 15 decline in
  FY 2007

Source John Holahan, The Basics of
Massachusetts Health Reform, Presentation to
United Hospital Fund, April 2006. Jon Kingsdale,
Connector Update, October 2007
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Maines Dirigo Health

• Aim make affordable health care coverage
  available to every Maine citizen by 2009, slow
  the growth of health care costs, and improve the
  quality of care
• Estimated savings of 32.8 million in third year
  of operation
• Enrollment 23,914 as of February 2007
• Governors proposed reforms (April 2007)
• State reinsurance plan
• Insurers required to provide discounts for
  nonsmokers and worksite wellness programs
• Employer pay or play to begin July 2008
• Individual mandate to begin January 2009
• Dirigo able to self-insure and will grow
  moderately (legislation passed August 2007)
  switched to contracting with Harvard Pilgrim
• Blue Ribbon Commission endorsements (January
  2007)
• Increasing the tax on tobacco products
• Establishing a snack tax and a tax on soft drinks
  and syrups
• Beer and wine tax
• Continued capture and redirection of bad debt and
  charity care funding

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Pennsylvania Governors Proposal

• Prescription for Pennsylvania - Three part
  proposal
• a public-private coverage partnership called
• Cover All Pennsylvanians (CAP)
• 2. cost-containment agenda
• 3. quality improvement platform
• First elements passed July 2007
• Increase access to primary care by expanding
  scope of practice for mid-level practitioners
• Reducing hospital-acquired infections through
  surveillance and reporting
• Cover all Pennsylvanians
• Would subsidize comprehensive coverage for
  uninsured individuals below 300 FPL and small
  businesses
• Employer mandate, no individual mandate
• Funding would come from an employer assessment,
  increased tobacco tax, and federal matching funds

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New Jersey Raises Age of Dependent Status for
Health Insurance

• As of 5/2006, NJ requires all state insurers to
  raise dependent age limit to 30
• Highest age limit in country
• Covers uninsured, unmarried adults with no
  dependents who are either NJ residents or
  full-time students
• Premium capped at 102 of amount paid for
  dependents coverage prior to aging out
• 200,000 young adults expected to receive coverage
  under the law

Millions uninsured, adults ages 1929
Source S.R. Collins, C. Schoen, J.L. Kriss, M.M.
Doty, B. Mahato, Rite of Passage? Why Young
Adults Become Uninsured and How New Policies Can
Help, Commonwealth Fund issue brief, May 2006.
(Analysis of the March 20012005 Current
Population Surveys)
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State Coverage Expansion Targeting Employees of
Small Businesses

• Governor Henry recently authorized the expansion
  from 50 to 250 employees and from 185 of FPL to
  250
• Available to individuals on a sliding scale
• Waiver amendment to be submitted to CMS
• Premium assistance pays 60 of premium for low
  income workers employer pays 25 employee pays
  up to 15
• Funded from tobacco tax, federal Medicaid match,
  and employer/employee contributions
• 1,200 enrollees

• Small employers with 30 or more employees
  earning
• State reinsurance keeps premiums affordable
• The risk-sharing corridor was originally between
  30,000 and 100,000 however, it was lowered in
  July 2003 due to lower-than-expected claims
  activity
• State now reimburses health plans 90 percent of
  claims paid between 5,000 and 75,000 on behalf
  of a member in a calendar year.
• To reflect this change, most plans reduced their
  premiums by approximately 17 percent.
• 125,000 enrollees, Fall 2006
• Premium in NYC for family coverage ranges from
  656.49 to 878.66 for individual ranges from
  219.49 to 301.66

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State Coverage Expansion Targeting Employees of
Small Businesses

• Insure New Mexico!
• State Coverage Insurance (SCI) (
• Public/private partnership
• Working adults
• 4,400 enrollees, Fall 2006
• The Small Employer Insurance Program (SEIP)
• Comprehensive benefit package with an annual
  benefit limit of 100,000 per member available to
  employees and dependents
• Available for previously uninsured employees of
  small businesses

• Insure Montana (29 employees)
• Refundable tax credits (100125/employee/month)
• Small business purchasing pool (subsidized from
  increased tobacco tax)
• 8,000 enrollees in first year
• Over 1,400 small business are enrolled
• Currently waiting list for purchasing pool and
  tax credit

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Illinois Covered

• Illinois Covered Rebate
• Premium assistance for working families
• (between 100 and 400 FPL) with employer-
• based insurance
• Illinois Covered Assist
• Provides access to a medical home with consistent
  primary care for adults below FPL who do not
  qualify for Medicaid
• Low co-pays, no premium
• Family Care Expansion
• Access to insurance for uninsured parents up to
  400 FPL
• Sliding scale premium assistance
• Coverage for Young Adults
• Bridge for young adults ages 19 to 21 with
  pre-existing conditions who have no access to
  insurance
• Subsidized premiums for covered individuals
• Governor still pursuing further reform
• Dependent coverage extended up to age 29
• Illinois Covered Choice for all individuals and
  small businesses

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Learning from other StatesMedical Home
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Iowa MediPASS

• MediPASS, Iowas Medicaid Primary Care Case
  Management (PCCM) program, was implemented in
  1990 and studied for eight years
• Each county offered enrollees a combination of
  traditional FFS, MediPASS, or HMO option
• Program associated with 66 million in savings
  over eight years, 3.8 percent reduction in
  Medicaid expenses
• MediPASS program shifted program expenses away
  from the hospital and toward the outpatient
  setting substitution of medications and clinical
  visits for hospital services
• Cost reducing effects of the program increased
  over time

Source Momany et al., A Cost Analysis of the
Iowa Medicaid Primary Care Case Management
Program, Health Services Research, 2006 Aug41(4
Pt 1)1357-71.
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Community Care of North Carolina
Asthma Initiative Pediatric Asthma
Hospitalization Rates (April 2000 December 2002)

• Create nonprofit organization owned and governed
  by all Medicaid providers in county
• 15 networks, 3500 MDs, 750,000 patients
• Receive 2.50 PM/PM from the State
• Hire care managers/medical management staff
• PCP also get 2.50 PMPM to serve as medical home
  and to participate in disease management
• Care improvement asthma, diabetes,
  screening/referral of young children for
  developmental problems, and more!
• Case management identify and facilitate
  management of costly patients
• Cost (FY2003) - 8.1 Million Savings (per Mercer
  analysis) 60M compared to FY2002

In patient admission rate per 1000 member months
Source L. Allen Dobson, MD, presentation to
ERISA Industry Committee, Washington, DC, March
12, 2007
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Key Attributes of North Carolina Medicaid Medical
Home

• Provide 24 hr access
• Provide or arrange for hospitalization
• Coordinate and facilitate care for patients
• Collaborate with other community providers
• Participate in disease management/prevention/quali
  ty projects
• Serve as single access point for patients

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Learning from other StatesChronic Care
Management
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Wellness and Preventive Health Initiatives

• Vermont Blueprint for Health
• Pursuing change in broad areas
• patient self-management
• provider practice change
• community development
• information system
• development
• Information, tools and support
• that patients and providers need to successfully
  manage chronic conditions
• Web-based chronic care patient information system
• free to providers requiring only Internet access
• first site installed and tested in 2007
• Broad support for program from primary care
  providers

• Strong and Healthy Oklahoma
• A statewide effort to improve the health of all
  Oklahomans by sharing ideas for healthy eating,
  getting more exercise, and being tobacco-free
• Turning Point More than 50 local partnerships
  meet on a regular basis to talk about health
  issues and create policies to make Oklahoma a
  healthier place to live
• Workforce wellness programs
• Healthy schools (physical education and nutrition)

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Arkansas Leading the Way in Reducing Childhood
Obesity
Passage of Act in 2003

• Mandated that parents receive their childs BMI
• Prohibited in-school access to vending machines
  in elementary schools
• Called for the incorporation of nutrition and
  physical activity goals into annual school
  planning and reporting

• The results of the 20052006 annual body mass
  index assessments showed that 37.5 of
  schoolchildren were overweight or at risk for
  being overweight, compared to 38.1 two years ago

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Vermont Health Care Affordability Act Enacted
May 2006

• Coverage expansion Catamount Health Plan
• Non-group insurance plan for individuals
• without access to work-based coverage
• Premium subsidies based on sliding scale
• for individuals with incomes up to 300 FPL
• Comprehensive benefit package including
• primary, chronic, and acute care other
  services
• No patient cost-sharing for preventive or chronic
  care services
• Financing
• Employer assessment
• Increase in tobacco taxes
• Federal matching funds from Medicaid waiver
• Enrollment
• Began October 1, 2007
• 869 new individuals eligible for premium
  assistance as of Oct. 21
• 108 applications for Catamount Health Plan
  received as of Oct. 21
• New programs will provide coverage for an
  estimated 17,030 new individuals

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Take Care New York

• Mayors comprehensive citywide public health
  policy consisting of 10 evidence-based
  interventions by health care providers, City
  agencies, businesses, public-private
  partnerships, and individuals
• Since being introduced in 2003, Take Care New
  York (TCNY) has successfully
• increased access to health care (265,000 more New
  Yorkers have a regular health care provider in
  2006 compared to 2002)
• reduced smoking rates (21.6 in 2002 17.5 in
  2006)
• increased HIV testing and colon cancer screening
  (44 increase in colonoscopy screening rates)
• reduced childhood lead poisoning and infant
  mortality rates to historic lows (5.9 infant
  deaths per 1,000 live births in 2006)

Source Take Care New York A Policy for a
Healthier New York City, Third Year Progress
Report, New York City Department of Health and
Mental Hygiene, August 2007
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Missouri HealthNet Shifting the Focus to
Prevention and Early Detection

• New focus on preventive care
• 6 billion budget intended to direct state-funded
  health care to prevention and early detection
• Cover uninsured women making up to 185 FPL for
  cancer screenings and family planning services
• Raise payments to medical providers up to federal
  maximum
• New services designed to help patients create
  personalized long-term health plans and
  facilities to act as central point of contact

• Restore services previously cut from Medicaid
• Dental and vision care
• Coverage for necessary adult medical equipment
• Coverage for almost 14,000 children with limited
  premiums
• Coverage for over 3,000 disabled workers

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Healthy Washington Initiative

• Blue Ribbon Commission recommendations
• All Washingtonians will have coverage by 2012
• All children will have coverage by 2010
• Washington will be one of the top ten healthiest
  states
• The rate of increase in total health care
  spending will be no more than the rate of growth
  in personal income
• Improve Quality
• Establish Quality Forum to address disparities in
  care
• Modify provider reimbursement to promote
  prevention, implement pay-for-performance
• Expand chronic care management
• Increase Access
• Formation of Health Insurance Partnership,
  beginning Sept. 2008
• Expansion of coverage to dependents up to age 25
• Control Costs
• Decrease in unnecessary emergency room visits
• Widespread use of health information technology
  through a statewide exchange
• Increase in preventive care
• Implementation of Technology Assistance Program

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Learning from other StatesPay for Performance
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Assisting States in the Design of Medicaid
Pay-for-Performance Programs

• P4P Purchasing Institute Technical Assistance
  Series
• Commonwealth Fund grant to the Centers for Health
  Care Strategies to help states develop new
  provider-level strategies to promote the delivery
  of high-quality care to low-income, racially
  diverse, and chronically ill populations
• Seven state Medicaid teams attend two in-person
  training institutes and receive ongoing technical
  assistance from CHCS and other experts
• 2nd P4P Purchasing Institute held Oct 23-24
• Delivery systems represented at Purchasing
  Institute include FFS, PCCM, and MCO.
• Oklahoma was invited as a faculty state to talk
  about its experience with designing and
  implementing a physician-level P4P program.
• Oklahoma
• 1997 introduced an incentive program to increase
  
• EPSDT compliance
• Between 2002 and 2006, there was an 160 increase
  
• in the number of providers that received an
  EPSDT
• incentive payment
• 2006 OK EPSDT visits were above the National
• Medicaid mean
• 2002 introduced incentive for providers that
  administered a 4th DTaP to children prior to two
  years after realizing that almost all children
  were missing the 4th DTaP immunization
• Between 2001-2006, 29 more children received the
  4th DTAP before age two

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Pay-for-Performance in Arizona
Goal To implement a multi-stage P4P program as a
strategy for improving the quality of care
delivered

• Stage 1 incentives to primary care providers for
  improved treatment of diabetes, high risk
  pregnancies, early immunizations
• Stage 2 expansion to other providers and
  conditions over several areas
• Stage 3 use P4P as a vehicle to identify
  centers and providers of excellence, which AZ
  Medicaid members will be encouraged to use
• Status
• Identified clinical performance targets eligible
  for incentive payments
• Submitted budget request of 6.4M submitted to
  Gov for consideration in her budget
• CMS must also approve plan to pay providers
  directly (not through capitated plans) AZ is
  almost 100 Medicaid Managed care so far, CMS has
  viewed incentives to providers as payments and
  has insisted they go through the plans
• Fiscal reality AZ has a 600M budget shortfall
  and agencies have cut expenditures by 5 -
  inclusion/passage of request in Gov budget is
  uncertain

36
Building Quality Into Rhode Islands Medicaid
Managed Care ProgramRIte Care Higher Quality
and Improved Cost Trends
Cumulative Health Insurance Cost Trend Comparison

• Quality targets and incentives
• Improved access, medical home
• One third reduction in hospital and ER
• Tripled primary care doctors
• Doubled clinic visits
• Significant improvements in prenatal care, birth
  spacing, lead paint, infant mortality, preventive
  care

Percent
Source Silow-Carroll, Building Quality into
RIte Care, Commonwealth Fund, 2003. Tricia Leddy,
Outcome Update, Presentation at Princeton
Conference, May 20, 2005 updated.
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Toward a High Performance Health SystemCore
Strategies for Change

• Affordable coverage for all
• Aligned incentives and effective cost control
• Accountable coordinated care
• Aim higher for quality and efficiency
• Accountable leadership

Commonwealth Fund Commission on a High
Performance Health System
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Presidential Campaign Debate

• Health policy a top domestic issue will trigger
  important national debate on values and
  strategies for change
• Goal of universal coverage is important and
  should be embraced by all candidates
• But also needs to commit the financing required
  to attain this goal within a reasonable period of
  time
• Effective progress in slowing the growth in
  health care costs requires
• Correction of imbalance between primary and
  specialty care
• Moving away from fee-for-service to shared
  accountability for total care of patients
• Rewarding results in achieving high quality and
  prudent stewardship of resources
• Reorganizing care system
• Patient-centered medical homes
• Accountable care networks
• Sufficient funding and leadership to achieve
  universal implementation of electronic health
  records and repository of all patients health
  information
• National leadership/entity/process charged with
• Developing national aims for health system
  performance
• Setting priorities and targets for improvement
• System for monitoring and reporting on
  performance
• Recommending the necessary practices and policies
  required to achieve targets

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What Does it Take to Aim Higher?

• Cut uninsured rate for adults in half in five
  years and for children by three-fourths taking
  maximum advantage of federal funds
• Ensure that every Medicaid beneficiary is
  enrolled in a medical home within five years
• Medical home responsible for preventive care
  reminders
• Medical home for disease registries and standard
  protocol for management of chronic conditions
• 24/7 access
• Public reporting of quality, hospital infections
  and complications, readmission rates within five
  years
• Encourage payers to provide disincentives for
  hospital readmissions
• Experiment with Medicaid pay-for-performance over
  next five years

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OklahomaWhy Not the Best?
41
Visit the Funds website atwww.commonwealthfund.o
rg
42
Thank You!Sign up for e-alerts at
www.commonwealthfund.org

• Stephen C. Schoenbaum, M.D., Executive Vice
  President and Executive Director, Commonwealth
  Fund Commission on a High Performance Health
  System
• scs_at_cmwf.org
• Cathy Schoen, Senior Vice President, Research
  Evaluation, Commonwealth Fund
• cs_at_cmwf.org
• Sara Collins, Assistant Vice President, The
  Commonwealth Fund
• src_at_cmwf.org

Anne Gauthier, Senior Policy Director Commission
on a High Performance Health System ag_at_cmwf.org
Rachel Nuzum, Program Officer State
Innovations rn_at_cmwf.org
Katherine Shea, Research Associate, Commonwealth
Fund ks_at_cmwf.org