A CDC REACH, NIH, OPHS and HRSA CHC grantee applies lessons learned to create a new paradigm for community health care financing and delivery

A CDC REACH, NIH, OPHS and HRSA CHC grantee applies lessons learned to create a new paradigm for community health care financing and delivery

Census 2010 Population / % served: Grant County: 29,514 / 55.4% Hidalgo County: 4,894 / 74.4% Total Svc. Area: 34,408 / 60% Pop. Per Sq. Mile = 4.6

Grant Hidalgo NM U.S. Population under age 18 22% 1 31.7% 2 25.5% 1 24.5% 1 Under age 18 in poverty 29.1% 3 32.3% 3 24.1% 3 18.2% 3 Population 65 and over 19.4%- 3 13.6% 2 12.8% 1 12.6% 1 Population in poverty 19% 3 21.3% 3 17% 3 13.2% 3 Median Income $36,239 3 $34,236 3 $43,719 3 $52,029 3 Hispanic 48.8% 4 56% 4 42.1% 4 12.5% 4 Speak English less than very well 9.4% 5 15.6% 5 11.9% 5 8.1% 5 1. U.S. Census Bureau, 2006-2008 American Community Survey 2. U.S. Census Bureau, Census 2000 Summary File 1, Matrices P 13 and PCT 12 3. U.S. Census Bureau, Small Area Income and Poverty Estimates, 2008 4. U.S. Census Bureau, Census 2000 Summary File 1, Matrix PCT11 5. U.S. Census Bureau, Census 2000 Summary File 3, Matrices P19, P20, PCT13, and PCT14

Community Grant Hidalgo NM U.S. Percent uninsured (under age 65) 23.5% 1 28.4% 1 25.8% 1 15.5% 2, 3 Medicaid Enrollment 20.8% 4 19.1% 4 21.6% 4 14.1% 5,6 Medicare Enrollment 22.5% 7,8 18.3% 7,8 14.3% 9 14.3% 5,6 Practice HMS NM U.S. Percent uninsured 20% 25.8% 1 15.5% 2, 3 Medicaid Enrollment 35% 21.6% 4 14.1% 5,6 Medicare Enrollment 17% 14.3% 9 14.3% 5,6

HMS Core Services Primary Medical Care Family Medicine with Ob Pediatrics Internal Medicine Mental Health Services Psychiatry Psychology Substance Abuse Dental Full Range Implants Specialty Consultation ECHO Family Support (Non-Clinical Svcs.) Categorical Interventions Eligibility General Support Family Assistance Center for Health Innovations FORWARD New Mexico National Center for Frontier Communities Non-Profit Management Ed. National REACH Coalition Community Development HMS Resource / Program Development Research and Evaluation

Different Kinds of PC/PH Integration Structural State Plan Priorities Primary Care Obesity Clinical Preventive Services Mental Health Health Councils / Behavioral Health Collaboratives Planning Collaboration Co-location/Commons Cooperation MOU s/moa s Functional Integrated Mission / Strategic Plan Health Priorities: Patient Community Population Coordination Service Implementation Co-Determined C0-Delivered Contracts/Categorical Services State B&CC Dental Indigent Services Primary Care Smoking School Based Health Parenting / Fatherhood Operational Health Services Delivery Clinical Prevention Comp/ PC Management Family Support Services Social Marketing / Ed. Care Coordination Outreach Coverage /Other Eligibility Social Interventions Education Employment / Housing Economic Devel0pment AKA The Hidalgo Plan

Primary Care and Public Health Integration Hidalgo Plan Perspectives Service Systems Integration Improved Population Health Reduced Per Capita Cost Fully Integrated Financial Modeling Fully Integrated Electronic Records Social, Educational, Medical and Health Data

Payments Drive System -Current Payment Priorities Diagnosis / Treatment Delivery System Procedure Focused Technical and Expensive Invasive Health Outcomes Not a Priority Requires Separate, Unequal Systems Categorical Interventions Cost Outcomes Bottom Line Focus Unaffordable Payments Delivery Outcomes

The Spiraling Cost Incentives Almost 100% of Medical Care Investments are Private +/-70% of NM Medical Care Payments are Public ROI THE RVU / Payment System Encourages Investments in High Cost Procedures, Drugs, and Tests Volume and Intensity Medicare and Medicaid Pay for Physician Training (GME) Got Health?

$5,000 Relative Value.. $$$ Coding System Procedures High End Testing $50 Evaluation and Management Codes Well Child Checks Clinical Preventive Services Chronic Disease Management The Payment System Supports High Cost Health Care Investments, Not Prevention and Management

One Approach to Changing Incentives and Reducing Cost Bend the curve $75 Evaluation and Management Codes Well Child Checks Clinical Preventive Services Chronic Disease Management Meaningful Use / PCMH $$$ Coding System $4,500 Procedures High End Testing Change the Slope of the RVU / Payment System to Reduce Return On Investment at the High End Increase the Incentives for Better Health by Prioritizing Prevention and Management

The Hidalgo Plan: Accountable Health Services Change the System to Meet Health Goals of the Public

A Different Approach

Payments Still Drive System, but.. Payment Priorities Health Improvements Primary Care Outcomes Improved Population Health Lower Health Care Costs More People in a Health System Delivery System Population Focused Priorities Prevention Oriented Teams Management and Support Teams PC Diagnosis and Treatment Medical / Accountable Home Payments Outcomes Delivery

Health Focused Incentives Primary Care 3.0

Community Investments ROI Community-Determined Interventions Restructured Hospital Payments Sub-Specialty Relations Managed Referral System

Why We Think This Works Improvement in population health requires addressing socioeconomic determinants of health, including inequality and primary care availability and access Barbara Starfield HMS CDC REACH CA LA VIDA reduced average HBA1c levels in 500 Hispanic patients with Diabetes from 8.4 to 7.6 after only one visit with CHW in a year. Now a CEED / Legacy CDC dissemination program in NM, AZ and Missouri PLUS.

There s More REACH Model Extensions HMS ACF/OPHS Grant GUTS Teen Parent Support. NM Repeat Teen Pregnancies 22% / Guts 10.8% Teen HS Drop Out Rate 8.6% after one year 5.4%. HMS UNM Molina Care Coordinators Contract Reduced cost of most expensive Medicaid patients 65% Capitation payment method New NIH / REACH into Hypertension Hidalgo Plan Acceptance

Supportive Efforts ACA PCMH ACO Community Transformation Grants CMS FQHC Financing / Innovations CHC Expansion / Construction $ Workforce Development Exchanges State Support HB 35 Medicaid Department of Health UNM Molina MCO

Exchange Preparation Either Health Insurance Cooperative Health Action NM Non-Profit Created late 2010 Community Health Insurance Program Management Services Agreement Molina Health Plan Also supports Hidalgo Plan ($80,000) ACO Development

During 2010, HMS rotated 56 students and residents through its 11 locations: Medical Providers Dental Providers Midwifery and Family Nurses 6 Pediatric Residents 6 Family Practice Residents 1 Family Practice Resident 3 Physician Assistants 1 Medical Assistant 10 Dental Residents 5 Dental Students Masters in Public Health 2 students 18 Nursing Students 1 Family Nurse Practitioner Masters in Counseling 3 students LEGEND: University of New Mexico Arizona School of Dentistry & Oral Health Vista College Western New Mexico University New Mexico State University Frontier School of Midwifery & Nursing Memorial Medical Center

HB 35 Medicaid Creates Task Force Develop Demonstration Project Carve out Hidalgo County Pool Medicaid Patients Payments Support Base (Capitated / Budgeted) Meaningful Incentives Shared Risk Reports to Legislature 8/12 Companion activity CMS / HRSA?

University of New Mexico Primary Partnership Community Driven University Participation Aligning 2020 Goals / County Report Card Health Commons Model Development Health Extension Model Origin in NM Independent Research and Evaluation Publication Care Coordination Model Development Training Recruitment Workforce - CME Tele-medicine (Project ECHO) Contract Subspecialty Care

Charlie Alfero, CEO 530 DeMoss St. Lordsburg, NM 575-542-8384 ext. 403 575-538-1618 (c) Calfero@hmsnm.org www.hmsnm.org