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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
CALIFORNIA HEALTHCARE FOUNDATION
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
CALIFORNIA HEALTHCARE FOUNDATION
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
CALIFORNIA HEALTHCARE FOUNDATION
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
CALIFORNIA HEALTHCARE FOUNDATION
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
CALIFORNIA HEALTHCARE FOUNDATION
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
CALIFORNIA HEALTHCARE FOUNDATION
EXAMPLE 1: RETAIL CLINICS
CALIFORNIA HEALTHCARE FOUNDATION
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
CALIFORNIA HEALTHCARE FOUNDATION
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Retail clinics in grocery, drug and mass Retail clinics in grocery, drug and mass merchandise storesmerchandise stores
CALIFORNIA HEALTHCARE FOUNDATION
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
CALIFORNIA HEALTHCARE FOUNDATION
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
CALIFORNIA HEALTHCARE FOUNDATION
62 255 350800
1500
4000
6000
Jan. 2006 Dec. 2006 May-07 Dec. 2007 Dec. 2008 Dec. 2010 Dec. 2012
Number of clinics
13
Clinics continue to open at a rapid pace Clinics continue to open at a rapid pace around the country around the country
Forecast
CALIFORNIA HEALTHCARE FOUNDATION
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
CALIFORNIA HEALTHCARE FOUNDATION
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
CALIFORNIA HEALTHCARE FOUNDATION
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
CALIFORNIA HEALTHCARE FOUNDATION
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
CALIFORNIA HEALTHCARE FOUNDATION
EXAMPLE 2: TELEHEALTH/VIRTUAL VISITS
CALIFORNIA HEALTHCARE FOUNDATION
CALIFORNIA HEALTHCARE FOUNDATION
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
CALIFORNIA HEALTHCARE FOUNDATION
Safety net applications currently or soon to be tested
Telemedicine to improve access in clinics
Kiosk for uncomplicated UTI
Virtual practice
CALIFORNIA HEALTHCARE FOUNDATION
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?
CALIFORNIA HEALTHCARE FOUNDATION
EXAMPLE 3: SCOPE OF PRACTICE IN ORAL HEALTH
CALIFORNIA HEALTHCARE FOUNDATION
CALIFORNIA HEALTHCARE FOUNDATION
CALIFORNIA HEALTHCARE FOUNDATION
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
CALIFORNIA HEALTHCARE FOUNDATION
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
CALIFORNIA HEALTHCARE FOUNDATION
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
CALIFORNIA HEALTHCARE FOUNDATION
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)?
CALIFORNIA HEALTHCARE FOUNDATION
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)
CALIFORNIA HEALTHCARE FOUNDATION
Contact Information
Margaret Laws
Director, Innovations for the Underserved
California HealthCare Foundation
www.chcf.org