Voices of Detroit Initiative (VODI)

Voices of Detroit Initiative (VODI)

Taking Care of the Uninsured: A Path to Reform

Lucille Smith, M.Ed Executive Director

National Congress on the Un- and Under Insured/Health Reform Congress

September 22-24, 2008

September 22-24, 2008 2

VODI: Who We Are…Detroit Wayne County Consortium: Collaborating Around the Uninsured

A collaborative partnership between:

City of Detroit Department of Health & Wellness Promotion Wayne County Health Department, Community Mental Health Agency Henry Ford Health System St. John Health Detroit Medical Center Oakwood Health System Wayne State University School of Medicine Six (6) Federally Qualified Health Centers (FQHCs): CHASS*, Detroit

Community Health Connection*, Advantage Health Centers**, Health Centers Detroit, The Wellness, and Western Wayne **

Detroit Wayne County Health Authority Free Clinics Community Advisory Committee


VODI’s Mission

Providing leadership that help organize care delivery, expand and improve access to cost-effective, high quality health care, for the un- and under insured.


How Did VODI Get Started?

1998 Kellogg Foundation funded 13 cities out of 80 who applied

Kellogg Foundation’s Community Voices Initiative sought to achieve five goals towards improving access for the uninsured and underinsured


Kellogg Foundation’s five goals towards improving access

Sustained increases in access to care for vulnerable and uninsured populations

Strengthening the community safety-net through community driven change and community partnerships

Model should provide system change and be sustainable beyond the 5 years

Development of best practices that could be shared with other communities

September 22-24, 2008 6

W. K. Kellogg National Community Voices Consortium: $65 million Project Nationally

List of the 13 National Community Voices Projects1. Albuquerque, NM2. Baltimore, MD 3. Charleston, WV 4. Denver, CO 5. Detroit, MI (Voices of Detroit Initiative (VODI) 6. El Paso, TX 7. Lansing, MI 8. Miami, FL 9. Northern Manhatten, NY10. Oakland, CA 11. Pinehurst, NC 12. Sacramento, CA13. Washington, DC


Detroit Wayne County:•Rising uninsured and uncompensated costs ($400M annually), Uninsured with 25% higher mortality rate

•Since FY2000 number on State Medicaid increased by 40%, with 60% rise in GF expense

•60% decline in Detroit’s primary care physicians capacity

•Significantly higher rates of rising chronic illness in Detroit which, if not effectively managed in a Primary Care setting,

•results in higher ED utilization, and,•a 69% higher preventable hospitalization rate compared to the rest of the State, and, •therefore higher healthcare costs.

Continuing to do things the same way is not sustainable…


The Condition of Detroit’s Safety-net at the Beginning

Fragmented Inadequate capacity, especially primary care Lack of access to full continuum of health

services Did not provide an organized and

coordinated system of care for the uninsured In Detroit Wayne, there is no public hospital

or public funding mechanism to support safety-net care


VODI’s Objective

With active involvement in VODI’s collaborative network, VODI will keep enriching the approach to transform systems of care that increase medical services utilization in an appropriate setting for the uninsured, and, therefore improves their health status, reduce avoidable ED visits, inpatient stays and reduces costs

People with fragmented lives will never do well in a fragmented healthcare delivery system

Smitherman

September 22-24, 2008 10

An Overview of the VODI Project: A Path to Reform

The VODI Question: Could VODI transition adults (age 18 to

64), without health insurance, out of the ER to primary care settings by providing: Active ER>>PC Intervention healthcare coverage organized delivery system, and care/disease management?

September 22-24, 2008 11

VODI Intervention Model (VIM): Detroit providers agreed to provide care to:

27,500 uninsured Detroiters (13.75% of Detroit’s uninsured pop)

Kellogg Grant $ paid for no care, only infrastructure

Intervention: ER enrollment + case and care management linked to PCP/Medical Homes

VODI Providers provided primary care at no or significantly reduced cost

Commitment for the full continuum of care ED Diversion Strategy = significant cost savings Demonstrate the value of managing care of the uninsured.

VIM is an active outreach in ERs>>>PC sites Enrollment/registration/tracking/utilization data analysis

Primary Care Medical Home assignment, apt & use + case mgt


VODI Intervention Model (VIM) Required an Organized Delivery

System to Provide Care4Cs

Organized CollaborationThe framework for building agreement and commitment

Organized CoordinationWorking together in a common effort developing a common set of services and activities

Organized CoverageAgreement to pay for a set benefits to a defined population (registration, enrollment, medical home assignment, tracking, and data collection

Organized CareDirect provision of services (medical home use, basic services: PC/Pharmacy/Lab/Dental, Care and Disease Management, etc)

September 22-24, 2008 13

VODI Services: Organize System of Care

Assignment/Use of a “Medical Home (PCP)” Provides a Basic Set of Services

Pharm/Lab/Medical care/Care management Provides a Standard Eligibility & Registration

Process Provides Central Data Collection Provides Common Data Elements Tracks Patient Services Adding Information Technology (EMR) to

complete the model

September 22-24, 2008 14

During the Five-year (1999-2004) Demonstration; Target enrollment: 27,500

• VODI covered 25,373 uninsured individuals in Detroit by 2004

6,535 people were identified as eligible and enrolled in public insurance programs

18,838 uninsured people were enrolled in VODI

• VODI continues today, and as of January 2008, VODI has enrolled and provided coverage for 52,000 uninsured and underserved Detroiters, (37,000 active), well in excess of the initial goal of 27,500.

September 22-24, 2008 15

Characteristics of VODI (uninsured) Population 57% women - 43% men Age - 18 to 64 69% Single 92.4% African-American 64% total household income less than $1000/month 56.7% employed vs. nationally 83% employed

Only 20% of VODI enrollees earned more than $8/hr Average annual income: $10,851

53% with 3 or more persons in household 36% with chronic condition Summary: Single, African-American women, less

employed, poorer, sicker, supporting multiple family members

September 22-24, 2008 16

Active ER Enrollees Whose:

First encounter, after enrollment, was in a Primary Care setting: 39.4%

Second and later encounters, after enrollment, was in a Primary Care setting: 15%

Summary: Transitioned 55% of Active Enrollees out of ER to Primary Care Setting

September 22-24, 2008 17

Extrapolated 42% Rev/Cost Savings for Detroit Providers

$400 Million in Uncompensated

Care Costs

$232 Million in Uncompensated

Care Costs

VIM: Results in est. $168 Million in rev/expenditure reduction

September 22-24, 2008 18

ER Utilization for Medical Home Users vs. Nonusers

VODI Enrollment from ER and PC sites 300% decrease in ER use for those with

Medical Home (MH) use after VODI enrollment MH Use: 31 ER visits/100 enrollees No MH Use: 86 ER visits/100 enrollees

VODI Enrollment from ER sites alone 100% decrease in ER use for those with

Medical Home (MH) use after VODI enrollment MH Use: 53 ER visits/100 enrollees No MH Use: 97.2 ER visits/100 enrollees


Understanding Which Factors InfluencePrimary Care Seeking Behavior

Primary care visits for active enrollees was positively associated with: Females Increasing age Increasing household income Presence of a chronic condition

Primary care visits for active enrollees was negatively associated with” 30 hrs. or more worked/week


VODI Intervention Model (VIM) Insurance Assessment Table

Collaboration/ Coordination

Coverage Care

Workable Consensus

(National/Local)

Finance Eligibility Benefits Medical Home

Disease/ Care

Manage-ment

Access to the

Continuum of CareAssign

-mentUse

Medicaid X X

Medicare Part A & B

X X X X X

VODI X X X X X X X X

FFS Commercial Insurance

X X X X X

Commercial HMO/PPO

X X X X X X

X = Element is Present

September 22-24, 2008 21

Plan to Impact Highest Risk GLHP Members With MH, SA, Chronic Pain and Homelessness:

24 Members/313 Admits

Inpatient Admits Reduced by 55% With MH/SA/CP/H Focused Case Management

313

141

0100

200300

400

Pre- MH/SA/CP/HAnnual Admits

Post MH/SA/CP/H Annual Admits

September 22-24, 200822

Million Dollars Annualized Cost Savings With MH/SA/CP/H Focused Case Management

$1,872,000

$864,000

$0

$500,000

$1,000,000

$1,500,000

$2,000,000

Pre MH/SA/CP/H Annual Cost Post MH/SA/CP/HAnnual Cost

GLHP Personal Care Model: PCP/Case Management

24 Members/$1M Annual Savings

September 22-24, 200823

Detroit-Wayne CountyPersonal Care Model

Costs Down 24% for Members in Program; Costs Up 24% for Members Getting Usual Care

-24.0%

23.0%

-30.0%

-20.0%

-10.0%

0.0%

10.0%

20.0%

30.0%

MHSACPH CM in Program Members With MHSACPH UsualCare

Community Score Card Tool


Community Scorecard Healthcare activities of each community should be tracked in

nine areas. A community collaborative board of directors should set goals in each of these areas.

Target Population: Community’s Uninsured = ________. Enrollment (share of uninsured enrolled) # established enrollees, new enrollees, Medicaid eligible # of uninsured registrants, # screened and transferred to private insurance

Consumer Profile - demographic characteristics satisfaction with enrollment and care

Resources for Target Population -# of network access points for preventive and primary care, diagnostic/lab, pharmacy, and acute care# of specialty, ED and inpatient care providers linked to primary care centers

Enhanced Funding/Medicaid Match Funds - Federal grants and earmarks, state/county/city funds health system funds, Foundation grants


Community Scorecard Utilization of Network Services (compared to CDC and

published guidelines) ‘Medical Home’, preventive care and primary care visits, diagnostic/lab services, pharmacy scripts, specialty, ED and acute care visits; inpatient admissions and ALOS

Efficiency reduced ED usage (visit/enrollee), rate of preventable hospitalizations and ED visits, effective tracking (% care tracked)

Cost Effectiveness (measured using four benchmarks) MGMA benchmark for physicians costs; University Hospital Consortium for facility costs; Medicaid cost for types of services, and Medicare benchmark for Medicaid payment

Network Financial Viability revenues for care of target population; operating profit or loss on enrolled population; safety-net provider payer balance between Medicaid, Medicare, commercial insurance and uninsured (uncompensated care). Charity care (measured with standard community-wide metric)


Community Scorecard

Quality Measurements (HEDIS) Number of immunizations; frequency for diabetes tests, screening for Diabetes, Hypertension and Asthma; number of cancer screenings; prenatal/postpartum care; surveys on patient's experience; number of well visits; preventable ED and hospital admissions; and, frequency of selected procedures performed


Policy Recommendations Support Community Initiative for the

Uninsured Universal Coverage and Care Fund Primary Care that is Linked to the

Continuum of Care Fund Specialty Care that Helps Link the

Continuum of Care Organize Charity Care Community Choices

END

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Voices of Detroit Initiative (VODI)