Collaboration in Health Care: Success Wherever You Are

Julie Brunner

Minnesota’s health care model is admired across the United States as an efficient, high quality system. There are many reasons for this and one important component is that Minnesotans work together toward common goals.

Collaboration among the health plans, hospitals and clinics, and the State of Minnesota has resulted in a system which ranks high in quality and access and low in cost. Our common goal is to improve the health of Minnesotans while making our health care system more efficient. Through the Minnesota Council of Health Plans (Council) our state’s seven health plan companies work to improve the health of all Minnesotans. These companies are locally based, community-focused nonprofit organizations serving more than 4.3 million enrollees. At the Council we work to ensure affordable coverage and quality care by embracing three strategies to carry out our work—policy development, industry leadership, and collaboration.

Collaboration is a key component of Minnesota’s success because it improves the health of our population, improves health care delivery, improves access to care, and reduces long-term health care costs. This article provides some highlights of how collaboration drives health system improvements across our state in the areas of transparency and payment reform, improving quality, administrative simplification, community health and prevention, and government health care programs.

Transparency and Payment Reform

MN Community Measurement (MNCM). MNCM is the leading health care quality public reporting organization in Minnesota. Its mission is to accelerate the improvement of health by publicly reporting quality information. After all, you cannot improve what you don’t measure and you cannot move a payment system toward paying for value if you do not have outcome-based data.

Launched by the Council and Minnesota Medical Association (MMA), MNCM is driving health care systems improvement. Today the Minnesota Hospital Association (MHA) and the state of Minnesota are also MNCM partners. The nonprofit organization is governed by a board of directors, with members representing employers, consumers, payers, and providers. Data is provided by health plans as well as directly from more than 300 medical clinics.

Reports provide clinic level, outcome-based quality results on health conditions such as diabetes, vascular disease, depression, ADHD, colds, sore throats, COPD, bronchitis, and asthma. Screenings included are colorectal, breast and cervical cancer, and chlamydia infection. MNCM also reports on other aspects of high quality care such as the experience of patients and the use of health information technology. Employers and health plans use these results to reward clinics and medical groups that are providing superior value.

Results include:

• The number of people with diabetes receiving the best possible care has almost tripled. In 2011 almost 10,000 more Minnesotans with diabetes worked with their doctors to meet the aggressive treatment goals that research shows is vital to managing the disease (blood pressure less than 140/90 mmHG; bad cholesterol, LDL, is less than 100 mg/dl; blood sugar, A1c, is less than 8 percent; documented as tobacco-free; aspirin as appropriate). We know from research that by meeting these goals, people with diabetes will likely avoid the disease’s serious complications—strokes, heart attacks, amputations, and vision problems.
• The percent of people who receive all the screenings they need for breast, cervical, and colorectal cancer has surpassed 50 percent.
• Since 2006, the rate at which children receive all their childhood immunizations has increased from 52 percent to 76 percent.
• More than 4,000 more patients with hypertension now have their blood pressure under control since reporting on that measurement began, reducing their risk of developing cardiovascular disease or experiencing other complications.

In addition, the Minnesota Department of Human Services works with MNCM to analyze and report on the care received by enrollees in programs such as Medical Assistance and MinnesotaCare.

MNCM’s role in the community is part of a cycle of quality improvement that requires the participation of all those concerned with improving the quality. The end goal is that patient care improves and Minnesotans live healthier lives. Quality of care information is available at mnhealthscores.org. News about MNCM’s work, leadership, and organizational structure is at www.mncm.org.

Pay-for-Performance Measures.To accelerate clinical quality improvement and address the administrative burdens faced in the clinical practice and at the health plan level, the MMA and the Council led an effort to bring physicians, payers, and organizations representing purchasers and patients together to make recommendations on aligning measures and measure specifications used in incentive programs. Membership of the group included health plans, the State of Minnesota Department of Human Services, practicing physicians, organizations representing consumers and business, and MNCM. The group’s charge was two-fold: make recommendation for aligned performance measure specifications, and 2) develop a long-term proposal for a coordinated approach to measurement to assure consistency across incentive programs.

At the time there were more than 150 pay-for-performance measures or variations on measures across the state. The group recommended that MNCM standards and measures be used whenever possible. Over time (2008 to 2011) the number of measures used decreased 41 percent. From 2009 to 2011 alignment of the clinical areas with those measured by MNCM increased by 56 percent, while at the same time specifications alignment with MNCM measure specifications increased by 109 percent. The number of independent measures—or measures not used by MNCM or another incentive program—decreased by 11 percent.

Administrative Simplification

Minnesota’s health plans pay for an average of $55 million in health care every day, 365 days a year. While the federal Affordable Care Act calls for the health care system to streamline administrative work, many of the efforts being talked about across the country have been in process in Minnesota for years. For example:

Minnesota Credentialing Collaborative (MCC). By credentialing health care providers, health plans help ensure doctors, therapists, and other clinicians who provide care are qualified to do so and meet each company’s standards. Credentialing is also required by organizations that accredit health plans such as URAC and the National Committee for Quality Assurance (NCQA). The process is also one of the most burdensome for doctors and other practitioners as they must apply to each health plan and hospital with which they want to work. In the past the application, which has to be repeated every three years for health plans and every two years for hospitals, was a manual process. Now, the MCC has developed a centralized, web-based clearinghouse for information used in the credentialing process. The product is an online, easy-to-use way to prepare, save, and send the credentialing application that is accepted by plans and hospitals. Once the information is entered into the secure website, users select the destination—health plan(s) and/or hospital(s). The system electronically sends the information. The information is stored so users may quickly access and update the next time an application is needed. Partners in creating a web-based credentialing application were the Council, MMA, MHA, and the Minnesota Medical Group Management Association.

Administrative Uniformity Committee. For more than fifteen years, health plans, hospitals, clinics, and other providers have worked through the Administrative Uniformity Committee (AUC) to streamline billing activities across Minnesota. The group recently completed work required by Minnesota law to establish standardized, electronic health care billing transactions. Now operational in Minnesota, the single set of billing codes used through an electronic transaction dramatically simplifies the billing system. Health care providers now accomplish three important tasks with the click of a mouse: 1) check on a whether a patient has health care coverage and find out the services for which the patient is eligible; 2) send claims electronically; and 3) receive responses from health plans about payment of the claims. The AUC continues to develop agreement on standardized administrative processes when implementation of the processes will reduce administrative costs. The processes and user guides are available on the AUC’s website.

Improving Quality

Institute for Clinical Systems Improvement. Minnesota’s Institute for Clinical Systems Improvement (ICSI) is an independent, nonprofit organization that brings together diverse groups to transform the health care system to one that delivers patient-centered and value-driven care. It is comprised of 55 medical groups representing more than 9,000 physicians, and is sponsored by five health plans. In the early years of ICSI, the organization focused on bringing together physicians and other health care experts to create health care guidelines—evidence-based documents of how to prevent or manage a particular symptom or disease for an individual patient under normal circumstances. The guidelines take into account the preferences of the patient or his or her family and have become the community standard on which quality of care is measured, reported, and rewarded. ICSI is now working with health plans, hospitals, care centers, rehabilitation facilities, employers, and others across the health care system to transform how health care is delivered and paid for. Examples of this work include initiatives such as Reducing Avoidable Readmissions Effectively (RARE), Accountable Care Organizations, Cancer Prevention Learning Collaborative, Palliative Care, Diagnostic Imaging, Health Care Homes, Depression Care, and more. Details around ICSI’s work are featured on its website. Following are summaries of two initiatives, diagnostic imaging and improving care for people with depression.

Diagnostic Imaging. The diagnostic imaging challenge included concerns about the rapid growth each year in the use of MRI, CT, and other high diagnostic imaging services. When growth was 13 to 14 percent overall, high tech imaging topped 20 percent. In addition to spending, imaging services also carry safety concerns: one abdominal CT scan is equivalent to the radiation level of 500 chest x-rays.

Initially health plans raised concerns in various meetings and conversations with providers, but increases continued. Then a health plan asked practitioners to notify the plan when they were ordering a MRI, CT, PET, or nuclear cardiology scan. The plan would then work with accepted scanning guidelines to give the provider immediate feedback on whether the scan that was being ordered was appropriate in the specific situation. The approach did not work well. It added administrative burden, lowered clinic efficiency, lowered patient satisfaction, and took the decision-making away from where the service was provided.

Innovation was needed. The goal—to reduce overtreatment—continued to be the same. The solution had to minimize disruptions in patient care and provider workflow, get more and better data on the issue, and at the same time increase the provider’s accountability for quality care and ordering appropriate tests. With Minnesota’s high penetration of electronic medical records, a decision support tool within the electronic medical record was possible. Partners Healthcare in Massachusetts had experienced early success in building physician decision support tools into its electronic medical record. In Minnesota, HealthPartners Medical Group was willing to invest in developing a program and testing the concept in Epic, the community’s most used electronic medical record system. Work began on a “Build-Your-Own” Physician Decision Support tool that allowed physicians to use their electronic medical record to compare their decision on which scan was ordered to accepted guidelines. The tool also provided clinics a monthly report detailing the appropriateness of the scans that had been ordered.

Collaboration made the work possible. HealthPartners Medical Group relied on the ICSI collaborative to facilitate discussions to build the framework for the Physician Decision Support option. All five regional health plans agreed to accept Physician Decision Support as an alternative to prior notification and seventeen medical groups agreed to the new process.

Statewide results (2007) showed goals were met. Quality and safety improved—75,000 unnecessary scans were prevented meaning twenty lives saved from reduced exposure to radiation. Costs were reduced with more than $60 million being saved and the administrative burden on physicians and clinics was lowered. Data showed while the old system of prior notification took 10 minutes to complete, the Physician Decision Support model took 10 seconds.

Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND). DIAMOND is one of our nation’s most promising efforts to improve health care for people with depression because it changes the way care is delivered and how health plans pay for it. The ground-breaking work was created by extensive collaboration.

At any given time, 9 percent of the United States’ population has a depressive disorder. In addition, depression decreases overall health and causes people to miss work, greatly impacting employers across the country. According to ICSI’s analysis of the research, almost 75 percent of patients with depression see a primary care provider, but they detect only 35 to 50 percent of adult patients with major depression. About 50 percent of these patients get treated, and only 20 to 40 percent of treated patients show substantial improvement in the year following diagnosis. Stakeholders came together to research and study the complex issue and to ultimately change how depression is treated and paid for at primary care clinics in Minnesota.

All stakeholders were involved: primary care physicians and psychiatric specialists from large and small clinics; those who had electronic medical records and those that did not. Health plans, government, and other payers participated, along with employer representatives from corporations such as Minnesota-based General Mills and Wells Fargo. Patients with depression and a representative of the general public were involved as well. The work was supported by Jürgen Unützer, M.D., M.P.H., from the University of Washington in Seattle, WA, and Project IMPACT (Improving Mood – Promoting Access to Collaborative Treatment).

A white paper describing the details of the development of the DIAMOND care model and overall reform effort, along with other fact sheets, bibliography, cost effectiveness literature, a depression care toolkit, FAQs for patients, and more is available on ICSI’s website, www.icsi.org.

The result of the group’s planning was launched in 2008 and by the beginning of 2012, more than 8,000 adult patients with major depression or dysthymia had participated in the DIAMOND program in Minnesota and bordering regions. The clinics reported that 30 percent of their patients with depression were in remission—a rate six times higher than results reported for primary care clinics statewide.

Community Health and Prevention

Public Health Collaboration Plan. An industry-wide collaborative plan focuses the work of health plans and local public health departments toward achieving high priority public health goals. The plan includes: 1) specific measurement strategies and a description of activities; 2) description of the process for coordinating activities with community health boards; 3) documentation of local health department involvement; and 4) documentation of compliance with the previous plan.

Council members continue to identify and work on shared priority areas ensuring our work mirrors both the state and local health departments’ priorities including nutrition, physical activity, tobacco, disparities, and emergency preparedness (pandemic flu). The collaboration plan provides detailed examples of how health plans address these priority areas in collaboration with the state and local health departments. Additionally, there are other important public health areas that health plans actively address through their work with 130 groups throughout the state.

State Health Improvement Program (SHIP). SHIP works to prevent disease before it starts by helping create healthier communities that support individuals seeking to make healthy choices in their daily lives. Health plans and others are working with the state to help improve health and reduce demands on the health care system by decreasing the percent of Minnesotans who are obese or overweight or use tobacco. This collaborative effort to support the state’s health improvement program includes information on Disease Management /Health & Wellness Coaching, Tobacco Cessation Programs, Health Club Membership & Fitness Discounts, Member Incentives, Employee Assistance Programs, 24/7 Nurse Information Line, Provider Services, and other programs.

Government Health Care Programs

A two-decade old partnership among the government and local nonprofit HMOs ensures more Minnesotans have guaranteed access to the same doctors and providers as enrollees insured by employers. Gone are the days when people with Medical Assistance couldn’t receive care near their home. Minnesota plans have an established history aligning goals and payments to health care providers to achieve better outcomes at a lower cost. The state is able to leverage that expertise in administering its public programs, including Medicaid and MinnesotaCare.

Data show better performance on a number of quality measures and care is coordinated, quality is improved, and costs are lower than in a traditional fee-for-service or completely government-run model. In addition to increased access, health plans offer a number of services including general health education, condition-specific support and services, administrative expertise, and services for physicians and clinics.

Collaboration: Success Wherever You Are

While some believe “collaboration fairy dust” falls like snowflakes across Minnesota, collaboration to improve health systems can be successful anywhere in the world. Following the important and often difficult steps below will be worth the effort when the results produce an improved health care system.

1. Bring all key stakeholders together. Be sure to include patients and employers.
2. Talk about the issues with candor and bring facts to the discussion.
3. Listen to one another with respect.
4. Develop trust.
5. Discuss hard issues—do not put them off to another day.
6. Seek a common vision.
7. Develop a common solution—don’t expect it to look like you thought it would when you started.
8. Build implementation and measurement teams of experts from various stakeholder groups who work together to create specific processes and systems that work for all key stakeholders.
9. Celebrate and share successes.

Julie Brunner is the executive director of the Minnesota Council of Health Plans. Brunner participates in the Berlin Seminar on Health Policy organized by the Center for German and European Studies at the University of Minnesota. In addition, this year she was a guest presenter at the American-German Institute conference in Berlin.

The views expressed in this publication are those of the author(s) alone. They do not necessarily reflect the views of the American-German Institute or the Minnesota Council of Health Plans.