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5/8/15
HEALTHCARE REFORM IN COLORADO:
WHAT ABOUT THE CHILDREN?
David Keller MD
and
Steve Poole MD
DISCLOSURE STATEMENT
Speaker: David Keller
Dr. Keller serves as a pediatric consultant to
the Division of Health Care Policy and
Finance, State of Colorado.
These slides reflect the views of the speaker alone, and do not
represent those of the UCDenver SOM, Children’s Hospital
Colorado, the Department of Health Care Policy and Finance
or the State of Colorado.
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Objectives
By the end of today’s session, you will be able to:
•  Discuss the ways in which the health care landscape is
changing nationally and within Colorado, as the Affordable
Care Act enters it's fifth year and Colorado moves to
become the healthiest state in America.
•  Describe how payment reform, narrow networks,
telemedicine, quality measures and health information
technology will affect your practice
•  Outline challenges to assuring that changes in payment
and practice improve the health of children
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March 23, 2010: PPACA Signed
•  Access:
• Getting people on insurance
• Medicaid/ Exchanges
•  Quality:
• Improving the quality of care
• Set standards/Pay for meeting
them
•  Cost:
• Bending the cost curve
• Try things/Take them to scale
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So, what happened next?
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What about 2015?
•  115th Congress: Elections have consequences
•  Senate and House are controlled by Republicans
•  White House still run by Democrats
•  Major health issues
•  PPACA repeal
•  SGR fix/CHIP reauthorization and re-appropriation
•  21st Century Cures/ ACE-Kids
•  Supreme Court: King v. Burwell
•  Will there be subsidies for the Marketplaces?
•  Likely outcome: Stalemate until 2017
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Shared Savings
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But for children: A small piece of the pie!
•  13% of total spend
•  Savings may not be
enough to fund
transformation
•  Outcomes
• Take longer
$359
$2,342
Children 0-18
• Cross systems
Adult Over 18
• Social determinants
Total Health Spend, 2011, in $Billions
What’s Different about children?: The 5 D’s
In settings goals and
establishing measures,
children are different.
CONSIDER:
•  Developmental change
•  Dependency
•  Differential Epidemiology
•  Demographic Patterns
•  Dollars
From Children’s Health, the Nation’s Wealth. 2005. IOM: Washington. P. 42.
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So What About Colorado?
•  Senate Bill 208 Commission & Commission on Affordable
Health Care: bipartisan and public/private commitments to
upgrade health policy
•  Comprehensive Primary Care Initiative (CPCI): Convened
public/private payers to engage in joint-decision making &
develop data aggregation solution
•  Accountable Care Collaborative (ACC): Colorado Medicaid
advancing public sector delivery/payment reform
Coming Soon:
•  State Innovation Model (SIM)
•  Colorado Opportunity Project (COP)
•  Coordinating All Resources Effectively (CARE)
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The Accountable Care Collaborative
Is the ACC working?
Per the Colorado Health Institute:
•  The ACC is iterative: The program continues to evolve to
include new populations and strategies.
•  A spike in utilization among members enrolled fewer than
six months in the program may suggest pent-up demand
for services.
•  The ACC achieved the greatest net savings for ACC
members with disabilities.
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Is the ACC working?
The Future of the ACC
•  Enhancing collaboration between RCCOs
and providers
•  New KPIs
•  WCC 3-9
•  Screening for post-partum depression
•  ER Utilization
•  Rethinking the shared savings
•  Rebidding the RCCO Contracts
Coming Soon:
The State Innovation Model
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What else?
The Colorado Opportunity Project
FAMILY
FORMATION
EARLY
CHILDHOOD
MIDDLE
CHILDHOOD
ADOLESCENCE
TRANSITION
to ADULTHOOD
ADULTHOOD
INDICATORS (measures)
may include:
•  use available, high-
quality, cost-effective,
evidence-based
programs
•  improve them with better
coordination and welldefined goals and
measures, GOAL:
Increase the percentage
of Coloradans in the
middle class by age 40.
  Intended Pregnancies
  Emotional Well-being of
Parents
to Affordable Food
Readiness & High School Graduation
Income
  Grade Level Advancement
  Access
  School
  Family
INTERVENTIONS
(programs) may include:
  Family Planning
  Early & Periodic
Nurse Home Visiting Programs
Screening Diagnosis & Treatment
Communities
Literacy and Math Programs
  Workforce Development & Job Training
  Healthy
  Early
How are children faring in Colorado?
•  Many processes, many silos
•  Children benefited from 2008 legislation
•  Multi-payer initiatives focused on adult care
(HealthTeamWorks, CPCI)
•  Children currently in majority in the RCCOs
•  Challenges remain
•  What are the measures that matter?
•  What is the measure of a medical home?
•  How does one integrate public and private sector
initiatives?
•  Where do children fit into the State Innovation Model?
What’s that mean for your practice?
Be at the table, to assure
focus on primary prevention
and acute illness, not just
chronic disease
•  Learn to measure process and
outcomes
•  Develop QI and analytic
infrastructure
•  Ingrain the triple aim onto your
practice
•  Firm up your partnerships
•  Develop capacity to coordinate
care
•  Don’t forget your roots
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What’s that mean for your practice?:
Learn to measure process and outcomes
ER Follow-up & Transition Care :Data
July
August
Numerator
Denominator
Result
Numerator
Denominator
Result
Hospital
Discharge
5
6
83%
7
8
88%
Chronic
ER Visit
3
3
100%
1
1
100%
Form Pediatric Associates of Hampden County, Westfield, MA
What’s that mean for your practice?:
Develop QI and analytic infrastructure
•  Patient level
•  Practice level
•  System level
•  Your EHR
must be more
than a
typewriter!
From Somerville Pediatrics
What’s that mean for your practice?:
Ingrain the triple aim onto your practice
AIM STATEMENT: Patients in our pediatric practice for
whom we prescribe ADHD medications will have guideline
concordant management including:
•  Initial ADHD evaluation and follow-up appointments with their PCP
•  Medication refills written by their PCP
•  ADHD follow-up visits at least 2x/year (can include well-visit)
PRIORITIES FOR IMPROVEMENT:
•  Create ADHD medication refill and follow-up guidelines
•  Streamline our refill process
•  Improve documentation
•  Develop patient registry
•  Ensure follow-up at regular intervals
From UMass Pediatric Associates
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What’s that mean for your practice?:
Firm up your partnerships
CEDDAR
NHPRI
RIPIN/Family Voices
Newport Hospital
FRCs/FSCs
Child Outreach
Head Start/Child Care
Special Education
Medical Home
-Physician
-Family
(PPEP)
Parent Consultant
EBCAP
Sub-specialists
Early Intervention
Home Care
Mental Health Services
Rehab Services
From Aquidneck Medical Associates
What’s that mean for your practice?:
Develop capacity to coordinate care
A Whole Person, Team-Based Approach to Care Management
Community
Community Health Worker
Patient’s
life
Medical
Complex Care
Management Team
for top 5% RN, SW + CHW
Psychosocial
Social Work
Care Manager
Nurse Care
Manager (RN)
Planned Care Team
95%
From Broadway Pediiartics
And Don’t Forget Your Roots:
Remember what’s different for children
The Five D’s
• Developmental change
• Dependency
• Differential
Epidemiology
• Demographic Patterns
• Dollars
•  Need to look at life-course
outcomes with multiple
inputs
•  Need to include families
•  Need to focus on behavioral
health and mental health
outcomes
•  Need to account for diversity
and poverty
•  Need to reward incent with
more than shared savings
Keller et. al. Not Just Little Adults: Policies
to Support
Medical
Home
Transformation
Pediatric
Practice.
From
Children’s
Health,
the Nation’s
Wealth.in2005.
IOM:
Washington. P. 42.
http://www.qualitymeasures.ahrq.gov/expert/expert-commentary.aspx?id=47896
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It’s a Moving Target: Stay Informed!
§  Federal Government: https://www.whitehouse.gov/healthreform
§  Kaiser Health News: http://kaiserhealthnews.org
§  Health Reform GPS: www.healthreformgps.org
§  AAP Federal Affairs:
https://www.aap.org/en-us/advocacy-and-policy/Pages/State-HealthInsurance.aspx
§  AHRQ Medical Home Site:
http://www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483
§  Patient Centered Care Collaborative: http://www.pcpcc.net/
§  National Center for Medical Home: http://www.medicalhomeinfo.org
§  Colorado Health Institute: http://www.coloradohealthinstitute.org
§  CCHAP: http://cchap.org
§  CO SIM: https://sites.google.com/a/state.co.us/sim-colorado/
§  ACC: https://www.colorado.gov/pacific/hcpf/accountable-care-collaborative
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