Delaware rolls out health care reform

• The Delaware Center for Health Innovation is working to reform health care in the state.
• United Health Foundation ranks the state 32nd in the nation for health.
• Total health care costs amount to $8 billion annually in Delaware.

The Rev. John Riley takes his health seriously.

Diagnosed with cancer in 2014, the military veteran and pastor with Smyrna First Presbyterian Church is vigilant about check-ups and his overall well-being, but hasn't seen a primary care doctor in the last year.

That hasn't been by choice; his doctor's office has had issues hiring another physician after his left. Though he enjoys working with the nurse practitioner, he said, he would like to see a doctor.

"It's more than just an interview problem," Riley said.

Riley's issues are not unique.

Delaware is plagued with numerous health care issues. There are shortages of psychiatrists and dentists, and the general health of the state's population is less than stellar, ranking 32nd in the nation, according to the United Health Foundation. But one of the most urgent problems, experts say, is the cost to the state for providing care.

Total health care costs amount to $8 billion each year, about 25 percent more than the national average. Care associated with diabetes accounts for $1.1 billion alone.

Doctors, hospital officials, insurance companies, patient advocates and policy analysts are now working to change Delaware's costly and very sickly path.

Bolstered by a $34 million federal grant, stakeholders from a public-private partnership called the Delaware Center for Health Innovation have put together a health care transformation plan and are in the process of rolling it out over five years. So far, $8.287 million has been spent on research, an IT plan and new recommendations for primary care doctors.

Delaware was one of 28 states to receive such grant money, which was allocated from appropriations authorized by the 2010 Affordable Care Act. The center coordinates the work of five committees made up of community leaders, insurers, doctors and patients to evaluate all facets of Delaware's health care sector.

Part of the effort includes revamping how physicians get paid for diagnosing and treating patients, increasing behavioral health resources, recruiting more medical professionals and creating 10 "healthy neighborhoods" to support health outreach already being done in the community.

There will be public meetings in all three counties through October to discuss the initiatives.

"We want to make sure we are engaging the public," said Matt Swanson, chairman of the Delaware Center for Health Innovation, at the first meeting held at the Cheer Community Center in Georgetown on Tuesday.

A case for change

In white papers posted on the Delaware Center for Health Innovation website, preliminary estimates show the state could save more than $700 million annually by financing health information technology, new payment models and resources that support doctors. But a $350 million investment will be needed over 10 years before savings come through.

"You are going to see over the next year or two the results as the design work is translated into action," said Wayne Smith, president of the Delaware Healthcare Association, which represents the state's hospitals. "We have high hopes for care management for population health, for physician integration and payment reform."

Smith, however, warned that since there is so much change occurring at one, there is the possibility of unintended consequences, especially around payment reform.

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"I think a big issue that still needs to be resolved is access to patient data. We have an environment where we are being asked to take on more risk for outcomes. In order to properly assess risk, we need better access to patient data," he said.

Health care claims data in Delaware is considered private, and only insurers have access to the sensitive information. But legislation working its way through the General Assembly would create an all-payer claims database based on every insurance claim made for healthcare. Though insurance companies have concerns about the bill, it passed the state Senate unanimously on Thursday. The database would give providers a general picture of the population, said Tom Brown, senior vice president of Nanticoke Health Services and one of the leaders of the new payment models.

Providers would then know the difference in cost of services and what ZIP codes have a prevalence of a certain illness or procedure, such as knee replacements. Then they could to budget and negotiate with insurance companies to financially support a specific population's care.

"In order to arrive at a negotiated price, we really need to know what the experience has been," Smith said.

The state also has piloted a physician scorecard which includes benchmarks a physician should discuss with a patient, such as HPV vaccinations, high blood pressure medication adherence and screening and screening follow-ups for clinical depression.

Ideally, insurance companies would base reimbursements on how well doctors and their patients are following the guidelines.

“We strongly believe we need to change the payment model to place more emphasis and reward on quality outcomes,” said Tim Constantine, president of Highmark Blue Cross Blue Shield of Delaware. He added that he does not anticipate the changes to result in monthly premium increases to consumers. In fact, it may do the opposite, by helping reduce duplicative testing with incentives for physicians to keep patients healthier.

A new program, debuting in all Highmark plans in January, for example, will provide financial incentives for physicians to hire additional staff, implement electronic medical records and have practices stay open later if they hit similar quality measures.

To comply with scorecard benchmarks, Dr. Harry Anthony, a primary care doctor and medical director of the Nanticoke Physician Network, said Nanticoke Memorial Hospital's seven primary care practices have each hired a care coordinator. The coordinators work with higher-risk patients, with chronic diseases such as hypertension and diabetes. They make sure patients come to appointments, run educational programs, negotiate prescription costs and coordinate transportation when necessary.

So far it has worked. Anthony said recent hospital quarterly data showed the number of high-risk patients seen regularly by the office reduced by 20 to 30 percent.

Patients are healthier under the model, but not without some cost. The offices did need to spend $30,000 to hire each care coordinator, he said, and not every office is going to be able to lay out the financial capital.

"That is going to be much harder for small practices to do that," he said. "I think in today's day and age, it's getting more difficult to survive as a solo, small practice."

For the last two years, the state has been working to retrain Delaware's current health workforce on how to best coordinate a person's care, said Kathy Janvier, vice president and campus director at Delaware Technical Community College's Stanton/George Campus and chair of the center's workforce committee.

"This is a plan to change healthcare that involves much more than what happens in the provider's office," she said.

Educating the workforce is only one step; educating the community on care coordination is another.

Leaders from the Delaware Center for Health Innovation plan to meet with local groups from the first three designated "healthy neighborhoods" to help brainstorm ways to improve the overall health of the community, tackling topics such as maternal and child health, mental health and addiction and chronic disease prevention and management.

The first three neighborhoods encompass the Wilmington/Claymont area, Smyrna/Dover area and western Sussex County. Often communities face barriers beyond not having adequate health insurance. Lack of food, stable housing and employment are major issues.

Riley runs a weekly food pantry program in conjunction with the U.S. Department of Agriculture out of Smyrna First Presbyterian Church and regularly interacts with people grappling with drug addiction and diabetes.

"We try to give them food in order to maintain life itself," he said. "If they have any other needs we make them aware of any other federal programs. We do what we can. Of course it's just one stop along the way of many to restore people to full health."

On a recent Wednesday, donated apples, cheese, raisins and bread covered the cafeteria of Smyrna First Presbyterian Church. Linda, of Smyrna, who declined to give her last name because she was concerned about her job, practically danced her way inside, handing her three granddaughters and a friend, bags upon bags of food.

It's time to make some apple pie, she said.

Linda can't imagine her life without the food pantry. Since she and her husband took in her daughter and granddaughters three years ago, her house became full quick, and she is the only one currently working.

Making sure the girls are healthy, fed and clothed is a priority, even if it means shelling out $500 for new clothes so they won't get made fun of at school and visiting a food pantry weekly.

"I went out in my car and cried," Linda said of the first time she picked up donated food. "This helps me so much."

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New resources 

Delaware is short of seven primary care providers, four psychiatrists and 31 dentists to meet standard workforce requirements set by the Health Resources and Services Administration.

A subcommittee within the Delaware Center for Health Innovation is looking at how to increase medical educational opportunities and eliminate barriers in licensing and credentialing so Delaware can become an attractive state to practice medicine.

Though the state has relationships with other institutions such as Temple University and Thomas Jefferson University hospitals, the fact that Delaware does not have a medical or dental school poses challenges with health care recruitment.

The challenges, especially with the recruitment and hiring of hospital-based psychiatrists, are not unique to Delaware, said Sharon Kurfuerst, senior vice president of Health Services Operations for Christiana Care Health System. Such professional shortages happen in waves. Years ago, there were shortages in nurses, now there is a lack of psychiatrists, she said.

Even with less psychiatrists, the state is pushing to integrate behavioral health services into the primary care offices to get people mental health services faster and keep people out of the emergency rooms.

Christiana Care began integrating behavioral health consultants in 2014, Kurfuerst said, and now has specialists in the hospital's 12 primary care offices, heart and vascular offices, cancer care and women's health.

An initial behavioral health screening is free. Then patients can schedule follow-ups.

So far, 4,600 patients have had consultants, and the hospital has logged 11,000 individual treatment sessions. Previously staff would see 2,000 patients on average annual for behavioral health needs.

Integration into neuroscience offices may be next, she said.

"It also helps reduce the stigma around accessing behavioral health," Kurfuerst said.

Lewis, 61, was in denial of his anxiety for the longest time. Lewis, who declined to give his full name because he works as a counselor, consistently had gone to the emergency department thinking he had heart or other related health issues, only to find out after tests, that physically nothing was wrong.

At a primary care visit with Christiana Care he decided to take the next step and see a psychologist.  After some self-care tips, he learned how to breathe deeply to calm his body and what triggered his anxiety in the first place.

"I feel much better about myself," he said.

Over the next six months the Delaware Center for Health Innovation will continue to introduce the new health plan to the public through community forums. The plan is fluid and can change with input. The next forum will be held in Dover July 11.

Health care reform effort in Delaware

The Delaware Center for Health Innovation was formed in 2014 after the state acquired a $34 million federal grant to help reform how patients receive care and to lower the costs over five years. Delaware's health care costs are 25 percent higher than the national average, something experts say is unsustainable. In the first year Delaware was allotted $12,259, 694 for start-up activities. About $3 million could be carried over into next year if the feds approve. 

Between Feb. 1, 2015 to Jan. 31, 2016 the state spent:

• $1,050,000 for population health initiatives
• $2,361,029 for clinical upgrades
• $1,912,500 for new payment methods and outreach
• $1,476,500 for new health tech development
• $383,475 for workforce and education research and planning
• $372,475 for patient engagement research 
• $731,000 for overall management resources
• $886 for travel

Total $8,287,865
Carryover $3,971,829

Where's your doctor? 

Delaware's doctors are spread disproportionately across the state's three counties. Though New Castle County has the largest population base, there are still shortages of dentists and psychiatrists in the state's more rural areas.

New Castle County
▪ 504 primary care providers
▪ 302 dentists 
▪ 73 psychiatrists 
▪ 7,110 nurses

Kent County
▪ 77 primary care providers
▪ 50 dentists 
▪ 9 psychiatrists 
▪ 1,279 nurses

Sussex County
▪ 122 primary care providers
▪ 43 dentists 
▪ 7 psychiatrists 
▪ 1,481 nurses

If you go

What: Delaware Center for Health Innovation forum

Where: Modern Maturity Senior Center, 1121 Forrest Ave., Dover

When: 5 p.m. July 11

More information: Visit www.choosehealthde.com for more information.