In Hennepin County, Minnesota, which has one-fifth of the state’s population, the government has worked with the healthcare system to create a different way to care for people.
Hennepin is home to Minneapolis, and North Minneapolis has one of the places most impacted by health disparities linked to race and ethnicity in the state, according to Ross Owen, health strategy director of Hennepin County. Owen and Nathan Shippee, assistant professor of Health Policy and Management at the University of Minnesota, presented the Hennepin Health model and outcomes that were found during a retrospective study at Putting Care at the Center, during the inaugural conference of the Camden Coalition of Healthcare Providers’ The National Center for Complex Health and Social Needs.
Residents of Hennepin enrolled in Medicaid have a unique way of receiving care. Hennepin Health is a county-based accountable care organization (ACO) that was created through a partnership with Hennepin County Medical Center, NorthPoint—located in North Minneapolis—and the Hennepin County Human Services and Public Health Departments.
When the county decided to get involved with an ACO about 5 years ago, it concentrated its efforts to coincide with Medicaid expansion. As such, the county focused early expansion on a very specific group of people: adults without dependents earning up to 75% of the federal poverty line.
“The population that this was designed for was a unique slice of a unique slice of a Medicaid population,” Owen said. This group was disproportionately men of color. “So a lot of the intervention that we built out was really tailored to the social needs of this Medicaid expansion group.”
The beneficiaries enter Hennepin Health through the existing system, and the structure of payment is a Medicaid managed care system; they select or default into the ACO through Medicaid. The county created a risk-sharing funding model and manages the total cost of care bucket and then splits up proceeds after paying for required services and the core health plan structure.
“That managed care structure that we have allows us to spend those Medicaid dollars or just about anything that we think is going to help the patient population, as long as we’re delivering that core entitlement,” Owen said.
Any savings that are achieved stay local and in the community. The members of the partnership that makes up Hennepin Health all get some money back to offset the work they do that doesn’t get reimbursed. The savings also get reinvested in the community through little projects.
The primary care clinics anchor the model of care at Hennepin Health and the patient-centered medical home is a baseline across all the clinic sites, Owen said. From that, Hennepin Health built an ambulatory intensive care unit, which is a team-based model of care for the most complex patients.
“This is not all about money and improvement,” he said. “This model has really allowed us to build out and accelerate a different way of taking care of people.”
All of the teams and sites of care throughout Hennepin Health are connected through a shared electronic health record. This means that a clinician at one site can write a referral for a social worker or case manager in the community or job support counselor.
So how well does the Hennepin Health model work? Shippee presented preliminary findings of a retrospective cohort study of the early Medicaid expansion population in Hennepin County and the neighboring county of Ramsey, covering approximately 90,000 people. This study examined the healthcare use of people enrolled in Hennepin Health compared to similar people in other Medicaid managed care organizations. Initial results showed favorable, statistically significant impacts on some forms of healthcare utilization, with no significant benefit in others.
The second part of the study included interviews with 35 Hennepin Health enrollees to better understand for whom and how Hennepin Health might have achieved better outcomes. The researchers looked at combinations of several factors in patients' lives, and the care they received, that were associated with improved quality of life over the study period. Initial results highlighted just a small number of key aspects of the care model that were consistently important.
Owen concluded the workshop by identifying the elements of success in the Hennepin Health model:
Communicating across the system electronically in real time
Understanding the social needs and screening for them
Targeted intervention where healthcare complexity and social needs converge
Capturing savings and reinvesting them locally
Incentives to go beyond the clinic walls
Broadening concept of accountability
Owen added that Hennepin Health has the benefit of being able to make investments that aren’t going to have a return immediately. The public health services they provide will have outcomes further down the line.
“How do we understand early intervention to avoid continuing to create so-called ‘super-utilizers’ that our systems are failing?” Owen concluded. “We are in an environment where we can think longer term and we can think about those upstream investments that are so crucial.”