Introduction

his plan represents nearly six years of work and study conducted by the Cape Care Coalition, a group of Cape residents, medical professionals and public officials. The goal of this document has been to present a draft for discussion of how a community-owned health care system for the residents of Barnstable County, based on a self-insurance model, might be organized.

As we have studied, discussed and come to consensus through an engaged group process, varied aspects of the proposal program elements have been systematically incorporated into this Model Plan, and have been released periodically on our website since it was first drafted in June 2007.

Through this development process, we have come to envision this document as the ‘operating manual’ for a new model, comprehensive community health plan for Cape Cod, available to all residents.

This release represents substantial completion of the key model plan components, adding much critical new material on Board of Trustee composition and funding, and is consistent with the legislation for the Cape Care Community Health Trust.

Version 2.9

III. A c – Organization: to provide health care services for every enrolled resident of Barnstable County…

VI. A. – Cost Containment: include global payment mechanism under administrative simplification

XII. I. 2 –Provider Relations: global payment mechanisms to be considered

Yours,

Brian O'Malley, MD

Cape Care Model Plan Editor

brom@ccwork.info

Cape Care Coalition

Phone 877-700-8070

P.O. Box 3023 Email capecare@earthlink.net

Wellfleet, MA 02667 www.capecare.info

Contents

Introduction................................................................................................ 1

I. Executive Summary................................................................................. 3

II. Values and Principles (adopted by Cape Care July 2006).................... 4

III. Cape Care Organization....................................................................... 5

9IV. Covered Benefits................................................................................ 7

V. Health Promotion and Wellness............................................................ 9

VI. Cost Containment.............................................................................. 10

VII. Eligible Participants.......................................................................... 12

VIII. Administration................................................................................. 13

IX. Board of Trustees ("the Board"); Composition; Powers and Duties 14

X. Professional Advisory Board.............................................................. 16

XI. Cape Care Community Health Trust................................................. 17

XII. Health Care Provider Relations........................................................ 22

XIII. Provider Billing and Reimbursement............................................... 23

XIV. References....................................................................................... 25

XV. Version Notes................................................................................... 25

XV. Appendix A...................................................................................... 28

XVI. Acknowledgements......................................................................... 29

INDEX..................................................................................................... 30

I. Executive Summary

A. Cape Care is more than merely a simplified, efficient way of financing health care for residents of Barnstable County through a self-insured plan. While it makes use of the single payer attribute, akin to Medicare, to put scarce health care dollars to work providing care - devoid of the administrative inefficiencies, arbitrariness, and inconsistencies of conventional commercial insurance - Cape Care recognizes that good health is much more than just a matter of financing. Cape Care is, above all, an integrated, population-based health care plan, specific to Cape Cod, designed to preserve the primacy of the needs of individual patients, while at the same time systematically addressing the requirements of this particular population.

B. At the core of Cape Care are the following:

1. Comprehensive lifetime health care coverage, through the existing independent network of providers and institutions, available to all residents of Barnstable County.

2. Use of health care research and our own health care data to assure the quality, cost effectiveness, and appropriateness of care; and to engage in health planning specific to the County.

3. Incorporation of public health and preventive medicine practices to maintain and improve the healthcare status of individuals and of the County as a whole.

4. Enhancement of access to, and coordination of care, though a systems approach, communications, education, and electronic health records.

5. Reporting to the County on an annual basis on the County's health status, on the performance of Cape Care, and on the health care issues of the Cape community.

C. Cape Care works like this:

1. The Cape Care Community Health Trust will be the self-insurance core; managed by a new not-for-profit organization called Cape Care. This public entity will have its own community-based, elected and representative Board of Trustees, responsible for the collection and disbursement of funds, plan management, and policy development and decisions.

2. Current federal and state health care funding, which constitutes about half of the total expenditures, will be directed to the Cape Care Community Health Trust, through participation as a health plan for enrolled individuals under Medicare, Medicare Advantage, MassHealth, CHIP and Commonwealth Connector programs.

3. Residual funding, beyond existing Federal and State entitlement payments, will be through a property-based Barnstable County Health Tax, and a payroll-based Employer Health Contribution.

4. Savings are projected from the administrative simplification inherent in the plan; from the bulk purchasing power for prescription drugs, supplies and some services; reforming care delivery, by using appropriate provider and consumer education to reduce clinical waste, and from the expected real reduction in preventable disease and disability, both by early effective detection services and by a truly preventive, community health orientation.

5. Enrolled Cape residents are free to choose their own doctors, dentists, and other providers.

6. Issues of quality, cost effectiveness and control, and appropriateness of care are the responsibility of Cape Care's Professional Advisory Board, composed of participating health care practitioners and institutions, public health policy experts, clinical pharmacists, health educators and other professionals as are determined to be necessary for health policy development.

7. As the roles of proper diet and nutrition, physical fitness, tobacco control and social supports are integral to good health, and can reduce the need for more costly medical interventions and therapies, Cape Care would cover the assessment of these contributors to an individual's health, and include programs and practices along these lines in its promotion of individual and community health.

8. As good health care, and ultimately health care that is affordable, is a responsibility of both the patient and the provider, the individual and the community, Cape Care emphasizes keeping the individual apprised of his or her health, and the community apprised of its collective health status, as well the performance of Cape Care in meeting the goals of each. In this way, the individual, the provider, and the health plan itself, individually and jointly, can make better-informed decisions on attaining the best achievable level of health.

II. Values and Principles (adopted by Cape Care July 2006)

A. Universal accessibility to health care is fundamental to the well-being and security of both individuals and communities and should be regarded as a human right to be provided to every individual as a matter of public policy and law.

(Ed. Note: a resolution defining health care as a human right was approved by over 71% of voters in the three Cape legislative districts where it appeared, Nov. 2008.)

B. The adoption by a community of a universal, not-for-profit, single-payer healthcare system creates a social responsibility that must be shared by that community and its citizens.

C. A universal, not-for-profit, single-payer healthcare system must be comprehensive, accessible and affordable. It is designed to reduce administrative overhead and provide an unrestricted choice of providers without changing the ownership status of existing providers.

D. Defined benefits must be established by an independent, fair and transparent process which involves a broad spectrum of citizens. These benefits must be portable, independent of health, employment and income status, and guaranteed for life.

E. Uniform standards must be established for lifespan core benefits, e.g., wellness, preventive, oral, mental/behavioral, primary, specialty, end-of-life, and chronic disease management.

F. Administration of the plan must be in compliance with the following guiding principles:

1. identification and evaluation of effectiveness based on evidence-based science and/or expert consensus.

2. resource allocation guided by a public health perspective.

3. individualized care that is culturally respectful and appropriate to linguistic ability and literacy level, is accessible and affordable to all residents.

4. integrated care is facilitated, to improve outcomes, decrease medical errors, and strengthen the health care delivery system.

G. Services and treatment beyond the core benefit package may be covered by commercial insurance, or purchased.

H. Development of the draft plan will involve a public process of open meetings and hearings, and the final Model Plan will be subject to some form of community referendum prior to implementation.

III. Cape Care Organization

A. Cape Care will be organized as a public authority- “ a corporation that administers a public enterprise,” -with the ability to receive tax revenues and issue bonds.

This is an important structural issue, which continues to require the most knowledgeable legal and political consultations. Review of applicable state statutes and discussions with elected officials have been initiated. We have filed the enabling state legislation in 2009- HB138. It was heard Jan. 20, 2010 by the Joint Committee on Health Care Finance.

1. The entity shall be a not-for-profit; community controlled "Community Health Organization" with the following characteristics:

a. provides health care services primarily through arrangements with direct care providers, organized on a group practice or individual practice basis, and with health care institutions.

b. has revenue raising authority, or obtains some of its funds through state authority

c. functions as the public agency, or "single payer", responsible for the collection and disbursement of funds required to provide health care services for every enrolled resident of Barnstable County

d. utilizes large-quantity purchasing power to negotiate price discounts for prescription drugs and all needed durable and nondurable medical equipment and supplies

2. With the following powers:

a. to make, amend and repeal by-laws, rules and regulations for the management of its affairs

b. to sue and be sued in its own name;

c. to make contracts and execute all instruments necessary or convenient for carrying on the purposes of Cape Care, including bond issuance;

d. to acquire, own, hold, dispose of and encumber personal, real or intellectual property of any nature or any interest therein;

e. to enter into agreements or transactions with any federal, state, county or municipal agency or other public institution or with any private individual, partnership, firm, corporation, association or other entity;

f. to appear on its own behalf before boards, commissions, departments or other agencies of federal, state, county or municipal government;

g. to appoint officers and to engage and employ employees, including legal counsel, consultants, agents and advisors and prescribe their duties and fix their compensation;

h. to establish advisory boards;

i. to procure insurance against any losses in connection with its property in such amounts, and from such insurers, as may be necessary or desirable;

j. to invest any funds held in reserves, or any funds not required for immediate disbursement, in such investments as may be lawful for fiduciaries.

k. to accept, hold, use, apply, and dispose of any and all donations, grants, bequests and devises, conditional or otherwise, of money, property, services or other things of value which may be received from the United States or any agency thereof, any governmental agency, any institution, person, firm or corporation, public or private, such donations, grants, bequests and devises to be held, used, applied or disposed for any or all of the purposes specified in this chapter and in accordance with the terms and conditions of any such grant. Receipt of each such donation or grant shall be detailed in the annual report of the Trust Fund; such annual report shall include the identity of the donor, lender, the nature of the transaction and any conditions attaching thereto;

3. Cape Care is hereby constituted a public instrumentality of the County and the exercise by Cape Care of the powers conferred by this chapter shall be deemed and held the performance of an essential governmental function. Cape Care is hereby placed in some relation, to be determined, to the Barnstable County Department of Human Services but shall not be subject to the supervision or control of said office or of any board, bureau, department or other agency of the County except as specifically provided.

This is a part of the important organizational structure, which involves ongoing substantive consultation with the leadership of Barnstable County government. This discussion is in process, and includes an Assembly vote to “support and encourage” Plan development. It has been made clear by all that the County will not be responsible for funding or operating the proposed plan. As noted above, an Authority form is anticipated.

a. Annually, Cape Care administration will prepare a report to the County, reflecting Cape Care's performance, changes in community health status and other relevant health care issues for Barnstable County residents.

This is seen as an important, ongoing feedback process, which maintains a focus on the health of the community, as measured by accepted indicators, and on the effectiveness of the health system in improving those indicators.

IV. Covered Benefits

A. Cape Care shall pay for all professional services provided by enrolled providers and facilities to eligible participants, in order to:

1. provide high quality, appropriate and medically necessary health care services;

2. encourage reductions in health risks and increase use of preventive and primary care services;

3. integrate physical health, mental and behavioral health and substance abuse services, and;

4. assure a primary care "medical home" for every enrolled Barnstable resident.

This does not require any eligible participant to have a local primary care provider. Its intent is to provide every resident access to a PCP.

B. Standard covered benefits shall include all high quality health care determined to be medically necessary or appropriate, and recommended by the Professional Advisory Board and approved by the Trustees, including, but not limited to, the following:

1. prevention, diagnosis and treatment of illness and injury, including immunizations, laboratory, diagnostic imaging, inpatient, ambulatory and emergency medical care, blood and blood products, dialysis, organ transplants, endoscopic screening, mental health services, acupuncture, physical therapy, chiropractic and podiatric services, and a specialist second-opinion option.

2. promotion and maintenance of individual health at all ages through appropriate screening, counseling, and nutrition and health education;

3. the rehabilitation of sick and disabled persons, including physical, occupational, speech, psychological, and other specialized therapies;

4. prenatal, perinatal and maternity care, family planning, fertility and reproductive health care, and genetic counseling;

5. developmental evaluation; medical and behavioral;

6. behavioral health services, including effective mental illness prevention strategies; inpatient and outpatient testing, diagnosis, counseling, and treatment in the most appropriate settings; coordination with medical providers; and advocacy services as indicated;

7. clinical nutrition services;

8. medical social work services;

9. home health care including personal care; other needed support services; foster care; adult day care;

10. long term care in institutional and community-based settings;

11. hospice care, both inpatient and at-home;

12. language interpretation and such other medical or remedial services as Cape Care shall determine;

13. emergency and other medically necessary transportation;

14. dental services, other than cosmetic dentistry;

15. basic vision care and correction, other than laser vision correction for cosmetic purposes;

16. hearing evaluation and treatment including hearing aids;

17. podiatry services;

18. prescription drugs; (with an open formulary development, and appeals, process)

19. durable and non-durable medical equipment, supplies, prosthetics and appliances.

C. Mental health services

1. Services for mental illness shall be integrated, to the extent possible, with comprehensive health care delivery.

2. Communication between disciplines should be facilitated.

3. Centralized triage and referral could facilitate timely, appropriate evaluation and therapy.

4. Reduction of barriers to access services is critical.

5. Suicide prevention strategies will be more available through a community wide network of efforts.

a. Cape-wide on-call teams

b. central phone resource line

c. community education

d. police training resources

D. Because tobacco abuse, poor diet choices, inadequate physical exercise and alcohol account for over a third of all deaths, and that individual choices significantly predict health outcomes, a comprehensive wellness and health promotion program will be central. Individual Health Resources Assessment (Appendix A) will be conducted for all enrollees.

1. Financial and other incentives to risk-reduction behaviors for participants and providers will be offered.

2. Adequate resources must available and affordable to the system.

Programs are costly to run, but returns on investment have proven to be significant.

3. Public health focus on tobacco, diet and physical exercise in collaboration with other community agencies will be developed.

4. Linked electronic medical records will be utilized for their potential to prompt all providers to the most appropriate interventions.

E. Standards for appropriate utilization of covered services will be promulgated. These will be transparently developed and open. An appeal process for non-covered benefits must be elaborated and available.

F. Not covered are therapies and procedures determined to be principally of cosmetic intent.

G. It will be Cape Care policy to provide, facilitate, support and promote population-based strategies that improve acceptance of and adherence to fitness and nutrition goals for the prevention of chronic diseases. It is intended that the benefits of services provided pursuant to such strategies will be available to all residents

H. Under the requirements of the Ch. 58 “Commonwealth Care” program, every individual is required to have health care insurance coverage that satisfies certain criteria of adequacy. The coverage provided by Cape Care will meet all such criteria, and Cape Care will seek approval by the Commonwealth Connector as a valid insurance plan option for eligible Barnstable Residents.

This will greatly facilitate access to needed health care services for covered individuals, compared to current experience, as nearly all providers would be expected to participate in Cape Care. This is particularly critical for specialist care.

V. Health Promotion and Wellness

Important to the promotion of health is the ready access to services that reduce the incidence and impact of preventable diseases.

A. Some portion of the payments into the Cape Care Community Health Trust each year will be designated for health promotion and wellness activities.

B. Cape Care will probably contract with a third party provider of health promotion and wellness services to provide to members a range of services that would include:

1. A Computerized Health Risk Appraisal (HRA), described more fully in Appendix A, expected of each enrolled member initially, and periodically.

2. A Self Care book provided on initial enrollment to each household with one or more enrolled members

To be most effective, providers have copies of the Self Care books in their offices and reinforce their use with patients, especially those with chronic conditions such as asthma.

3. A Nurse Call Line, available to all plan members, and able to make referrals to a pre-approved list of designated, local wellness professionals

4. Access to a high quality Health Information Website

5. Telephonic and email based health coaching for those with risk factors identified on the HRA.

VI. Cost Containment

The Cape Care plan is intended to control rising health care expenditures through diverse mechanisms. Among the most evident are:

A. markedly simplified administration of health care finance. For providers, most fee-for-service claims would be handled by the single payer; and innovative models of global payment would further reduce administrative costs.

B. volume purchase discounts on pharmaceuticals and medical supplies and services.

C. detection of potential health risks at an early stage, and intervening in a timely manner, through universally available primary and preventive care, and Health Promotion and Wellness initiatives (Sect V, above.)

D. promotion of community health by fostering lifestyle change related to nutrition, fitness, lifelong learning, and social support systems.

E. Utilizing a public health approach to risk reduction, disease surveillance and control and other community health initiatives.

F. Reduction of clinical waste through practice management reform to support a more rational allocation of resources. Among the available strategies are the following, all possible in the coordinated care setting:

1. Internal peer utilization review process to monitor physician performance, according to Evidence Based Medicine guidelines of value to patients, with a goal of education, and reward for performance.

2. Physician and health care consumer education; non-commercial, evidence-based.

a. Physicians

a) Clinical pharmacists, as a source of objective prescribing perspective, and formulary consensus.

b) Clinical imaging specialists to improve appropriate utilization of advanced imaging (CT, MRI, PET scans.)

b). Cape region-specific continuing medical education (CME) programs tailored to identified needs.

c) Online access to medical information services through a group subscription.

b. Patients

a) Educational materials available in a variety of formats.

b) Self care, management of common conditions, tools for understanding of physiology, disease and therapies.

c) Navigating this new health care system- Cape Care.

3. Development of a drug formulary, probably three-tiered, based on proven value and cost.

4. Utilize PCP’s as care coordinators, to prevent unneeded care and expense. It is expected that every enrolled resident will have a primary care “medical home” with a known caregiver team.

5. Promote a common-platform Electronic Health Record (EHR) to improve coordination among providers and enhance care by providing embedded prompts, warnings, suggestions and quality assurance data.

a. group licensure for such systems will significantly reduce high startup costs- the major current impediment to wider implementation.

b. community-wide adoption of a system will reduce provider concerns of a technologic ‘dead-end’ in this expensive purchase.

6. Utilize nurse case managers for patients with chronic health conditions to help monitor and coordinate treatment, in conjunction with PCP or Specialist.

7. Implement a Nurse Call Line to direct patients to the most appropriate level of care;

a. Can triage after-hours call only, or all scheduling calls

b. Facilitate timely referral to all needed care

8. Determine to improve quality of care in late life

a. Currently:

1) The vast majority of health care spending is concentrated on the care of a small number of people at the end of life.

2) A home environment is preferred by most patients and families for the end of life. The presence of family and friends, familiar surroundings, accustomed food, one’s own bed and comforts all facilitate meaningful reflections on life.

b. Appropriate responses

1) Encourage discussion, understanding and adoption of Proxy Designation, “Living Will,” and other Advance Directives, Palliative Care, and Hospice.

2) Develop a coverage and reimbursement policy to encourage provision of the most appropriate care in the most appropriate setting.

Deeply held cultural beliefs influence many decisions at the near-end of life concerning diagnostic procedures, treatments, and surgeries which often do little to improve quality of remaining life. Discussion may not be easy, but will be very important, in seeking a better approach.

3) Expanded home health services

I. “Transition” case management (acute hospital to rehabilitation to skilled nursing facility to home care).

II. Nurse home visits:

III. Regular review of medications, assessment of patient safety and hygiene issues, talk with caregivers and educate about care and testing techniques (weight, blood pressure, blood sugar, oxygen saturation, peak flow.)

IV. The PACE Model of home care, attending to global needs of individuals at risk of institutional care, would be appropriately incorporated.

Program of All-Inclusive Care for the Elderly (PACE). This model of care is centered around the belief that it is better for older adults and for their families if their chronic care needs are provided in the community whenever possible. This is an innovative program in that it provides services to those who would otherwise need nursing home care while they remain in the community in their own home or the home of loved ones, all needed preventive, primary, acute, and long term health care services so that qualified (or eligible), older individuals continue to live in their homes as long as possible

V. Telephonic monitoring and review of home care services (Telemedicine.)

These instruments enable patients with chronic conditions to regularly self-monitor, and transmit the data to caregivers for interpretation.

VII. Eligible Participants

A. Covered Residents: All Barnstable County residents are eligible for coverage, regardless of employment status, but with no mandate to enroll or utilize Cape Care for coverage of health care services. "Resident" means a person who lives in Barnstable County as evidenced by an intent to continue to live in Barnstable and to return to Barnstable if temporarily absent, coupled with an act or acts consistent with that intent. The Trust Fund shall adopt standards and procedures for determining whether a person is a resident.

1. Such standards and procedures shall include:

a. a provision requiring that the person seeking resident status has the burden of proof in such determination;

b. a provision requiring reasonable durational domicile requirements not to exceed 2 years for long term care and 90 days for all other covered services;

c. a provision that a residence established for the purpose of seeking health care shall not by itself establish that a person is a resident of the County; and

d. a provision that, for the purposes of this chapter, the terms “domicile” and “dwelling place” are not limited to any particular structure or interest in real property. Homeless individuals meeting criteria above shall specifically be considered “resident.”

Implicit here is the understanding that all persons resident here are eligible to enroll.. Standards which define “…an intent to continue to live in Barnstable…” will be adopted.

B. Visitors: Non-resident patients requiring emergency treatment for illness or injury, or their insurance carrier if applicable, shall be billed by providers for all services received. Cape Care may establish intergovernmental arrangements with other states and countries to provide reciprocal coverage for temporary visitors.

Providers will continue to be responsible for collection of the reimbursement for all individuals and services not covered under Cape Care.

C. Seasonal Residents (“sunbirds”);

Resident status will be the prime determinant of qualification for enrollment in coverage. See “Out-of-Network coverage, E. below.

D. Non-resident employees;

An employer mandate to purchase pro-rated Cape Care or commercial health coverage would have potential benefits for such employees, their employers, and the health of the community. Such a provision is not yet included in this plan.

E. Out-of Network coverage: Payment for emergency care of Barnstable residents obtained out of Cape Care Region shall be at prevailing local rates. Payment for non-emergency care of Barnstable residents obtained out of Cape Care Region shall be according to rates and conditions established by Cape Care. Cape Care may require that a resident be transported back to Cape Cod when prolonged treatment of an emergency condition is necessary. Contracts with the regional tertiary-care and specialty institutions that regularly provide care to Barnstable residents will be established.

Nearly all health insurance policies provide for coverage for services out-of-network; Cape Care will develop similar arrangements, including contracting with Boston-area hospitals.

F. Tri-County "Health Care District"

A possible incorporation, at a later date, of Dukes and Nantucket has in the past been informally discussed, given the many similar community health issues. This

is not a currently active initiative.

VIII. Administration

A. Will be professionally managed, administratively simplified, accountable, responsive to community needs. Some functions may be provided through contracted services.

1. Will be subject to the approval of the Board

2. Will be responsible for enrollment of all beneficiaries

3. Will manage the Community Health Trust Fund, including collection of all designated revenues, judicious investment for income production, and payment of all covered services and other obligations.

4. Will maintain reinsurance (catastrophic) coverage

5. Will budget for program operating costs; administration; public outreach

B. Cape Care would maintain three physical sites as home bases for Health Promotion and Wellness activities, as well as other member services, one in the upper Cape, one in the mid-Cape and one on the outer Cape. These would be staffed by benefits/wellness counselors. Services to include:

1. Help Centers for enrollment and benefit questions

2. Center for Cape Care case management activities

3. Provision and coordination of health promotion and wellness activities, including meetings with non-physician health professionals, classes, workshops, health resource information, assistance with completion of Health Risk Appraisals

4. Venue for providing provider education

Free, quarterly presentations on health promotion, wellness, appropriate utilization of medical resources, the Cape Care philosophy, and other topics can be offered for CME credits to area physicians who are plan members and to other licensed health care providers.

C. Will prepare an annual report for Barnstable County government, to include fiscal performance, noted trends or changes in health status indicators, effectiveness in reaching defined populations at risk, and other relevant health care issues for Barnstable County residents.

D. Will approve any proposed community health policy goals, and the reimbursement schedules and modifiers recommended by the Professional Advisory Board needed to achieve those goals.

E. Will make prompt payments to providers and facilities for covered services.

F. Will establish a claims fraud control process, through beneficiary notification of claims paid in their name.

G. Will participate in the Commonwealth’s Determination of Need process for capital needs for health care facilities in Barnstable County. An evaluation and public report on any DoN application will be prepared and submitted to the responsible state agency.

An existing state process exists, with public comment and hearings, for DoN for capital facilities. Rather than duplicating that process, we would provide mandated review and input. Significant exemptions to this process have altered the health care landscape, however. These will need re-examination.

IX. Board of Trustees ("the Board"); Composition; Powers and Duties

The Board of Trustees of the Cape Care Community Health Trust, consists of one elected representative from each of the six state legislative districts in Barnstable County, and of not less than seven, nor more than eleven, specified ex-officio delegates, for a Board of not less than thirteen nor more than seventeen members.

A. Elected trustees will be chosen every two years, concurrent with the regular election of state representatives.

B. Trustees must be residents of Barnstable County

C. The terms of elected trustees shall begin with the first Wednesday in January succeeding their election and shall extend to the first Wednesday in January in the third year following their election and until their successors are chosen and qualified.

D. Ex-officio representatives will be selected as delegates by designated organizations on Cape Cod that have significant involvement or stakeholder role in health care and human services delivery. The initial organizations will be defined in the process of establishing the Trust; and changes thereafter will be by action of the Board of Trustees.

E. Each appointed trustee shall serve a term of three years; provided, however, that initially three appointed trustees shall serve one-year terms, three shall serve two-year terms, and three shall serve three-year terms. The initial appointed trustees shall be assigned by lot to a one, two or three year term. Any person appointed to fill a vacancy on the board shall serve for the unexpired term of the predecessor trustee. Any appointed trustee shall be eligible for reappointment. Any appointed trustee may be removed from his appointment for cause. No trustee will serve more than three full terms.

F. The board shall elect a chair from among its members every two years. A simple majority of trustees shall constitute a quorum, and the affirmative vote of a majority of the trustees present and eligible to vote at a meeting shall be necessary for any action to be taken by the board. The board of trustees shall meet at least ten times each year and will have final authority over the activities of the Cape Care Trust.

G. The trustees shall be reimbursed for actual and necessary expenses and loss of income incurred fore each full day serving in the performance of their duties to the extent that reimbursement of those expenses is not otherwise provided or payable by another public agency or agencies. . For purposes of this section, “full day of attending a meeting” shall mean presence at, and participation in, not less than six hours of meeting and travel time.

H. No member of the board of trustees shall make, participate in making, or in any way attempt to use his or her official position to influence a decision in which he or she know or has reason to know that he or she, or a family member or a business partner or colleague has a financial interest.

I. The Board will:

1. Be responsible for oversight of Cape Care administration

2. Establish all necessary policies, and review and amend them from time to time

3. Assure ongoing compliance with an approved "Mission Statement" or Guiding Principles

4. Attempt to resolve disputes that may arise from time to time

5. Serve as an Appeals Board for Benefits coverage determinations

6. Manage investment of Community Health Trust Fund; maintain adequate reserves to cover reasonably projected losses; derive safest investment income

7. Contract and monitor reinsurance (to cover possible high-loss events)

This is a budgeted ongoing operating expense.

8. Establish policy on medical issues, population-based public health issues, research priorities, scope of services, and expanding access to care, based on recommendations of the Professional Advisory Board

9. Evaluate proposals for innovative approaches to health promotion, disease and injury prevention, health education and research, and health care delivery. The specific public health goals of improving diet and exercise patterns, and curtailing tobacco use and smoke exposure will have specific emphasis, for their demonstrated significant role in reducing a population’s cardiovascular disease and cancer risks

10. Develop methods for reporting and making recommendations to municipal and/or County government, in order to facilitate improved access to healthy foods, nutrition services and exercise, as well as to limit tobacco use and environmental smoke exposure across the community

11. Establish standards and criteria by which requests by health facilities for state approval for capital improvements shall be evaluated

12. Oversee preparation of annual operating and capital budgets for the countywide delivery of health care services

13. Regularly evaluate system performance for effectiveness, efficiency, accessibility and other review criteria as determined by the Board

X. Professional Advisory Board

Composed of participating health care practitioners and institutions, public health policy experts, clinical pharmacists, health educators, economists, administrators and other professional advisors as are determined to be necessary for health policy development by the Executive Director. The Medical Director, as chief medical officer and head of the Quality Assurance Division, will be Chair. It will:

A. Provide representation and develop policy and procedure recommendations to the Director.

B. Monitor health care promotion and delivery to all covered residents.

C. Recommend to the Director a standard benefit package of health care determined to be medically necessary and appropriate. A preventive health focus will be a core value. This requires adoption of a public health approach to screening standards, and assuring that resources are adequate to achieve goals.

D. Evaluate and recommend changes to Covered Benefits, including new technologies, over time. Reference to authoritative external reviews of costs and benefits will be incorporated.

E. Recommend goals for appropriate allocation of limited financial and health care resources.

F. Be responsible for the drug formulary development, periodic revisions, and oversight of pharmaceutical benefit; with approval of Board of Trustees.

G. Recommend to the Director a reimbursement schedule, including fee modifiers, in order to implement community health policy goals.

H. Recommend health manpower development goals to meet regional care needs.

I. Oversee credentialing process of all eligible practitioners.

J. Develop systems to facilitate integrated, effective and efficient health care delivery, in an organization where providers will continue to be independently owned and managed. This will involve the following probable components

1. Coverage determinations, and payment and/or provider reimbursement schedules. These would be evidence-based, reflect best practices, and would encourage provision of all necessary and appropriate community health care services. Assuring access to primary care providers for all residents will be a priority.

2. Monitoring of community health trends for health care planning, and support for initiatives to improve health indicators.

a. Claims data analysis for disease patterns and variance, as surveillance for acute- and chronic-illness risk reduction.

Because nearly all claims would be processed through one system, patterns of disease outbreak or environmental hazard would be more readily noted. This would improve disease-prevention efforts.

b. Long-term health trends and unusual patterns

c. Coordination with findings of Barnstable County Health and Human Resources reports and staff and Town health departments.

3. Education of health care consumers and providers, especially concerning appropriate use of health care resources.

The great potential for cost control in this approach represents an exciting series of future discussions. Clinical pharmacists could provide objective, current consultations to providers, substituting for pharmaceutical company representatives. Self-care assists for patients with chronic diseases have potential for both health and cost savings.

4. Practice support systems will be evaluated and adopted as determined necessary.

Some examples of ‘practice support’:

-A centralized phone triage system might provide safer, more appropriate scheduling of emergency, urgent and routine evaluations.

-Chronic disease support or management programs within a primary care context may be effective in improving outcomes and controlling costs.

-Medical information services

-A shared medical record information and imaging management system is currently being advanced through the Cape Cod Healthcare system. Means of facilitating communications among all responsible caregivers would be developed.

XI. Cape Care Community Health Trust

A. The Cape Care Community Health Trust , hereinafter the Trust, is hereby established, management of which shall be the responsibility of Cape Care Administration, subject to the approval of the Board.

B. Purpose of the Trust:

1. to pay eligible health care providers and health care facilities for the provision of all covered services rendered to eligible individuals;

2. to pay for preventive care, education, outreach, and public health risk reduction initiatives, as determined by the Board;

3. to supplement other sources of financing for education and training of the health care workforce, as determined by the Board;

This goal is desirable from the standpoint of developing and maintaining an community-based supply of health care workers. It has not been discussed in detail, and must be considered TBD.

4. to supplement other sources of financing for medical research and community health-related innovation as determined by the Board;

5. to provide coordination, communication, education, and practice support initiatives to health care providers; and community health education;

6. to fund a reserve account to finance anticipated long-term cost increases due to demographic changes, inflation or other foreseeable trends that would increase Trust liabilities, and for budgetary shortfall, epidemics, and other extraordinary events, not to exceed 1% of Trust income in any fiscal year: provided, however, that the Trust reserve account shall at no time constitute more than 5% of total Trust assets; and to maintain sufficient reinsurance to cover catastrophic losses; and,

7. to pay the administrative costs of the Trust which, within two years of full implementation of this plan, shall not exceed 5% of Trust income in any fiscal year.

C. Recovery of certain current health care expenditures for services is expected to effectively transfer some portion of current spending to the Trust .

1. Existing Federal and State health care expenditures, notably Medicare, Medicaid, Commonwealth Care and SCHIP, would be redirected to the Trust Fund.

Approvals will be required from governing authorities.

2. Cape Care will act at the policy and legislative level to obtain relief of other current health insurance expenditures (for services covered and provided through Cape Care)

D. The Trust Fund shall be the repository for all health care funds and related administrative funds.

E. Initial capitalization of the Fund initially may be through a one-time bond issuance by the state-chartered Cape Care authority.

1. An alternative approach would be to partner with an existing insurance company.

The cost of bond issuance would be repaid as a predictable long-term operating expense. On the short-term, the latter option may offer lower start-up costs, by utilizing an insurers’ capital reserves and claims processing capabilities. This is TBD based on feasibility models and negotiations with insurance companies.

F. Operating Revenues

Some combination, to be determined, of county property and payroll taxes will supplement the expected current and ongoing contribution of Federal and State funding from the Medicare, Medicare Advantage, Mass-Health, SCHIP, and Commonwealth Connector programs.

These taxes represent the community’s support for the fundamental concept of universal health insurance coverage.

1. A new Barnstable County Health Tax, to collected by each of the towns, based on equalization and apportionment of all property in the county subject to local taxation, under MGL Ch.35 Sect. 30, 31 (County tax authority); Ch. 40 Sect. 1A (District defined.)

Current financing models envision this as in the 0.8% range ($8 per $1000 assessed property value)

2. A payroll-based Employer Health Care Contribution would represent a cost shift for the employer, from privately purchased insurance to the Trust Fund.

a. The amount of this premium shall be in line with, or less than, the average contributions that employers make toward employee health benefits as of the effective date of this act.

We currently project this to be in the 6-7% range

b. Employers will have no responsibility for financing coverage of individual employees who are eligible residents of Barnstable County.

An employer who makes payment to the Trust as required under this section, will need to not be held responsible for additional payments to the Commonwealth under the provisions of Ch. 58 (Commonwealth Care.) This will require Commonwealth approval.

G. As a community health organization, Cape Care will function as a Medicare Advantage program to provide care for eligible enrolled residents. The capitation funds would go to the Trust Fund. An individual must be permitted to “opt out” of Cape Care coverage if so desired, to use other coverage.

It is anticipated that federal waivers will be sought for this demonstration project. However, this is a well-established model in many parts of the country, typically run by HMO’s. A health plan receives a regular payment (“capitation”) from Medicare, and in return, provides all covered services to covered individuals. The plan does well when it effectively maintains the health of its covered population.

H. Cape Care would be contracted with the Commonwealth as a community health organization. Barnstable County residents covered by MassHealth and Commonwealth Care programs would be enrolled, as the default option, in Cape Care, which would provide coverage for all covered benefits.

Clearly, approvals from the Commonwealth will be necessary, but again, this model is established for MassHealth coverage.

I. Cape Care will seek to recover all other monies the Commonwealth of Massachusetts currently appropriates to pay for health care services or health insurance premiums in Barnstable County for, including but not limited to, all current state programs which provide covered benefits and appropriations to counties, towns and other governmental subdivisions to pay for health care services or health insurance premiums; provided, however, that the Trust Fund shall then assume responsibility for all benefits and services previously paid for by the Commonwealth of Massachusetts with these funds. All current state health care programs that provide covered benefits shall be included in this requirement. Cape Care shall seek from the Legislature a contribution for health care services that shall not decrease in relation to state government expenditures of health care services for the county in the year that this chapter is enacted.

J. Cape Care will seek to recover all monies the Commonwealth of Massachusetts receives from the federal government to pay for health care services or health insurance premiums for eligible Barnstable residents; provided, however, that the Trust shall then assume responsibility for all benefits and services previously paid by the federal government with these funds. The Trust shall seek to maximize all sources of federal financial support for health care services in Massachusetts. Accordingly, Cape Care shall obtain waivers, exemptions, agreements, or legislation, if needed, so that all current federal payments for health care shall, consistent with the federal law, shall be paid directly to the Cape Care Community Health Trust. In obtaining the waivers, exemptions, agreements, or legislation, the Trust shall seek from the federal government a contribution for health care services in Massachusetts that shall not decrease in relation to the contribution to other states or counties as a result of the waivers, exemptions, agreements, or legislation. If, and to the extent that, federal law and regulations, waivers, exemptions, agreements, or legislation allow the transfer of Medicaid and Medicare funding into the Trust, any premiums, deductibles payments, and coinsurance for qualified Medicaid and Medicare beneficiaries shall be paid by the Trust for all individuals eligible for both the Trust and federal insurance programs.

K. The Cape Care Community Health Trust shall retain:

1. all charitable donations, gifts, grants or bequests made to it from whatever source consistent with state and federal law;

2. payments from third party payers for any covered services rendered by eligible providers to non-eligible patients but paid for by the Trust;

3. income from the investment of Trust assets, consistent with state and federal law.

4. All monies from collateral sources of payment for health care services, such as insurance policies written by insurers, including the medical components of automobile, homeowners, and other forms of insurance; pension plans; government benefit programs; and any other third party who is or may be liable to an individual for health care services or costs, except where prohibited by law.

L. It is the intent of this Model Plan to establish a single public payer for all health care in Barnstable County. However, until such time as the role of all other payers for health care has been terminated- effectively, when a single-payer system is adopted nationally- health care costs shall be collected from collateral sources whenever medical services provided to an individual are, or may be, covered services under a policy of insurance, health care service plan, or other collateral source available to that individual, or for which the individual has a right of action for compensation to the extent permitted by law. Collection of these costs will generally be the obligation of the provider of services.

M. Collateral sources:

1. An entity described as a collateral source is not excluded from the obligations imposed by this section by virtue of a contract or relationship with a governmental unit, agency, or service.

2. Cape Care shall attempt to negotiate waivers, seek federal legislation, or make other arrangements to incorporate collateral sources into the Trust .

3. Whenever an individual receives health care services under the system and s/he is entitled to coverage, reimbursement, indemnity, or other compensation from a collateral source, s/he shall notify the health care provider or facility and provide information identifying the collateral source, the nature and extent of coverage or entitlement, and other relevant information. The health care provider or facility shall forward this information to Cape Care. The individual entitled to coverage, reimbursement, indemnity, or other compensation from a collateral source shall provide additional information as requested by the executive director.

4. The Provider shall seek reimbursement from the collateral source for services provided to the individual, and may institute appropriate action, including suit, to recover the costs. Upon demand, the collateral source shall pay to the Provider the sums it would have paid or expended on behalf of the individuals for the health care services provided.

See comment in IX. H. (above.)

5. If a collateral source is exempt from the obligation to reimburse the Trust as provided in this section, the executive director may require that an individual who is entitled to medical services from the collateral source first seek those services from that source before seeking those services to be reimbursed by the Trust.

6. To the extent permitted by federal law, contractual retiree health benefits provided by employers shall be subject to the same subrogation as other contracts, allowing the Trust to recover the cost of services provided to individuals covered by the retiree benefits, unless and until arrangements are made to transfer the revenues of the benefits directly to the Trust.

7. Default, underpayment, or late payment of any tax, premium, or other obligation imposed by the Trust shall result in the remedies and penalties provided by law, except as otherwise provided.

8. Eligibility for benefits shall not be impaired by any default, underpayment, or late payment of any tax, premium or other obligation.

9. All claims for health care service rendered shall be made to the Trust , and all payments made for health care services shall be disbursed from the Trust. This is not intended to preclude possible claims processing by current intermediaries, in accordance with the policies established by the Cape Care plan, if such contract services are determined to be cost-effective.

10. Control of claim fraud will be achieved by a process of routinely notifying beneficiaries of all claims payments made in their names.

XII. Health Care Provider Relations

A. The ownership and governance structures of all existing individual, group and institutional health care providers are not altered by this plan.

B. All health care providers currently licensed by the Commonwealth of Massachusetts would be eligible for participation as Cape Care providers. "Health care provider" means any professional person, medical group, independent practice association, organization, health care facility, or other person or institution licensed or authorized by law to provide professional health care services to an individual in the County.

C. Enrollment of other providers will be determined by the Board, with the recommendation of the Professional Advisory Board.

D. Conditions of enrollment will include, but may not be limited to:

1. acceptance of fee schedule. No balance billing (collecting a fee higher than the allowed rate) or out-of-pocket charges (e.g. deductibles, co-payments) will be made for covered services unless otherwise provided.

2. agreement to participate in care-management and educational programs as approved by the Board of Trustees on recommendation by the Professional Advisory Board.

3. provision of care that meets quality standards which may be promulgated to meet the community health goals established by the Board.

4. periodic uniform (re)credentialing process

E. Cape Care administration will support networking of clinicians to improve communication and efficiency, and to deliver services most effectively and lower overall costs.

F. Electronic Health Records have a number of recognized potential benefits, including improved information exchange and patient care, as well as reduction in the costs of care.

1. adoption of standards should be pursued, in order to facilitate communication and care coordination among providers. A single common platform is ideal.

2. participation in large volume licensing could reduce current expense barriers to implementation of an EMR.

3. assurance of personal data security will be critical and an absolute necessity.

G. All health care services will be provided without discrimination on the basis of age, sex, race, national origin, sexual orientation, or income status.

H. All covered Participants shall have free choice of enrolled and participating physicians and other clinicians, hospitals, inpatient care facilities and other providers and facilities.

I. Novel system approaches to the delivery of health care will be evaluated for possible utility

1. The cost and health savings associated with the diminution of the economic incentives to over-treatment are substantial

2. As fee-for-service reimbursement tends to favor over-treatment, global payment mechanisms may have advantages.

The recommendations of the Recommendations of the Special Commission on the Health Care Payment System, July 2009, strongly propose global payment as a short-term goal.

XIII. Provider Billing and Reimbursement

A. All claims for covered health care services rendered to enrolled residents shall be made to the Trust Fund and all payments made for health care services shall be disbursed from the Trust.

1. This is not intended to preclude possible claims processing by current intermediaries, following Cape Care plan policies, if such contract services are determined to be cost-effective

B. Medicare codes and claims procedures will be an initial standard; these are currently known and used by all health care providers

C. Fee structure to be set by Board, on recommendation from Professional Advisory Board

1. Payment systems for covered services will provide prompt and fair payment to eligible providers and facilities.

2. Such payment rates may be made on a fee for service, capitated system or overall operating budget basis and shall remain in effect for a period of 12 months unless sooner modified by the Trust. Except as otherwise provided, reimbursement for covered services by the Cape Care shall constitute full payment for the services rendered.

3. The Board shall provide for retrospective adjustment of payments to eligible health care facilities and providers to:

a. assure that payments to such providers and facilities reflect the difference between actual and projected utilization and expenditures for covered services; and

b. protect health care providers and facilities who serve a disproportionate share of eligible participants whose expected utilization of covered health care services and expected health care expenditures for such services are greater than the average utilization and expenditure rates for eligible participants.

c. payments provided under this section can be used only to pay for the operating costs of eligible health care providers and facilities, including reasonable expenditures, as determined through budget negotiations with Cape Care, for the maintenance, replacement and purchase of equipment. Payments for operating costs shall not be used to finance capital expenditures; for the payment of exorbitant salaries; or for activities to assist, promote, deter or discourage union organizing.

4. Reimbursement multipliers may be used to influence the health care provider specialty mix, as determined necessary by the Professional Advisory Board, to provide adequate access to needed care. The demonstrated need for improved access to primary care medical and mental health services will be given priority in planning.

D. A fee-for-service reimbursement will apply for independent providers and groups unless otherwise contracted. This does not preclude the development of capitated payment arrangements in physician groups.

E. Acute-care and rehabilitation hospitals, and sub-acute care facilities will have global budgeting based on caseload, past budgets, projected programs and demand.

Institutional budgeting has not yet been determined as policy, and needs full evaluation and discussion with institutional providers, in particular. This is currently TBD; discussion has been initiated. No opposition has been expressed. It is the efficient standard in most single-payer programs. The transition phase, in which significant numbers of patients treated are not-enrolled visitors, will involve some complexity, and probably a blended payment.

XIV. References

A. “Ten Principles to Guide Healthcare Reform,” The Cape Cod Healthcare Reform Task Force, 2003- on the website for Barnstable County Department of Human Services <bchumanservices.net>

B. "Consensus Points"- Cape Care Working Group; July 28, 2004

C. Town Meeting Resolution on "Cape Care" Universal Health Care Proposal adopted by ten Cape Cod Town Meetings and the Barnstable Town Council, 2006

D. Cape Care "Values and Principles"; July 2006

E. Cape Care Benefits Task Force "Plan Benefits Comparisons -Draft-" June 4, 2007

F. “An Act To Establish the Massachusetts Health Care Trust Fund” - S.755, 2005 and S.703, 2007

G. “Promoting Healthy Lifestyles; Policy, Program, and Personal Recommendations for Reducing Cancer Risk.” Presidents Cancer Panel, 2006-2007 Annual Report, National Cancer Institute of the National Institutes of Health, August 2007.

H. The European Collaboration for Assessment of Health Interventions and Technology (ECHTA/ECAHI) Project Executive Summary.

I. “Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries;” Annals of Internal Medicine, Position Paper, American College of Physicians. Ann Intern Med 2008; 148.

J. Introduction to Public Health, 2^nd Ed., Mary Jane Schneider. Jones & Bartlett, 2006.

K. “Durable Health Care for All Will Require Cost Control,” Alan Sager, PhD, and Deborah Socolar, MPH, Boston University School of Public Health, 2006.

L. “Cutting Health Care Cost and Covering Everyone by Negotiating a Political, Financial, Clinical, And Legal Peace Treaty with Doctors;” Alan Sager, PhD and Deborah Socolar MPH, presentation at American Public Health Association, Washington, D.C., Nov. 5, 2007.

M. “The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way” The Commonwealth Fund Commission on A High Performance Health System. February 2009.

N. “Recommendations of the Special Commission on the Health Care Payment System”, Commonwealth of Massachusetts, July 16, 2009.

XV. Version Notes

Version. 2.2.1 includes new sections on preventive health focus of data collection, and coordination with “Human Condition” reports; sect. VIII. J. 2.

Version 2.3 has new language concerning: IV.E.- cost sharing;

V.A.-residency requirements;

V.B.1.-billing for visitors;

VI.K.- capital facility Determination of Need process;

VII.A.- Board of Trustees composition;

VII.- the advisory role of the Professional Board;

X.B. –clarifies provider eligibility.

Version 2.4

Executive Summary C.1, 2.

Sect. III.A.1. - Authority form of organization; bond issuing, overlay tax receipt

Sect. VI. – Administration; required participation in state Determination of Need process for health care capital facilities

Sect. VII.A.7.- Board of Trustees composition; proportional weight of town representative votes

Sect. VII.B. - Community Health Trust Fund; initial development; state overlay tax

Sect. VII.C. - Medicare Advantage organization for eligible beneficiaries

Version 2.5

Sect. IV.B.5, 6. and C. - Mental health services integration with comprehensive care

Sect. IV. F. Cost sharing / service co-payments

Sect. IV.H.- Benefits will meet Ch. 58 (“Commonwealth Care”) standards for participation as an insurance provider

Sect. VI. – Administration oversight by Board; Trust responsibilities

Sect. IX. - Community Health Trust Fund; EXTENSIVE SECTION REVISION; initial capitalization; revenue sources; enrollment premiums; coordination with other agencies

Sect. X.F. – Electronic Health Records support

Version 2.6

Index- [with thanks to Prof. Robert Holt of Truro.]

Version 2.7

Sect. IV. D. – Comprehensive wellness and health promotion program; Individual Health Assessments; focus on tobacco, diet, inadequate exercise, and alcohol

Sect. V- new section – Health Promotion and Wellness

Sect. VII. G. – Regional Cape Care Member Service Centers

Sect. XI. F.1. – EMR common platform is goal

Sect, XI. I. – Novel system approaches to the delivery of health care encouraged

Sect. XII. D. – Provider reimbursement; fee-for-service or capitated

Sect. XII. E. – Institutional budgeting

Sect. XIII- G thru K – References

Sect. IV – Appendix A; Health Risk Appraisals

Version 2.8

Introduction

Sect. III.A.- delete reference to income tax basis

Sect. VI- Cost Containment- New Section

Sect. VII.C. replace “off-cape” with “out of Cape Care region” for coverage. This could include Nantucket and Martha’s Vineyard, should these counties partner with Barnstable.

Sect. IX – (and throughout)- the term Board of Directors has been replaced by Board of Trustees, reflecting responsibility for oversight of the Cape Care Community Health Trust.

Sect. XI.C.1- redirection of existing Federal and State funding

Sect. XI.F. Funding sources; property and payroll tax basis, delete reference to income tax, delete premiums for enrollment; and citing basis for county property tax.

Sect. VIII. H. comment on Commonwealth Care expanded access

Sect. IX- Board of Trustees composition; election; ex-oficio members; terms

Sect. XIV – reference the influential “Ten Principles” declaration, 2003

XV. Appendix A

Purpose and Utility of Health Risk Appraisals (HRA)

A. An HRA is a computerized health and lifestyle questionnaire. It is available in multiple languages and can be completed either on-line or in a paper and pencil format.

B. HRA’s play a central role in the health promotion and wellness activities of Cape Care, not only in identifying health risk factors for the individual member and educating the member about those risks, but also in providing a snapshot of the health of the enrolled population and in monitoring the health of individuals and of the enrolled population longitudinally over time.

C. An HRA is completed by each plan member on initial enrollment and annually thereafter. A financial incentive may be provided to members for completion of the HRA.

D. The HRA would include annual measurements of height, weight and blood pressure, in addition to blood sugar and cholesterol on an age/risk based schedule.

Blood work could be obtained every year on all members, however there is probably no benefit to be derived from repeating it annually in a young, healthy person with normal initial values.

E. After receiving their HRA results, members contact a health coach to develop plans to address the most pressing health risks that were identified. Members can continue to work with their health coaches telephonically, and may be referred to local resources to help address particular risk factors (e.g. smoking cessation classes, nutrition counseling, stress management).

1. Additional incentives are provided to members who have met their

health goals at the end of the year.

This would probably involve the PCP signing off on the goals at the beginning of the year and certifying at the end of the year that the member had met or substantially met the goals or was “doing as well as possible”, such as with blood pressure control. It is anticipated that members would work in collaboration with their PCPs on health goals like hypertension or elevated lipids, although they might choose to address other risk factors, such as overweight, inactivity or poor diet with their health coach and self-help tools. Incentives could include further cash awards, gift certificates or others.

F. When taken in subsequent years, the HRA provides individual members with feedback on progress toward reducing risk factors. It also provides data for the plan management personnel to assess how successful the program is, and to prepare an annual aggregate health status of enrolled members for the County.

G. Plan members are provided with pedometers to assist and help motivate them to increase their daily exercise.

XVI. Acknowledgements

The Editor wishes to acknowledge the countless contributors to the development of this Cape Care Model plan.

First, the participants in the Cape Care Coalition – what I refer to as the “Dream Team”- and its antecedents over the last four-plus years, whose labors have energized this process. Many people have given so many hours to so many meetings and discussions. From these efforts emerge this exciting vision of community health as it could be.

And also appreciated are the comments, questions, challenges and stories we’ve heard in our countless conversations with friends and neighbors, in our presentations to the many town and community meetings, and in our interviews with the press. These have helped to shape the outlines-becoming-details of a plan that we believe can best provide for our individual and collective health needs.

It has been a gratifying experience to be a part of this groundbreaking team effort.

Brian O’Malley, MD

Editor