This blog is part of a series to highlight the dangers of the repealing the Affordable Care Act. Multiple times a week, Community Catalyst will highlight a different constituency to draw attention to the benefits the ACA has afforded them and to outline what a loss of coverage would mean.
Lesbian, Gay, Bisexual and Transgender (LGBT) older adults face many of the same health and aging challenges other older adults face, but more pronounced. As a result, they are arguably more at risk if the incoming administration and Congress repeals the Affordable Care Act (ACA) without a replacement plan and/or makes significant and harmful changes to Medicaid and Medicare.
LGBT older adults face unique risks within the health care system due to the standard issues facing an aging population combined with their sexual orientation or gender identity, such as:
- Aging Combined with Discrimination: Similar to the older population in general, LGBT older adults face challenges with aging: declining health, diminished income, and the loss of friends and family. LGBT older adults, however, also face the added burden of actual or feared discrimination on the basis of their sexual orientation and/or gender identity. Many choose to go back into the closet for fear that caregivers will discriminate against them. Transgender adults, however, do not even have that option. Despite federal prohibitions on discrimination based on sex stereotyping and gender identity and the prohibition of discriminatory practices toward LGBT individuals based on health status - such as being HIV positive - built into the ACA, the sex stereotyping and gender identity protections are currently under attack in the courts, and LGBT older adults remain one of the most invisible, underserved and at-risk elder populations.
- Isolation from Society, Services and Supports: Studies show that LGBT older adults are twice as likely to live alone; half as likely to have close relatives to call for help; and more than four times less likely to have children to help them. Nearly one-in-four LGBT older adults has no one to call in case of an emergency. At the same time, studies document that LGBT older adults access essential services – including visiting nurses, food stamps, senior centers and meal programs – much less frequently than the general aging population.
- Lack of Access to Culturally Competent Health Care: The U.S. Department of Health and Human Services has found that LGBT older adults face additional health barriers because of isolation combined with a lack of access to social services and culturally competent providers. These barriers result in increased rates of depression; higher rates of alcohol and tobacco use; and lower rates of preventive screenings.
- Higher Rates of Poverty: LGBT older adults reflect the diversity of our nation in terms of gender, race and ethnic identity. But there is one critical statistic where they do not reflect the norm: they have much higher poverty rates and lower average household income than their straight and cis-gender counterparts. In fact, 35 percent of SAGE clients in New York City have annual pre-tax incomes below $10,000 and rely on Medicaid – a program with looming threats of block grants or per capita caps - to provide their medical care. An additional 35 percent subsist on annual pre-tax incomes of $20,000 or less and qualify for coverage under Medicaid expansion or could utilize tax credits to purchase insurance on the Marketplace. The Medicare-eligible segment of this population benefits from the ACA having lowered Medicare Part B premiums, the closing of the “donut hole” for prescription drugs, and payment and delivery reforms aimed at improving quality and the coordination of care for individuals with complex care needs.
- HIV: As of 2015, the CDC estimates that one in two people who are HIV positive in the United States are now over 50. Yet little attention and money is targeted towards prevention for this population. One of the free preventive services covered by the ACA is HIV screening, though recommended testing in the U.S. cuts off at age 64. As a result, older adults are much more likely to be dually diagnosed with HIV and AIDS if and when they are ultimately tested.
Because of higher rates of health disparities, un-insurance, poverty and a greater reliance on programs like Medicaid and Medicare - two programs that could be facing significant retooling and subsequent funding cuts in the coming years - the protections provided by these programs and enacted in the ACA are critical for improving the quality of life for older LGBT individuals.
As we enter an uncertain time, we believe that we must do more to honor and support the LGBT elders who fought the fight and paved the way for the recent advances we have seen on LGBT rights. The least we can do is ensure that this population still has access to the foundational supports provided by the ACA, Medicaid and Medicare.
Aaron Tax, Director of Federal Government Relations, Services and Advocacy for GLBT Elders (SAGE)
This blog is part of a series to highlight the dangers of repealing the Affordable Care Act. Multiple times a week, Community Catalyst will highlight a different constituency to draw attention to the benefits the ACA has afforded them and to outline what a loss of coverage would mean.
In 2014, Community Catalyst shared Olivia Richard’s story in a video. Olivia is enrolled in the One Care program, the Massachusetts demonstration project which coordinates care for people with disabilities eligible for both Medicare and Medicaid (“dual eligibles”). Olivia uses a wheelchair and relies on personal care attendants (PCAs) to help her with activities of daily living. Before enrolling in the One Care program, she had not been receiving an adequate amount of PCA hours, nor other services she needed to achieve the quality of life and degree of independence she envisioned for herself. After enrolling in One Care, Olivia was able to live independently, with services that met her needs, preferences and goals, thanks to a coordinated plan developed together with her Independent Living-Long Term Services and Supports Coordinator. This was possible because of the Affordable Care Act (ACA), which enabled the creation of the dual eligible demonstration projects now ongoing in Massachusetts and 12 other states (formally termed the Financial Alignment Initiative.)
Fast forward to November 9, 2016: Individuals like Olivia now face the serious possibility that this much-improved coordination of their Medicare and Medicaid benefits may be significantly undermined by repeal of the ACA, impacting the delivery of critical services. Dual eligibles are a particularly vulnerable population – doubly in the line of fire – not only from the immediate attack on the ACA, but also from proposals circulating among the Republican-controlled Congress that threaten to seriously undermine each program in other ways in the future.
Beyond the unfolding rush to repeal the ACA, proposals in favor among Republican congressional leaders and the nominee for HHS Secretary, Rep. Tom Price, would permanently rework the structure and financing of Medicaid and could end the existing guarantee of coverage for all those who qualify for the program. In addition, House Speaker Paul Ryan has for years floated proposals to change Medicare from a defined benefit program to one in which adults over 65 get “premium support” to purchase private insurance, a plan slanted toward benefitting those older adults who are more affluent and in better health, leaving low-income elders in poorer health without the safety net that they have counted upon.
Who Are the Duals?
Dual eligible beneficiaries are entitled to Medicare either by virtue of age (being 65 or older) or by having a permanent disability and receiving Social Security Disability Insurance (SSDI). They are also eligible for Medicaid based on low-income eligibility guidelines. Currently, there are over 10 million dually eligible beneficiaries, with the majority (59 percent) aged 65 and older, and with most of them (73 percent) also eligible for full Medicaid benefits. Dually eligible beneficiaries comprise 14 percent of all Medicaid beneficiaries, but account for 33 percent of Medicaid spending; they also make up 20 percent of the Medicare population, but account for 35 percent of Medicare spending. In part, this disproportionate spending is because dual eligibles tend to have complex health needs, with higher rates of diabetes, mental illness and cognitive impairment. Another reason is that these beneficiaries have to navigate two complex systems, Medicare and Medicaid, which more often than not, has resulted in very fragmented and inefficient care.
Altering Medicaid Will Have Serious Implications
The most significant implication of GOP proposals to restructure Medicaid – like changing to block grant or per capita cap funding methods – is the strong likelihood that eligibility will be limited and critical services will be cut, as the total federal dollar payments to states would be greatly reduced. Block grants or per capita caps would also limit states’ abilities to pursue innovative strategies that address issues beyond medical services such as access to long-term services and supports and the addressing of social determinants of health, which result in better integrated and more coordinated care. This is true for many low-income populations, but the dually eligible population is particularly at risk.
Medicaid, especially since the passage of the ACA, has served as fertile ground for innovative solutions to addressing health care cost, quality and access issues. Medicaid programs have been vital to improving care for dual eligibles, often serving as a catalyst for innovation. Fundamental changes to the Medicaid program could jeopardize such innovative programs as:
- The Dual Eligible Demonstration Projects: as noted above, thirteen states are running demonstration programs – like the One Care program in Massachusetts helping Olivia – to better align the financing of the Medicare and Medicaid programs in order to better integrate services for dual eligible enrollees. These demonstration projects could not have been possible without the ACA creating the Center for Medicare and Medicaid Innovation (CMM) and the Medicare-Medicaid Coordination Office (MMCO) within CMS.
- Medicaid Accountable Care Organizations (ACOs): ten states are actively running Medicaid ACO programs to improve care coordination and delivery of Medicaid benefits by holding providers accountable through quality improvements, increased financial risk and innovative information technology. Some states are using or are planning to use ACOs as a model of care for dual eligibles, such as Maryland and Oregon.
- Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents - the MMCO and CMMI are spearheading an initiative to help improve the quality of care for people in long-term care (LTC) facilities by reducing potentially avoidable inpatient hospitalizations. The most recent evaluation report for this initiative shows a decline in all-cause hospitalizations and potentially avoidable hospitalizations in participating sites. The evaluation report also finds that there were reductions in overall Medicare expenditures relative to a comparison group.
Innovations such as these will be seriously impacted if the ACA is repealed and/or if Medicaid funding were to be radically undermined. Investments in delivery and payment reform in Medicaid are critical and must continue. The dual eligible population has complex medical and social needs and taking away needed services and shifting costs onto a group of consumers the least able to take on new financial stresses is bad policy. If innovative changes to our health care system can work better for the most vulnerable, they can work better for everyone. Stakeholders, including providers, plans, payors and advocates, need to come together now and raise their voices loudly to protect the ACA and the Medicaid program itself. This fight is nothing less than a fight for health care justice, period.
This blog is part of a series to highlight the dangers of repealing the Affordable Care Act. Multiple times a week, Community Catalyst will highlight a different constituency to draw attention to the benefits the ACA has afforded them and to outline what a loss of coverage would mean.
(From left to right: Center for Consumer Engagement in Health Innovation (CCEHI) Deputy Director Renee Markus Hodin, Medicare Rights Center Policy & Client Services Associate Emily Balkan, CCEHI Consumer Engagement Advisor Rosa Palacios and Ms. Lezrette Hutchinson)
Last month, my colleagues and I presented at Putting Care at the Center, the first conference hosted by the National Center for Complex Health and Social Needs. The conference sought to explore the science of care for individuals with complex needs, examine best practices in care, discuss using innovative funding as a lever for system change and present a vision for the future of care.
I was honored to learn from consumers such as Ms. Lezrette Hutchinson, a woman with chronic illness who is dedicated to fixing the health care system and empowering other consumers to do the same, as well as innovative organizations such as the Camden Coalition, Southcentral Foundation, Commonwealth Care Alliance, Cherokee Health System and Health Leads. The conference allowed all of us in attendance to hear the stories behind the statistics and the realities of growing up in places where only a couple of your childhood friends will still be alive by the time you turn 65.
Overall, the conference did an excellent job elevating the importance of improving care for people with complex care needs and how that care has already been improved by the coverage and gains made possible by the Affordable Care Act (ACA) through the expansion of Medicaid (studies have shown the majority of this population have one or more chronic condition such as stroke, asthma or diabetes), the prohibition on denying coverage to people with preexisting conditions and the creation of better coordinated models of care in Medicaid and Medicare.
These protections, coupled with the recent release of The Playbook: Better Care for People with Complex Needs, has put us in a better place than ever to partner with individuals and communities with complex needs and make a real difference in their health and lives.
That is why Republican threats to repeal the ACA should be worrisome to consumers with complex needs and to their providers, caregivers, advocates and collaborators.
Well before the ACA, I remember how my uninsured patients would come to the hospital for severe asthma attacks or out of control diabetes, conditions which could have been avoided if they could have gotten the preventive care and prescription medications they needed. And I remember discharging these patients, with three days’ worth of medications and no follow-up care, knowing full well that it wouldn’t be long before they were back, with their disease even worse than it was before. Before the coverage and services provided by ACA, this was the best providers serving these populations were able to do.
This is why those of us who work with consumers with complex health and social needs should step up now to fight the repeal of the Affordable Care Act this January. For people with complex health needs who are among the 30 million people at risk of losing coverage, access to routine care, much less to the types of innovative care showcased at the conference, will evaporate.
This repeal vote will have real impact on real people, and people with complex care needs are at greatest risk. With all of the progress that we’ve made in improving care for people with complex care needs, this is not a time to turn back the clock. We must work together to ensure access to the life-saving services that Medicaid provides under the ACA and continue the innovations that hold the promise of better care and better health, particularly for those with the greatest need.
This final 2016 edition of Health Innovation Highlights comes to you on the Winter Solstice. For those of us in the Northern Hemisphere, today we experience the inflection point from the days getting shorter, to the gift of a few more minutes of daylight each passing day through winter and spring. In other words, we enter a phase of “gathering light,” even as we prepare for our coldest months.
In these coldest months, we face threats to health coverage, access, innovation and quality. Along with our colleagues here at Community Catalyst and in coalition with health care and social and economic justice groups nationwide, we are fighting efforts to take away health care, particularly from those who are most vulnerable, like older adults, individuals with disabilities, and those with complex health and social needs.
As we prepare for the year ahead, I’d like to spend a few moments during this holiday season to reflect on the many things for which we are grateful. We’ve been blessed to have had the chance to celebrate many successes – not just of the Center, but our partners as well – in our mission to elevate the consumer voice as the key to health system innovation.
A few highlights from our first trip around the sun:
Launching the Center: At our January launch, Dr. Donald Berwick called on all of us to think about health beyond the traditional enclaves of the health care system and in the context of communities. He observed, “The new news is that to achieve health and justice, we have to reconsider and redesign the very fabric of what we call health care today.” His words, and the insights shared by panelists John Arnold, Amy Berman, Stuart Butler, Robert Crittenden and L. Toni Lewis, gave us our marching orders to create a health care system that better meets the needs of all.
Supporting Maryland’s Faith Community Health Network: In February, the Maryland Citizens’ Health Initiative, a longtime Community Catalyst partner, in collaboration with LifeBridge Health and faith leaders from throughout the state, launched the Maryland Faith Community Health Network with a training retreat for participating clergy and lay leaders. The concept is simple and effective – connect liaisons from participating congregations with congregants who are in the hospital to help them get the most out of their inpatient care and get the services and assistance they need once they are discharged.
Helping consumers prepare for Managed Long-Term Services and Supports in southwestern Pennsylvania: In June, we were welcomed to Pittsburgh by the Jewish Healthcare Foundation to lead a training for community and consumer groups. We were honored to play a role in helping these groups prepare for and engage in the launch of the Community HealthChoices program. We believe that the active engagement of consumers and community members will be critical to ensure that this program ultimately provides better, more coordinated care to Medicaid beneficiaries who need long-term services and supports.
Documenting best practices in consumer engagement in Medicaid ACOs: Medicaid accountable care organizations (ACOs) are an increasingly popular option for improving the quality of care and health outcomes while containing health care costs. But if Medicaid ACOs are to be successful, members and communities served by these programs must have a voice in their design, implementation and ongoing oversight. We dug into program documents and debriefed consumer advocates engaged in the design and rollout of these new programs to learn about what is working and what isn’t, and to identify ways that health care organizations can encourage meaningful consumer engagement.
Fighting to improve transportation services for low-income individuals: We have been hearing consumer horror stories from partners across the country about non-emergency medical transportation (NEMT). NEMT is a critical service that helps Medicaid beneficiaries without access to transportation get to doctors’ appointments, dialysis and cancer treatment. We have heard about children with compromised immune systems sharing transportation with sick individuals, patients with kidney failure who can’t get to their dialysis treatments and elderly people who are abandoned for hours at the doctor’s office. To address this issue, we are coordinating consumer organizations that are working to improve NEMT in their states. We also worked with our friends at Justice in Aging on a brief that highlights recommendations that policymakers and advocates can adopt to improve NEMT across the country.
Protecting care for people with disabilities in Massachusetts: In Massachusetts, advocates for people with disabilities scored a significant win when MassHealth, the state’s Medicaid program, backed off its proposed limits on personal care attendant hours. Disability advocates organized to raise awareness about how harmful the proposed limits could have been for the elderly and people with disabilities, who depend on personal care attendants to help them live with independence and dignity. While the fight is not over – the state loosened its restrictions but didn’t eliminate them entirely – the work of the advocates, on a very short timeline and in the midst of many other battles, was impressive indeed.
Bridging the gaps between health and housing: Every day, doctors and nurses care for people with serious illness who live in shelters, on the streets or in unsafe housing. And we know that unless we address these patients’ need for safe and secure housing, they will be back to the emergency room and hospital again and again with ever-worsening (and more expensive) conditions. In Pennsylvania, our partner Pennsylvania Health Access Network launched a collaborative Housing as Health campaign that brings together a statewide coalition of physical and behavioral health care providers, social services, housing-related entities, faith and community groups, advocates, and people enrolled in Medicaid to build a case for supportive housing services. Our state partners have been successful in elevating the issue of housing as a social determinant of health that should be prioritized by educating communities and policymakers, sharing the impact and savings of supportive housing services and sharing personal stories that illustrate the importance of their campaign.
Building the consumer voice in Rhode Island’s dual eligible demonstration project: In Rhode Island, advocates played a major role in the creation of a new Implementation Council to guide the state’s dual eligible demonstration project. Our state partners, Rhode Island Organizing Project (RIOP) and Senior Agenda Coalition, were instrumental in everything from the drafting of the bylaws, to training of consumers as they take their places on the council. We hope that these strong consumer voices will help steer this demonstration toward truly person-centered care.
The “lights” that I’ve gathered here – and so many more that space doesn’t allow for – illustrate the dedication, passion and commitment of the consumers, consumer health advocates, providers, health care leaders, and others we at the Center have had the honor to encounter, learn from and collaborate with in our first year. Even as we confront the challenges ahead, I know that we will continue to gather light, on our journey to consumer-centered care. In this holiday season, I wish you peace and light in the year to come.
On December 1, Community Catalyst hosted the third webinar in its series on Health and Housing – “Aging in Place: Housing and Health Integration for Low-Income and Chronically Ill Seniors.” Two resources are now available – both a recording of the full webinar and the slides presented. The three presenters shared various state and local examples of innovative and successful practices to integrate support for safe and continuous housing with well-coordinated home-based care and services for vulnerable older adults with complex and chronic conditions.
Taken together, the speakers’ presentations make clear the centrality of adequate and sustainable housing as a vital social determinant of health for vulnerable older adults, and highlighted new partnerships across communities and service sectors that are emerging to address needs in this area in comprehensive and person-centered ways.
The timing of this webinar coincided with the recent release of a Center for Consumer Engagement in Health Innovation issue brief that bears on this topic, Bringing Independence Home: Housing-Related Provisions Under Medicaid 1915(c) Home and Community Based Services Waivers. Many of the best-practice approaches examined in six states discussed in this brief can be generalized beyond this specific type of Medicaid waiver, to address the issues presented in the webinar.
The three webinar presenters featured in the recording are:
- Robyn Stone, Executive Director of the Leading Age Center for Applied who discussed HUD-assisted housing facilities, with an example from an innovative model in Vermont
- Nancy Archibald, Senior Program officer at the Center for Health Care Strategies, who shared examples of state approaches in California , New York, Tennessee and Oregon
- Marty Lynch, Executive Director of Lifelong Medical Care in the San Francisco Bay Area, which provides services to vulnerable older adults through 15 clinical locations
We were very excited to see the highly multi-disciplinary registration for this webinar which in itself speaks volumes about a growing convergence, from many quarters, of folks who work with vulnerable populations, all raising the vital connections between health and housing. The 250-plus participants came from advocacy groups in the health or housing spheres, direct service providers at community-based organizations, hospitals, public health departments, managed care organizations, legal services staff, health plans and government. Community Catalyst is energized to be helping build bridges in this movement toward new and synergistic approaches to supporting older adults living according to their preferences in the community setting.
There will be additional webinars in our Health and Housing series which will be announced in the months ahead to continue this conversation, so please stay tuned!
This is the first blog in a series to highlight the dangers of the repealing the Affordable Care Act. Multiple times a week, Community Catalyst will highlight a different constituency to draw attention to the benefits the ACA has afforded them and to outline what a loss of coverage would mean.
One of the great joys of my work over the last several years has been working with our advocacy partners from the disability community here in Massachusetts. It’s been through their eyes that I’ve come to deeply appreciate the essential nature of Medicaid and the Affordable Care Act to this population. That’s why I am deeply troubled that the results of one election could undermine critical aspects of the infrastructure that allows millions of people with disabilities to live independently and with dignity.
Just the Facts, Ma’am
So who is this population? According to a 2015 report from the Centers for Disease Control and Prevention, 53 million - or one out of every five - adults in the United States live with some kind of functional disability. This includes difficulty walking, seeing, hearing, remembering, doing errands, dressing or bathing. The report also revealed that Black and Hispanic adults were more likely to have a disability than White adults. Additionally, those with lower education and income levels, and those who are unemployed were also more likely to have a disability. And it’s because of this strong correlation between disability and poverty that we must look first at the major role Medicaid plays for the population.
Medicaid Matters… More Than Ever
Medicaid serves as a critical safety net for the 10 million+ kids and adults who qualify for the program on the basis of a disability. These people, who represent approximately 15 percent of all Medicaid beneficiaries, live with a wide range of physical, mental health and/or functional disabilities.
One of the reasons Medicaid is so critical to people with disabilities is its coverage of long-term services and supports (LTSS). Indeed, it is the only public or private program to cover LTSS. And increasingly these services are being provided at home or in the community, rather than in institutions. Home and community based services allow people with disabilities to live independently in their homes and with dignity. It also allows them to maintain relationships and pursue meaningful work. This is what’s required by law and what’s desired by the vast majority of beneficiaries with disabilities.
As critical as Medicaid has always been to people with disabilities, the ACA provided new and faster pathways to eligibility. This has been particularly true in the 32 states that expanded Medicaid thereby allowing even greater numbers of people with disabilities to enroll in the program.
Innovation Nation in Peril?
With the creation of the Center for Medicare and Medicaid Innovation through the ACA, The Centers for Medicare and Medicaid Services (CMS) began investing in targeted experiments aimed at achieving the Triple Aim: better care for the individual, better care for the population and lower health care costs. For people with disabilities, this has meant the opportunity to have better coordinated care and improved access to LTSS that prevents unnecessary hospital and nursing home admissions. Examples of ACA-sponsored innovations that benefit people with disabilities include:
- The Dual Eligible Demonstration Projects: Through this initiative, CMS is working with states to test two models to integrate primary, acute, behavioral health and long-term services and supports for Medicare-Medicaid enrollees and better align the financing of the Medicare and Medicaid programs.
- Initiative to Reduce Hospital Readmissions Among Nursing Home Residents: This effort aims to improve the quality of care for people residing in nursing homes by using evidence-based clinical and educational interventions with the goal of reducing avoidable, and expensive, hospitalizations.
- Community-Based Care Transitions Program: This program seeks to improve transitions of Medicare beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, reduce readmissions for high-risk beneficiaries and document measurable savings to the Medicare program.
The future of these and other innovations that improve care for people with disabilities and other vulnerable populations is most certainly in question.
Private Market Protections
Finally, for people with disabilities who have private insurance, several well-known (and popular!) ACA provisions are particularly important. These include the prohibitions against:
- denying coverage for any reason, including pre-existing health conditions
- lifetime monetary caps
- charging consumers different rates based on their health status or claims history
Additionally, the ACA added two key nondiscrimination provisions that provide important protection for people with disabilities in the individual and small markets, namely:
- That health plans must offer the same ten essential health benefits
- The extension of the federal mental health parity law
The Bottom Line: Nothing About Us Without Us!
The results of the 2016 election create new threats to some of the most fundamental supports that the tens of millions of people with disabilities in our country rely on today. Together, we must work to protect Medicaid and Medicare and the continued investment in delivery and payment reforms that seek to improve the programs rather than tear them down. The rallying cry of the disability community, “Nothing About Us Without Us,” is particularly fitting as we enter the fight of our lives: for health care justice.
I spent the Wednesday after election day in my primary care clinic and found myself incredibly grateful to be immersed in clinical work. Caring for people who are facing tough circumstances like the functional declines of old age, cancer treatment, spinal cord injury, addiction or homelessness reminds me that our work goes on - though now with more urgency and importance than ever. The president-elect and Republican leaders in Congress have vowed to repeal the Affordable Care Act, a law that provides health insurance to 22 million people. In response, Community Catalyst is mobilizing resources to challenge the rollback of the Affordable Care Act and other critical health programs. At the Center, we are particularly focused on ensuring continued access to health care for the most vulnerable, including older adults and individuals with disabilities or serious chronic illness.
As we mobilize to fight the looming threat to coverage for millions of Americans, we are also thinking about how our work to improve health and the delivery of care fits into this chaotic new landscape. Here’s what our Magic 8-Ball has told us so far:
You May Rely On It
Some of the factors pushing improvements in health care will continue. For instance, Medicare drives a large part of federal spending, and there has long been widespread, bipartisan acknowledgment that the current fee-for-service system is expensive, fragmented and failing many of the people it is intended to serve.
The Obama administration, through the Affordable Care Act, accelerated the move to tie payment to quality through initiatives such as Accountable Care Organizations, bundled payments and primary care medical homes. I expect that this shift will continue.
For example, the Medicare Access and CHIP Reauthorization Act (MACRA), which shifted Medicare physician payment into value-based models, was a bipartisan solution for repeated cliffs in physician payments. While some aspects of implementation could change, I do not expect legislative changes to this law. As a result, the template for value-based payments to physicians in Medicare (which tends to strongly influence health care in other sectors) is already set.
Ask Again Later
In other areas, uncertainty dominates. While MACRA is expected to stand, the fate of the Center for Medicare and Medicaid Innovation (CMMI), which was created by the Affordable Care Act to test new payment and delivery models, is uncertain. CMMI is disliked by many Congressional Republicans and the Ryan plan proposed repealing it in 2020. But repealing it poses two complications. First, it was scored by the Congressional Budget Office as budget saving, which means repealing it would add to the deficit. Second, CMMI designed the models that MACRA relies on. While the question of its repeal is uncertain, I expect its authority will be significantly curtailed.
Though it is unclear how efforts at health system transformation will interact with other policy developments, there are several new threats to success. The most pressing and obvious is loss of coverage. Lots of people in Marketplace and expansion populations have serious/chronic illnesses and improving care won’t help these individuals if they lose their coverage. In addition, I am concerned that in the new environment, where funding cuts to Medicaid and other social services are likely, there will not be interest in the investments of time and money needed to make health system transformation successful for those populations who stand to benefit most. And finally, we will need to guard against models of payment that put the consumer at risk through high deductibles or co-pays. We’ve known for decades that cost-sharing has serious consequences for the poorest and sickest among us.
One influential factor to watch is how much private payers will continue to support value-based payment models, and to what degree provider systems have already adjusted the way they deliver care - the health care system is a tanker and if it has already started to turn, its momentum may carry it on its course.
Without a Doubt
Whatever happens, as consumer advocates we must continue our fight for health care policies and practices that achieve better health, particularly for vulnerable populations. Here are four reasons that improving care and engaging consumers in the process at every level is both a moral imperative as well as a movement with ongoing strategic and political importance.
- First, improving care through solutions that advance the triple aim of better care, better health and lower costs give us mechanisms for sustaining public programs in the long run. In contrast to simply slashing benefits or cutting provider rates, these strategies can start to address the structural factors that impact the long-term cost curve. For example, we’ve seen how care coordination can reduce costly and unneeded services and how programs can prevent costly conditions such as diabetes and asthma.
- Second, consumer engagement has resonance across a broad range of models. It’s no accident that consumer engagement and person-centered care have been an important part of both Democratic and Republican strategies, as well as private entities like health plans and provider organizations. This reflects the understanding of the consumer’s central role in the success or failure of health care proposals. This resonance will give us, as consumer advocates, an entry point to define a model of consumer engagement that addresses consumer and community needs.
- Third, our work focuses on vulnerable communities - including older adults and people with disabilities and their caregivers - that are served by a Medicaid program whose future is at risk. It is critically important to empower and organize these consumers to be effective advocates for their health needs, including access to health coverage and a health care system that meets their needs.
- Finally, efforts to improve the delivery of care give us the opportunity to work with a wide range of partners, including payers, providers and community-based organizations. These relationships – including our ability to partner with unconventional bedfellows – will continue to be critical for our success as we face a daunting and challenging new landscape.
I know that in so many ways, our work just got a whole lot more difficult. But there is so much for consumers and consumer advocates to do. Health care was and remains local. We need to work in our own communities, health care organizations and states to ensure access to high-quality, person-centered care: the care that all of us, the consumers we serve, our parents and our children depend on.
While the health care landscape may be changing, our goal remains the same: find a better way to better health. For everyone.
Let me tell you about a consumer I’ll call Marie.
Marie lives in California and has End-Stage Renal Disease. She needs to get to a clinic three times a week for dialysis. Marie doesn’t have a car or any family to drive her, and she can’t possibly afford a taxi. She could take public transportation, but she would have to take three different connecting buses in each direction. That would take her two hours each way, and she’s just not well enough for that.
The good news for Marie is that she’s a Medicaid enrollee, and Medicaid has a benefit designed just for her situation. It’s called Non-Emergency Medical Transportation (NEMT), and the purpose of the benefit is to help low-income people get to their medical appointments. The logic behind the benefit is simple. It is more cost-effective and results in better health outcomes if people can get to their primary care and other outpatient appointments, as opposed to letting a health problem fester until it escalates into a crisis and they end up in the emergency room. This is why Medicaid provides transportation services to qualified enrollees to help them maintain their health.
That’s the good news. The bad news is that this service doesn’t seem to be working very well for Marie, and the problems with NEMT benefits transcend state boundaries. At the Center for Consumer Engagement in Health Innovation, we hear from advocates in numerous states who describe consumers struggling mightily to access NEMT benefits. The problems consumers describe are startlingly similar. Difficulty scheduling rides. Drivers who show up hours late, or not at all. Consumers left stranded at a doctor’s office with no one coming to take them home. NEMT is a critically important benefit, but if it’s not working properly, it doesn’t do anyone any good.
Over the last year, the Center and our friends at Justice in Aging have been working on an issue brief that describes the state of NEMT benefits around the country. The brief looks at how we got here and what some of the problems are with the service. Most importantly, the brief offers recommendations for policymakers that could help to improve the service and make sure it works for consumers.
Imagine Marie having to negotiate this service - the late drivers, the drivers who don’t show up at all, the missed appointments - three times per week, every single week! All just to stay alive and out of the hospital. We can do better, for Marie and for other consumers who desperately need this service.
In late October, we attended the Senior Agenda Coalition of Rhode Island’s Ninth Annual Senior Conference in Warwick. The theme was “Aging in Community: What’s Next?” We met older adults in their 60s, 70s, 80s and 90s who were engaged and determined to age with dignity, but unprepared or unclear on how best to do that in the current health care system. A few of the sessions we attended:
- “Aging Fully: Quality of Life in Our Last Stage” facilitated a deep and meaningful conversation, exploring thoughts, feelings and ideas through the posing of questions. Are we aware of being mortal? How do you manage losses? How do you keep your daily life interesting? How do you nurture your soul? However, when the presenter read the last question, there was a silence in the room – “How do you want the end of your life to be?” It is not an easy decision and it is certainly not an easy conversation for many of us to initiate with loved ones. But to increase the likelihood of having our end-of-life preferences honored in varied circumstances, we need to have this difficult conversation with our family, close friends and our health care providers.
- “Healthy Aging Data Report for Rhode Island.” The report, which was funded by Tufts Health Plan Foundation and researched by The Gerontology Institute at the University of Massachusetts Boston, found that Rhode Island has the highest proportion in the country of adults age 85 and older. The localized data in this report provides a great tool to help guide program and policy decisions at the community level to benefit older adults.
- “Aging in Community,” facilitated by the Rhode Island Organizing Project (RIOP), was a session in the format of the house meetings RIOP holds in the community, gathering small groups of older adult consumers and listening to their experiences with the health care system. Again, questions were posed for discussion: What does it mean to age with dignity? And what is needed to help elders remain in their homes and communities? Responses ranged from setting up age-friendly communities to the importance of maintaining opportunities for socialization as we age.
On our drive home, we reflected on the personal stories we had heard, and the challenges of aging in today’s society. The key messages: people do not want to grow old alone or in a nursing home; they hope to spend their later years in supportive and healthy communities that provide opportunities to remain happy, healthy and independent for as long as is possible.
We two agreed that is exactly how we want to grow old.
On October 22, the Center for Consumer Engagement in Health Innovation hosted a webinar in collaboration with Services and Advocacy for GLBT Elders (SAGE) that shared information about the unique needs and concerns of Lesbian, Gay, Bi-sexual and Transgender (LGBT) older adults. A video recording of the webinar, Meeting the Health Needs of LGBT Older Adults, is now available, as are the presentation slides and an LGBT Cultural Competency Self-Reflection Questionairre.
Statistics show many older LGBT people are less likely than the general older adult population to seek needed health care and preventive services out of fear of facing discrimination from providers. Additionally, many LGBT older people engage disproportionately in behaviors that put them at health risk, such as smoking, excessive drinking and non-prescribed drug use. LGBT older adults are also more likely to be dealing with mental health concerns – a risk factor for social isolation.
The webinar presenters, including a consumer who has benefited from SAGE-sponsored services, offered information and insight on two highly successful programs that incorporate multidisciplinary interventions:
- Elder LGBT Interprofessional Collaborative Care Program (ELINC) in New York City, affiliated with Columbia University School of Nursing, which trains a new generation of nurses to collaborate with other health professionals in providing culturally-competent care to LGBT people across the lifespan.
- SAGECAP Baltimore, a partnership between SAGE and The LGBT Health Resource Center of Chase Brexton, which provides LGBT individuals and their families with access to expert health information and resources including one-on-one counseling, support groups, monthly workshops, assistance with financial and legal issues, referrals to aging services, and linkage to medical care for LGBT older adults and their family caregivers.
These much-needed and forward-thinking programs are demonstrating successful approaches to addressing the unique challenges that may impact the health and well-being of older LGBT adults. We are grateful to each of our webinar presenters, and share their expressed interest in looking for opportunities to replicate these promising models in other states. Please have a look at our video recording to learn more!
State Advocacy Manager, Value Advocacy Project
A new report from The Commonwealth Fund demonstrates how Hennepin Health, a Medicaid Accountable Care Organization (ACO) in Minneapolis, Minn. is breaking new ground in creating partnerships to address the range of health and social needs of the most at-risk members in their community. As consumer advocates look at models that address social determinants of health and payment policies that will support such models, this case study is a must-read.
Hennepin County Medical Center has long served the low-income and uninsured community in the Twin Cities and has grappled with how to meet the needs of the most vulnerable, many of whom have needs that go far beyond medical care alone. So, in 2012 they launched a Medicaid ACO demonstration project to create a new model of care for Medicaid beneficiaries who suffer from debilitating mental health problems, chemical dependencies, and other hallmarks of poverty, trauma and social isolation. The ACO includes four partners: the county’s human services and public health department; Hennepin County Medical Center, a public teaching hospital; Metropolitan Health Plan, a county-run Medicaid managed care plan; and NorthPoint Health and Wellness Center, a federally qualified health center.
Using a care team approach whose members may include physicians, nurses, social workers, a psychologist and a substance use specialist, Hennepin Health was able to reduce ER visits and achieve significant savings. Hennepin’s efforts to identify and engage high-risk patients are key to its success, since the ACO is financially responsible for all of its enrolled members. Patients enrolled in care coordination programs also are given a lifestyle assessment to help staff understand their social challenges.
Last year, I had the privilege of sitting in on a team meeting at the Coordinated Care Center at Hennepin. Seeing this person-centered model at work, with all medical, social and behavioral issues being discussed by team members who exhibited high mutual regard for the expertise each brings, was truly inspiring. The Commonwealth report concludes that this is a model that can be replicated elsewhere, but doing so requires: a long-term investment; that state Medicaid agencies look at risk adjustment for social determinants of health, both in quality measures and payment models; and a community-wide approach to providing compassionate care for the most vulnerable high-need populations.
Back in 2013, Massachusetts became the first state to use a full managed care approach under the CMS-sponsored Financial Alignment Demonstration. This demonstration, known as One Care, serves people with disabilities ages 21-64 who have both Medicare and Medicaid and seeks to provide better care at lower cost. Since the launch, advocates from the disability community have regularly voiced the need for the public reporting of outcome data. And, nearly three years later, that day has arrived! Results from One Care’s first year (October 2013-December 2014) are now available!
While the evaluation did not reveal any big surprises, and findings are only from the first demonstration year, having the data to back up claims of successes and challenges is critical as our health care system shifts more and more toward integrated models of care for people with complex needs, utilizing various innovative payment mechanisms. A few key takeaways of note from the evaluation:
- One Care enrollees had a lower 30-day readmission rate compared to non-enrollees.
- There are opportunities to further improve beneficiary education and engagement. For example, focus groups convened to obtain participant feedback suggest that many beneficiaries were not aware of the formal complaint and appeals processes or available resources to assist them with problems.
- It’s important to ensure stable financing structures and adequate payments. The evaluation reports that One Care plans experienced losses during the first year, noting that Medicare and Medicaid capitation rates were inadequate to cover new costs associated with care coordination, additional benefits offered, and administrative start-up costs of the demonstration.
- With the large number of beneficiaries being enrolled during passive enrollment phases, One Care plans reported their greatest difficulty was reaching enrollees, including many who are homeless or without a stable address.
- The Long-Term Services and Supports (LTS) coordinator role, while widely supported and very much needed, was difficult to implement due to ill-defined roles and responsibilities, which led to inconsistencies and confusion in implementation. The plans and community-based organizations found it difficult to strike the right balance between flexibility and structure for the LTS coordinator role.
- Participants reported unmet needs for oral/dental care and substance use disorder services.
Though many of these early challenges have been largely addressed, there is still additional work to do both in Massachusetts, which extended the demonstration for another two years, and elsewhere. It will be important to take these early findings and use them to continue to improve One Care. Other states with ongoing demonstrations may also find much of interest within this report, as they work to refine their projects to provide maximum benefit to participants.
And, to continue the virtuous cycle of quality improvement, we eagerly await further demonstration evaluations out of CMS!
Today, Community Catalyst’s Center for Consumer Engagement in Health Innovation submitted comments on the proposed regulations updating the Program of All-inclusive Care for the Elderly (PACE) model. The regulations proposed by the Centers for Medicare and Medicaid Services (CMS) represent the first major update to the PACE program in a decade. PACE is a team-based program available to nursing-home eligible people over age 55 with Medicare or Medicaid, or both (in some states, only Medicaid beneficiaries are eligible). The program’s goal is to keep participants in the community in which they live rather than a nursing home or other care facility. PACE does this by coordinating care and connecting members to many specialists and other providers, as well as to a range of services and supports in the community to provide a well-integrated care experience. Despite evidence showing PACE participants have significantly lower rates of hospital, nursing home, and emergency department utilization and lower overall rates of inpatient days, both the numbers of PACE programs and the level of enrollment has remained relatively small.
To address some of these challenges, CMS is proposing a number of improvements including operational flexibilities, particularly around the Interdisciplinary Team (IDT) that is so central to the benefits of the PACE model. For example, the integration of community-based providers as primary care providers (PCPs) and expansion of the professions which would qualify as PCPs to include nurse practitioners and physician assistants are both steps in the right direction. The ACA has enabled CMS to explore and promote new models of care via demonstrations to integrate care for some of the most high-need, high-cost consumers. Our comment letter urges that some of this work, including the PACE program, be integrated into the work of the Medicare-Medicaid Coordination Office within CMS.
In general, the Center is supportive of the proposed regulations and believes it is important to build upon the lessons learned from PACE’s successes over the past four decades and expand these to other integrated models of care. In our comments, we urge CMS to make building awareness of this model more of a priority and in the final regulations, to encourage provisions that will allow for greater expansion of the number of PACE programs across the nation.
It’s here: the final rule for CMS’ Quality Payment Program (QPP/MACRA) has been released! You dug through 900+ pages, added new acronyms to your vocabulary, submitted comments, and, at the end of a long campaign, have another 2400+ pages to wrap your head around this weekend. We here at the Center for Consumer Engagement in Health Innovation are no different.
Overall, we are excited about the move that CMS is making toward value-based payment. CMS has been working to move the health care system away from one that is based solely on fee-for-service and toward a system that focuses on better coordination and quality of care. We are supportive of these efforts because of their potential to improve care for consumers.
At the same time, we think it’s important that consumers be the North Star for the kind of reform that is envisioned by MACRA. Thus, when we entered this process, we had four burning items we were looking for on behalf of consumers. As we begin digging into the final rule, here is our preliminary judgment on how well the rule addressed these core concerns:
QUESTION: Is enough being done to prepare consumers for system change?
This rule will have sweeping and lasting changes on this nation’s health care system and will have significant impacts on the care consumers receive. Consumer outreach and engagement will be necessary for ensuring that the implementation of new models remains patient centered, educating consumers about what these changes mean for how their care is delivered and effectively empowering patients to engage in their own health care decisions. Unfortunately, the final rule does not seem to strengthen consumer engagement requirements beyond what was in the previous proposal. For example, all but one of the beneficiary-engagement improvement activities are given only medium weighting, and CMS is now requiring practices to complete even fewer improvement activities. Additionally, CMS bypassed opportunities that would have ensured robust patient engagement in advanced alternative payment models, such as strengthening requirements for medical homes.
QUESTION: Are there protections in place for consumers as providers take on financial risk for the cost of care?
The Quality Payment Program incentivizes providers to take on greater financial risk for their patient populations. The hope is that this will lead to better care at lowers costs, but it also comes with the possibility that provider losses could lead to disruptions in care for patients. That’s why it’s so important that the final rule include provisions meant to protect consumers in these new payment models. As we continue to analyze the final rule we will be keeping an eye out for consumer protections such as the right to know what risk arrangements a provider is taking on, freedom for consumers to choose their provider, access to all covered services, easy-to-navigate appeals and grievances systems, and easy-to-read accessible program materials for beneficiaries including those with disabilities, speech and vision limitations, and limited English proficiency.
QUESTION: Will consumers get to define “quality” in this program?
VERDICT: NOT ENOUGH
A major goal of the QPP is to move toward a more integrated, person-centered system of care. To meet that goal, quality measures should reflect the experiences, goals, preferences and needs of consumers, in particular low-income older adults and other vulnerable Medicare enrollees. Unfortunately, of the 271 quality measurements to choose from, on our first look we only spotted about 15 that are patient reported. We are concerned about the lack of patient-reported measures because it sidelines one of the most important - if not the most important - voice in the room. If the quality of care within our health system is to improve, people must have a more important say in how quality is defined.
QUESTION: Will this new program improve or worsen health disparities in the United States?
The final rule represents a major opportunity to transform the health system in a way that better addresses the persistent health disparities that exist for marginalized and underserved populations. It’s not clear that CMS fully capitalized on this opportunity. For example, the list of clinical practice improvement activities was not expanded to promote cultural competency or implicit bias training. CMS does promise to release best practices for collecting data stratified by demographic characteristics and notes that in future rulemaking they will consider additional strategies for addressing health equity, for example finding ways to incentivize providers who reduce disparities and identifying appropriate measures of health equity. As CMS moves forward with implementing the QPP, we will need to advocate that health equity remains a priority and that payment methodologies do not unfairly penalize practices who are caring for socially and economically disadvantaged patients.
We appreciate that CMS has made changes to make it easier for providers to participate. However, the final rule illustrates the ever-present need for state and federal consumer advocates to continue to elevate the importance of consumer engagement in order to drive reform that will be truly transformative for consumers.
Last week, the Center for Consumer Engagement in Health Innovation at Community Catalyst published a report, Consumer Engagement in Medicaid Accountable Care Organizations: A Review of Practices in Six States. The Accountable Care Organization (ACO) model of care delivery is intended to incentivize better coordination of care and allow for more flexibility in the types of services provided to members. However, because ACOs also face financial incentives to reduce the total cost of care, there is potential that ACOs may focus on cost reduction at the expense of quality, person-centered care. We believe it is critical that the members served by ACOs have a strong voice in their design, implementation and ongoing oversight in order to ensure the goal of providing quality, person-centered care stays at the fore.
What We Did: We reviewed how six states – Colorado, Maine, Minnesota, New Jersey, Oregon and Vermont – are engaging consumers in the design, implementation and oversight of their Medicaid ACO programs. We reviewed state websites, spoke with consumer advocates in these states and reviewed relevant documents such as federal waiver applications, requests for proposals, model contracts and statutory language.
What We Learned: We found that all six states are engaging consumers at both the state and ACO levels, but the format and extent of this engagement varies widely. Our interviews with 14 consumer advocates across our sampled states illuminated the breadth of factors to consider when engaging consumers, and cautioned that just having consumer engagement requirements is not sufficient to create meaningful participation. Some of the ways state policymakers and health care organizations leaders can improve engagement include being mindful about meeting times and locations; providing adequate time and support for consumers to review and comment on materials; and ensuring appropriate funding and training.
A growing number of states are pursuing Medicaid ACOs and the experience of states that have already implemented them can help inform those that follow. We hope our report will be useful to consumer advocates, state policymakers, and ACO leadership, both in states that are considering Medicaid ACOs and those with programs underway that are looking to improve how they engage consumers. Ultimately, the voices of consumers should be the “north star” guiding the design, implementation and monitoring of the programs meant to serve them.
Over the last year, I have had the opportunity to serve on behalf of Community Catalyst on the Health Care Transformation Task Force - a consortium of patients, payers, providers and purchasers working to accelerate the pace of U.S. health care delivery system transformation and inspire a greater focus on person-centered care.
Since Community Catalyst’s founding, our work and investment in meaningful consumer engagement has made it clear to us that it is fundamental to transforming the health care system. Over the years, we have learned an immense amount through our work with low-income populations, seniors, people with disabilities and advocates on the ground, and were tasked with ensuring that those voices and interests were represented through our participation on the Task Force.
The result of seven months of collaboration and discussion among the members of the Advisory Group for Consumer Priorities, which I co-chaired, recently culminated in a new multi-stakeholder, consensus-based framework, “Addressing Consumer Priorities in Value-Based Care: Guiding Principles and Key Questions.” As one of the members tasked with representing consumers and consumer advocates, I am pleased that the recommendations made by the Advisory Group were fully endorsed by the diverse membership of the entire Task Force and are present in the final white paper.
The resulting document should raise eyebrows: this is a big deal. The Task Force is comprised 42 member organizations and individuals, which includes representation from six of the nation’s top 15 health systems and four of the top 25 health insurers, as well as leading national organizations representing employers, patients and their families, and the policy community.
This white paper should open the door for consumers and consumer advocates to have an increasingly meaningful seat at the table for discussions about value-based, people-centered care. In assessing their own consumer engagement efforts, plans, providers and payers agreed to examine the following six principles:
- Include patients/consumers as partners in decision-making at all levels of care. For example, are patients/consumers included as integral partners in all aspects of health care decision-making at every level, from system-level reform design to point-of-care decisions?
- Deliver person-centered care. For example, are patients/consumers and those who support them at the center of the care team?
- Design alternative payment models (APMs) that benefit consumers. For example, do APMs achieve cost-savings only through improvements in health and health care and ensure beneficiary rights and protections?
- Drive continuous quality improvement. For example, do the health care transformation policies and practices drive continuous quality improvement?
- Accelerate use of person-centered health information technology. For example, do alternative payment and care delivery models accelerate the effective use of person-centered health information technology?
- Promote health equity for all. For example, does the health care delivery system and payment reform model promote health equity and seek to reduce disparities in access to care and in health outcomes for all?
We have seen - over and over again - how meaningful consumer engagement in public health care reform has reaped dividends. In Massachusetts, consumer advocates drove adjustments to One Care, the Massachusetts dual eligible program, to provide more accurate rates for the complex care management and service needs of low-income adults with disabilities. In Ohio, advocates shaped the State Innovation Model on Patient-Centered Medical Homes to include Patient and Family Advisory Councils, community health workers and collaboration with community-based organizations. And in California the collection of data, driven by consumer advocates, will illuminate health disparities to promote greater health equity.
And now we are seeing proactive measures and the explicit endorsement of the need for meaningful consumer engagement from private purchasers, payers and providers.
The next steps are to bring these practices from the white paper to reality through our new Center for Consumer Engagement in Health Innovation in its mission is to bring the consumer experience to the forefront of health innovation in order to deliver better care, better value and better health for every community, particularly vulnerable and historically underserved populations.
Consumer advocates will play an equally important role as we work to engage health plans to invest time and resources to support meaningful patient and family advisory roles, to ensure purchasing contract provisions that emphasize patient-reported outcomes and to push proactive efforts to understand and address health disparities to create a better way to better health. For everyone.
Even with health care coverage, Medicaid beneficiaries still find themselves facing numerous barriers to accessing the care they need and achieving better health outcomes. One barrier that continues to cause serious access problems is transportation. There are an estimated 3.6 million people in the United States who miss or delay medical care because they don’t have access to transportation.
In early August, the Center for Consumer Engagement in Health Innovation (the Center) submitted a comment letter to the Centers for Medicare and Medicaid Services (CMS) regarding Iowa’s request to extend its waiver of Non-Emergency Medical Transportation (NEMT) benefits from its state Medicaid demonstrations (Iowa Wellness Plan and Marketplace Choice Plan). The waiver excludes coverage for NEMT services, a benefit that is standard in non-waiver Medicaid programs.
NEMT provides access to and from medical appointments for consumers who do not have other means of transportation. Reimbursed services can include shared van programs, taxis or public transit. Many in need of NEMT are lower-income beneficiaries, often older adults or people with disabilities. A high proportion of these individuals live with multiple chronic conditions such as end-stage renal disease, cancer or chronic obstructive pulmonary disease. Monitoring and treatment for these conditions require frequent medical appointments and limited transportation options may prevent access to timely, life-sustaining care.
Transportation barriers can have a “domino effect” on health outcomes and cost of care. Missed or delayed appointments can worsen health conditions and end up necessitating expensive ambulance services and costly emergency department visits. This is why NEMT has proven to be highly cost-effective.
For individuals in need of behavioral health services, NEMT is particularly critical. One study found that the largest proportion of adult beneficiaries who use NEMT do so to access mental and behavioral health services. More than 40 percent of NEMT trips in New Jersey and 30 percent of trips in Nevada were used to access mental health or substance use treatment appointments.
The Center is concerned that several states have sought to exclude NEMT for some of their Medicaid beneficiaries. These actions reveal the need for consumer advocates to ensure that other states do not follow suit.
This is why the Center submitted comments on Iowa’s waiver request and why we plan to also submit comments opposing Indiana’s similar proposal. We encourage others to do the same. The comment period for Indiana’s NEMT waiver request is open from August 12 - September 11, 2016.
Submitted by Andrew Jopson, Summer Intern. Andrew is a graduate student at the University of Washington, Seattle.
Massachusetts, always a leader in health reform, is on the move again. Last month, the state released a draft plan to shift its Medicaid program, MassHealth, from a fee-for-service model to one that relies on Accountable Care Organizations (ACOs). Under this new approach, provider-led ACOs will be responsible for the quality, coordination and total cost of many MassHealth beneficiaries’ care.
This move has been a long time coming. Even as the state led the nation in creating near-universal health coverage in 2006, it had already started to plant the seeds to improve the way care is delivered and paid for. Now, the state is on the verge of big changes that will impact up to 1.8 million low-income beneficiaries: children with special health care needs, adults with physical and behavioral disabilities and vulnerable older adults.
So what do these beneficiaries think of the proposed reforms? Our state advocacy partners in Massachusetts at Health Care For All (HCFA) and Disability Advocates Advancing our Healthcare Rights (DAAHR) – both of whom submitted comments last week in response to the state’s proposal – clearly outlined both the promise and the peril of these reforms for beneficiaries. Among the promises are better coordinated, more comprehensive care and a more financially-stable Medicaid program. Notably, the state also seeks to “address the opioid addiction crisis by expanding access to a broad spectrum of recovery-oriented substance use disorder services.” Also laudable is the requirement that ACOs must work with community-based organizations which will provide critical long-term services and supports and behavioral health services.
But the risks are also real: to give just one example, the state is proposing that beneficiaries be “locked in” to one ACO or Managed Care Organization for a year. This lock-in provision means beneficiaries could face increased costs, reduced provider choice and control, and a disconnect from critical supports and services they are currently receiving. This could place our most vulnerable consumers – those with chronic care conditions and children with special care health care needs – at risk.
In part, advocates’ concerns arise from simultaneously proposed reforms in the state’s Primary Care Clinician (PCC) plan, an existing managed care option for MassHealth beneficiaries. These changes are meant to incentivize members to move to a managed care organization or to an ACO, but in fact, they would penalize those who want to stay in the PCC plan. For instance, proposed PCC changes include eliminating coverage of chiropractic services, eyeglasses, hearing aids and orthotics and increasing member copays. Of particular concern to children’s advocates is the fact that reduced benefits in the PCC plans limit access to federally-mandated Early and Periodic Screening, Diagnostic and Treatment (EPSDT) service, which provides comprehensive coverage for dental, vision, hearing and medical screenings and treatment. EPSDT is the gold standard for children’s coverage, ensuring that children under 21 enrolled in Medicaid have full access to developmentally appropriate preventive and treatment services to support their growth and long-term health.
Advocates included specific recommendations for improving the proposal but they aren’t stopping there. For example, the day after submitting its formal comments, DAAHR hosted a public forum with over 90 participants representing the disability community, state government, community-based organizations, health plans and potential ACOs. The theme was “building partnerships” and it was well-reflected in the event as participants rolled up their sleeves to apply their best thinking on how to most effectively meet the needs of people with disabilities.
The Commonwealth delivered its proposal to CMS late last week, and CMS will soon open up another 30-day public comment period. Given that we’re nearing the end of the Obama administration, we expect quick action on approving the waiver proposal. Embodying the slogan, “Nothing About Us Without Us,” advocates will continue their dogged efforts to shape the final waiver so that it works to improve the quality of life for all MassHealth beneficiaries.
Last week, I had the privilege of attending the United Hospital Fund’s 2016 Medicaid Conference in New York City. This year’s conference focused on ongoing efforts in New York’s Medicaid program to develop delivery and payment systems that reward value instead of volume. New York has an innovative waiver that enables the state to reinvest $8 billion in federal savings generated by Medicaid Redesign Team (MRT) reforms. The goal of the waiver is to address critical issues throughout the state’s Medicaid program and allow for comprehensive reform through a Delivery System Reform Incentive Payment (DSRIP) program. Under the DSRIP program, funds for providers are tied to meeting a set of specified performance metrics.
As consumer advocates, we often have to fight to get the consumer viewpoint integrated into programs like Medicaid. Throughout the conference, panelists challenged audience members to build programs that truly consider the unique needs of Medicaid consumers.
One of the most compelling panels focused on engaging and protecting Medicaid members. The three-member panel included Christina Jenkins (President and CEO of OneCity Health), Rebecca Novick (Director of the Health Law Unit, Legal Aid Society) and Harvey Rosenthal (Executive Director of the New York Association of Psychiatric Rehabilitation Services). The panelists focused on transforming provider/patient relationships by training providers on motivational interviewing, building trust between providers and consumers, and using community health workers and peer counseling.
All three panelists agreed that Medicaid programs must look beyond the physical aspects of health care and seek to address beneficiaries’ behavioral health and social service needs. Dr. Jenkins recommended establishing formal contracts with community-based organizations. Another theme of the panel was the need for trust and empathy between providers, frontline staff and patients. For example, Mr. Rosenthal discussed the need to train frontline workers on meaningfully engaging with their patients and not just focusing on hitting the required benchmarks. Ms. Novick emphasized the need to change the current adversarial relationship many providers and Medicaid patients have with one another through long-term relationship efforts and practices that reach beyond just treating health symptoms.
The DSRIP program enables states like New York an opportunity to build a more person-centered culture of care. The panel highlighted some strategies that can be employed to build a health system that focuses on the whole person, providing a range of coordinated services that can best match her or his goals, values and preferences. When a health system embraces this mindset, improved quality of life for consumers and lower overall costs will generally follow. And that’s what we call value.
Stephanie Cohen, State Advocacy Manager, Value Advocacy Project
I recently attended Health Care for All’s (HCFA) 4th Annual Patient and Family Advisory Council (PFAC) Conference in Massachusetts, which was incredibly informative and inspiring. HCFA was a major force behind the passage of the 2008 law that required all Massachusetts hospitals to establish PFACs, and for the past eight years, has provided technical assistance, training and networking opportunities to strengthen patient and family engagement in hospitals.
So, what are PFACs and why do they matter? According to the Agency for Healthcare Research and Quality, PFACs are bodies made up of individuals who have received care at a hospital (or their representative family members) and are able to offer feedback and insights to inform and improve hospital care delivery, policies and operations to most effectively address patient and family needs and preferences. PFACs have the potential to help improve overall systems and processes of care, which can lead to better health outcomes for patients, as well as improve financial performance of health care organizations. PFACs are a great example how to actively and meaningfully engage consumers in order to realign the health care system and place consumers at its center.
But establishing a PFAC is only the first step. Learning how to make it meaningful is an entirely other story. And that’s what the HCFA conference was all about. It began by offering a three-part vision of what constitutes authentic engagement: First, engagement is purposeful; second, engagement is effective; and, finally, engagement is equitable. The conference covered a lot of ground across these three themes, providing the nearly 300 participants with opportunities to discuss everything from building internal credibility for PFACs, to creating effective meeting agendas, to understanding why PFACs should care about and provide their perspectives around quality measures. Most importantly, the conference provided PFAC members from across the state with an opportunity to network with – and learn from -- one another.
One cross-cutting theme of the day was the importance of consumers being engaged at every level, and from beginning to end of all hospital processes. Examples abounded, including in sessions focused on engaging patients in research as partners rather than subjects, integrating patients into hospital committees, and identifying the PFAC’s role in shaping hospital community health assessments and activities in order to best address identified needs.
Another theme was the importance of recruiting a diverse PFAC membership that represents the patient population by race, ethnicity, language spoken, sexual orientation, gender, age, disability status, employment status and so forth. One PFAC’s approach to recruiting and retaining diverse members included developing a Diversity, Equity and Inclusion Council that supports other PFAC members in understanding how to be more inclusive of people from different racial and ethnic backgrounds. Another PFAC in the state is working to adapt educational materials for different age groups, particularly older adults, by ensuring materials are printed in large, bold text and colors that are easy to read. Several PFACs are changing their meeting times or incorporating virtual meetings and social media in order to accommodate members who are working parents or others who have difficulty getting to in-person meetings.
The conference helped me better understand some of the challenges and opportunities PFAC members face as they continue to develop and establish their roles within health care organizations here in Massachusetts. I also walked away from the conference with an increased appreciation of the role consumer health advocacy organizations like HCFA can play – through convenings, trainings and providing a space for PFAC members to connect – in supporting these councils so that their engagement is truly purposeful, effective and equitable.
When Pennsylvania launches its Community HealthChoices (CHC) program for older adults and individuals with disabilities over the next few years, it will join a growing number of states shifting to managed care plans to provide long-term services and supports (MLTSS) to Medicaid beneficiaries. Up to 450,000 Pennsylvanians could eventually be enrolled in CHC. So far, Medicaid MLTSS has had mixed results around the country. If implemented well, MLTSS has the potential to provide better, more coordinated care. But there are also risks that its implementation could interrupt care, cut vital services and squeeze out community providers. Two things are certain though: there are many lessons to be learned from states that have already implemented MLTSS programs; and these programs can only be successful with meaningful input and feedback from the communities they serve.
The Center for Consumer Engagement in Health Innovation was honored to be invited by the Jewish Healthcare Foundation to travel to Pittsburgh last week to lead a day-long training for community and consumer groups aimed at helping them prepare for and engage in the launch of CHC in Southwest Pennsylvania. Over 50 people from a variety of organizations, most of whom work with and advocate for older adults and people with disabilities, attended the training.
We started off the day with an overview of best practices from around the country for consumer-centered MLTSS implementation using a Community Catalyst-designed tool. Then we moved into detailed discussions around four topics: successful beneficiary communications; smooth transitions of care; ensuring network adequacy; and building meaningful consumer engagement. We were joined by three dynamic guest speakers – Bill Henning from the Boston Center for Independent living (pictured with Alice Dembner of Community Catalyst), Larke Recchie from the Ohio Association of Area Agencies on Aging and Marisa Scala-Foley from the Administration for Community Living. During small group brainstorming sessions, participants shared their ideas on how to make consumer engagement in CHC as meaningful as possible, and what can be done to identify, recruit and support consumers who want to become involved.
There is much to do in preparation for CHC’s launch next summer. We are grateful to the staff of the Jewish Healthcare Foundation for their commitment to making sure CHC will be as successful as possible. We look forward to continuing to work with the foundation and advocates throughout Pennsylvania to support them in shaping this program.
(Last year, the Robert Wood Johnson Foundation launched a joint initiative with Community Catalyst called the Value Advocacy Project (VAP). The project is supporting consumer health advocacy organizations in six states in their non-lobbying advocacy efforts to pursue local and state policy and health system changes that increase the value of health care by improving health outcomes and lowering health care costs, especially for populations that have disproportionately poor outcomes. Building on the Center for Consumer Engagement in Health Innovation’s recently released Consumer Policy Platform for Health System Transformation, we will be highlighting our state partners working on issues outlined in the policy platform and encouraging them to share how their work can translate to advocates across the country.)
Ohio is one of the nation’s unhealthiest states, ranking 40th in overall population health, yet we spend more per person than all but 15 states. Additionally, the state ranks last in racial disparities of infant mortality, speaking to the need for a more robust approach to health equity.
In 2009, Governor John Kasich created the Office of Health Transformation to change the way we pay for and deliver health care, to move from volume to value. Leveraging the influence of large self-insured employers, the administration brought together the four largest insurers, public payers and providers to develop a payment/delivery reform plan (described below), leading to the award of a federal State Innovation Model (SIM) Implementation Grant.
But what about the role of consumers? That’s where we come in.
In the next five years, Ohio plans to move 80 percent of Ohioans into two new payment models: Patient-Centered Medical Homes (PCMH) and episode-based payments. Episode-based payments refer to paying providers for treating a whole “episode of care,” such as joint replacement, rather than the individual services. This incentivizes providers to get the care right (they get paid the same even if the patient gets a bad infection requiring multiple hospitalizations), creates more price transparency and narrows the wide variation in charges among providers for the same treatment.
The SIM application talks about patient engagement, but we need to identify the strategies for building in robust and meaningful patient engagement. Furthermore, strategies for addressing population health also need to be identified. Thus our coalition, Ohio Consumers for Health Coverage, is focusing its Value Advocacy Project campaign on shaping the PCMH model of care as an instrument to improve population health driven by a robust, institutionalized consumer voice at all levels of Ohio’s health transformation efforts.
Regional PCMH collaboratives in Ohio demonstrate both the potential and challenges of relying on primary care transformation to make strides in population health. On the one hand, we’ve seen PCMH practices virtually eliminate racial disparities in delivery of diabetes care in Cleveland (check out Better Health Partnership). On the other hand, The Southwest Ohio Comprehensive Primary Care Initiative (which is one of seven sites in the federal CPCI initiative), has Medicaid covering only 5 percent of patients, due to federal restrictions. And CPCI’s patient population does not reflect the racial and ethnic diversity of Ohio. Yet, the Kasich administration is calling it the model for Ohio’s PCMH model.
On the plus side, a handful of PCMH practices in the southwest Ohio demonstration are using Patient-Family Advisory Councils (PFACs) to involve their patients in improving care quality – a best practice for patient engagement that we plan to promote as a state benchmark.
Where do we begin?
We’re working in three areas:
- Advocating that the Ohio PCMH model include standards and metrics to measure and improve consumers’ experience – including their participation in their care – and promote population health by connecting consumers to resources like patient self-management programs, housing and food assistance that improve their health and overcome non-health barriers;
- Building the voice of consumers at several levels: at the individual level by promoting expanded use of PFACs in PCMHs and recruiting consumers for them, at the systems level by getting consumers and advocates more vocal, at the regional collaborative levels in our three largest metropolitan areas and the policy level where we recently won four seats on the PCMH model design workgroup; and
- Ensuring that Ohio’s PCMH initiative promotes health equity, including institutionalizing effective use of community health workers to reduce health disparities and engaging the Ohio Statewide Health Disparities Collaborative in developing a health equity action agenda for this initiative.
Perhaps our greatest challenge is figuring out how to energize consumers in the three biggest metropolitan regions (and beyond) to get involved as advocates for better primary care that supports efforts to lead healthier lives. We hope to draw in people newly enrolled by community-based assisters, especially ones we trained and placed primarily in communities of color, as part of our enrollment follow-up activities to promote better health literacy and patient engagement. And we’ll turn to our activated enrollees in our integrated care (“dual eligibles”) demonstration, some of whom we are training for managed care plan consumer advisory committees.
Most of all, we plan to borrow promising practices from consumer advocates in other states who have been infinitely creative in causing a stir. Ohio needs a lot of creativity!
Author: Cathy Levine, Former Executive Director, UHCAN Ohio
The distressing crime of elder abuse often occurs in quiet, private settings, making a vocal, public response that much more important. Let us strengthen our resolve to end this problem as part of our broader efforts to create a life of dignity for all.
U.N. Secretary-General Ban Ki-moon, U.N.Resolution 66/127
In 2011, the United Nations General Assembly designated June 15 as annual World Elder Abuse Awareness Day (WEAAD). It represents one day in the year when the whole world is urged to turn its gaze directly to the abuse and suffering inflicted upon some among our older generations. But the sad reality is that such abuse goes on 365 days a year and is far more prevalent than we would like to believe. Elder abuse is a global social issue which affects the health and human rights of millions of older persons around the world and an issue which deserves the year-round attention of the international community.
At the National Center on Elder Abuse (NCEA), we work daily with elders, their families and loved ones whose lives have been shattered at the hands of this devastating public health issue. First established by the U.S. Administration on Aging (AoA), this grant-funded resource center is now housed within the Keck School of Medicine at the University of Southern California. Our Mission: “To improve the national response to elder abuse, neglect, and exploitation by gathering, housing, disseminating, and stimulating innovative, validated methods of practice, education, research, and policy.” The NCEA is passionate about effecting real change to address this devastating problem. With attention, education, training and proper reporting, elder abuse can be significantly reduced.
Elder abuse can lead to serious physical injuries and long-term psychological consequences. The incidence of abuse toward older people is predicted to increase as many countries are experiencing rapidly aging populations. The global population of people aged 60 years and older will more than double over just a thirty-year period, from 542 million in 1995 to about 1.2 billion in 2025. Elder abuse is a tragedy that affects hundreds of thousands of seniors regardless of race, gender or socioeconomic class. Even though one in ten seniors has been subjected to financial, physical or emotional abuse, elder abuse is still a vastly under-recognized problem.
Elder Abuse takes many forms – physical abuse, emotional abuse, neglect, financial abuse and sexual abuse, making it multi-layered, complex and insidious. Many older adults are abused in their own homes, in relatives’ homes and even in facilities responsible for their care. It is important that if there is suspicion that an elderly person is at risk of neglect, physical abuse, undue influence or being preyed upon financially, that it is reported immediately.
Some of the warning signs of the different types of abuse are:
- Neglect – Disheveled appearance, home in disrepair, untreated pressure “bed” sores.
- Financial – Forged signatures on documents, unusual banking transactions/withdrawals.
- Emotional – Uncharacteristic changes in behavior, withdrawal, isolation, depression.
- Physical – Inadequately explained fractures, bruises, welts, cuts, weight loss.
- Sexual – unexplained sexually transmitted diseases.
A full listing of Red Flags of Abuse can be found here.
How to Help Prevent Elder Abuse
Isolation is a common denominator in many cases of abuse. It is important that older adults at risk of isolation be provided with connections to keep them anchored to their community, current events and resources. Many of us may come into contact with isolated older adults, whether in our professional roles or personally. The following points can help empower us all to take action to protect the older adults in our communities.
If you suspect abuse, report your concerns immediately to local law enforcement and adult protective services. If the suspected abuse is occurring in a licensed long-term care facility, contact the long-term care ombudsman for that facility. A poster should be hung in a conspicuous area of every licensed facility with contact information for reporting concerns.
Even if they’re able, many seniors don't report the abuse they face. Some fear retaliation from the abuser while others believe that if they turn in their abusers, no one else will take care of them. These are very difficult psycho-social issues to be cognizant of. When the caregivers are their children, they may be ashamed that their children are behaving abusively or blame themselves. He or she may be in denial, feel ashamed about needing help or worried about having to leave home. Don’t stop checking in with the older adult, even if you are brushed off at first. Enlist others to express their feelings of concern to the elder. Sometimes a peer or a neutral party, such as a geriatric care manager, may have a better chance of getting through.
It can be a real challenge to respect an older adult’s right to autonomy while at the same time making sure they are properly cared for. If you are concerned that a person’s ability to take care of themselves safely is compromised, reach out to law enforcement and adult protective services for advice.
So on this World Elder Abuse Awareness Day, let’s be reminded of the powerful quote from Margaret Mead, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has."
When it comes to Preventing Elder Abuse, an individual can do so much.
Julie Schoen, JD
Deputy Director of the National Center on Elder Abuse
Keck School of Medicine at the University of Southern California
Recently, CMS’ Medicare-Medicaid Coordination Office (MMCO) released a new report on the progress of the Financial Alignment Initiative. Through this initiative, thirteen states are running demonstration projects focused on improving care for vulnerable Americans enrolled in both Medicare and Medicaid, sometimes referred to as "dual eligibles." In most states participating in the initiative, dual eligibles are enrolled in managed care plans responsible for all aspects of their care, while in two states, they are part of health homes responsible for coordinating their care.
The new MMCO report examined enrollees’ experiences in the demonstrations in seven early-launch states – California, Colorado, Illinois, Massachusetts, Ohio, Virginia and Washington – and was based on data collected in 2015.
Those of us who have been following these demonstrations for the last several years have been awaiting these sorts of results with baited breath. So, I dug right in.
For the most part, the results seemed pretty promising: most enrollees reported good (though not always quick) access to needed care and prescription drugs and had favorable views of their health plans or health homes.
However, one category of findings really stood out for me – those around care coordination. Care coordination is the lynchpin of the demonstrations, aimed at countering the system’s fragmentation caused by the separate financing and benefit structures of Medicare and Medicaid as well as the complex health needs of many beneficiaries. Yet only 30 percent of enrollees in managed care plans recalled receiving help from their health plan and/or providers in coordinating their care. And, only 54 percent of enrollees in Washington and 62 percent in Colorado (the two health home demonstrations) indicated that they were usually or always helped by someone on their care team to make a treatment plan or plan ahead to take care of their condition. These findings echoed reports over the past year from the Government Accountability Office, an Early Indicators Project in Massachusetts, a consumer survey in Ohio and our own survey of ACAP health plans. Similarly, new evaluation results of the California demonstration project released this week found that only 34 percent of enrollees reported having a care coordinator and 40 percent of enrollees didn’t even know they could get care coordination.
We can do better, and not only in the context of these demonstrations. Care coordination, particularly for people with complex medical, behavioral and/or social service needs, must be at the heart of any delivery system reform. It should encompass comprehensive assessment, planning with the consumer and culturally-competent, team-based care.
By its very definition, any demonstration is a work-in-progress. Let’s take the learning shared in this and other evaluations, capturing the real experiences of dually eligible consumers, and find new ways to get more beneficiaries engaged in high-quality care coordination.
On April 4, my 73-year-old mother had back surgery. It was a difficult and lengthy procedure and, unfortunately, she experienced a series of post-operative complications. She remained in the hospital for 12 days, and for several of those days things looked very serious. For the first time since I started doing health system transformation policy work, I had an opportunity to experience the acute care side of our health system not merely as a policy advocate, but as a worried family member.
There was a lot about my mom’s medical care that was good. Crucially, the complicated surgery itself appears to have been successful with the focus now shifted to her recovery process. In addition, her providers were appropriately aggressive about pain control early on, and equally aggressive about transitioning my mom off of narcotics as quickly as possible, while still keeping her comfortable. I was also impressed with the hospital’s vigilance around infection control. Last but by no means least, her doctors and nurses were genuinely caring and concerned.
Nevertheless, I couldn’t help asking myself throughout her ordeal if the care my mother was receiving met the standards of patient-centered care for which we are all so strenuously advocating. The John A. Hartford Foundation recently posted a blog about patient-centered care in acute settings, and the authors’ admonition to “Think about the System” really resonates with me. The things that worried me about my mom’s care in the hospital all seemed to stem from systematized behavior that was centered around somebody’s needs, but that somebody didn’t seem to be my mother.
For example, doctors would visit my mother at 4:00 and 5:00 a.m. when neither my father nor I were there. They would awaken her, update her about her medical condition and leave. As the days unfolded, it became clear that the “system” was organized for doctors to do rounds before the day’s surgeries and clinical office hours. For them, pre-dawn visits were a convenient time. But was that the best time for my mom? Was that patient-centered care, or surgeon-centered care? The big problem with this system was that it resulted in very poor actionable communication with the patient and her supporting caregiver system – in this case, my father and me. “Drs. 4:00 and 5:00 a.m.” would awaken my mom and explain what was going on with her medically. At no point did my mother ever remember a single thing they ever told her. How could she, given her exhaustion and the narcotics she was taking? Technically, her doctors were sharing information with her, but it was not “communication” in any meaningful sense of that word.
Not just the early-rounding doctors, but also nurses and other hospital staff frequently interrupted my mom’s sleep, and this proved to be an enormous problem throughout her hospital stay. One of the things my mother needed most was sleep, but she was never undisturbed for more than two hours at a time. This is a common complaint of folks who’ve been in the hospital, and providers acknowledge it’s a problem. My mom’s nurses felt badly about this, and even agreed that it worsened her complications. But it was also clear from the helpless looks on their faces that they couldn’t imagine things any other way. Is the patient at the center of a system that deprives sick people of sleep for days at a time? Is there really no other way to organize a hospital?
Finally, I worried about the lack of continuity in my mom’s nursing care. Never was a nurse assigned to my mom for more than two days in a row. Just as one expert and caring nurse would get to know my mom’s medical situation, that nurse would disappear. I would see those nurses again, but they were always assigned to other patients. When I asked one of them about it, I got the same helpless look I got regarding sleep disruptions. Continuity would be impossible to ensure all of the time for every patient, but it seems like prioritizing continuity for patients having an extended stay would help both nurses and patients. Was this approach to patient assignment serving some administrative or fiscal function? It certainly wasn’t serving my mom’s best interests.
Our health system is in the midst of a significant transformation, and certainly not just within hospitals. This transformation will require administrators, providers and patients to behave differently. If my experience of the last few weeks is at all typical, it will also require that we look at the ways in which we structure systems and re-think how health care institutions organize themselves. Consumer engagement will be critical to redesigning these systems in ways that put the patient at the center of care.
P.S. My mom was transferred to a rehab facility on April 16, and she is working hard to regain her mobility and recover from this experience. Your good wishes are most appreciated!
It is Washington in April and the last year of the Obama administration and so – not unexpectedly – it has been a major week for health care policy proposals and rule changes; over 2,400 pages worth of proposals and rules that consumer advocates will be wading through for days. Stay tuned for our more in-depth analysis in the coming weeks, but in the meantime, here’s a quick rundown of some long-anticipated policies that rained down this week:
Medicaid Managed Care Regulations: After months of review of proposed rules and comments submitted from 879 stakeholders, the Centers for Medicare and Medicaid Services (CMS) issued a final rule that covers a range of issues including network adequacy and care coordination, disenrollment and appeals, managed long-term services and supports (LTSS), quality improvement and quality rating requirements, medical loss ratios and supplemental hospital payments. This 1,462-page rule is focused on four goals: 1) supporting state efforts on payment and delivery system reforms; 2) strengthening consumer experience of care; 3) strengthening program integrity and 4) aligning rules across coverage programs. The regulations are effective 60 days after the date of publication, with many key provisions going into effect on July 1, 2017 and more provisions phased in over 3 years.
MACRA: The new physician payment system was unveiled this week - a year after Congress approved what was referred to as the "doc fix" bill. CMS announced proposed rules for the “Quality Payment Program,” which gives doctors a choice of two paths, both of which seek to pay them in part based on how well they treat patients. The first path, called the Merit-Based Incentive Payment System (MIPS), would increase or decrease payments in the first year based on how well doctors meet benchmarks on quality, use of electronic health records and costs. The second path, known as advanced alternative payment models, would go even further in shifting towards rewarding quality. In our April 13 post on why consumers should care about MACRA, we emphasized the importance of measures that reflect patient experience and the importance of payment models that make sure providers who care for patients with complex social and medical needs will not be disadvantaged. CMS will accept comments on the proposed rules until June 27, 2016.
Medicaid Services: CMS issued guidance on facilitating access to covered Medicaid services for eligible individuals prior to and after a stay in a correctional institution. Medicaid coverage is important for a successful transition to the community, particularly since many have long-untreated, chronic health conditions, as well as a high incidence of substance use and mental health disorders.
April showers, the old saying goes, bring May flowers. May a thousand Health System Transformation flowers bloom!
For several decades, data has shown a trend toward the concentration of poverty and increasing income inequality in major cities across America. Take New York City for example, a metropolitan area often cited to demonstrate some of the highest gaps in income between wealthy and poor residents in the country. As the wealth gap has continued to grow over time, a distinct correlation between income level and life expectancy has emerged, with higher incomes found to be associated with longer life spans.
Some striking analysis from The Health Inequality Project provides new details on the impact of income inequality on life expectancy. The report found that the difference in life spans between wealthy and poor individuals has rapidly increased from 2001 to 2014. Overall, the wealthiest Americans have experienced about three additional years in life expectancy since 2000, while the poorest Americans have made no substantial gains. On average, men with incomes in the top one percent were also found to live 15 years longer than men with incomes in the lowest one percent. The corresponding life expectancy gap for women is about 10 years.
While the study focused on life expectancy differences based on income rather than race, the disproportionate representation of communities of color in the lowest income cohort gives these findings great significance with respect to racial justice. Income inequality has worsened particularly along racial and ethnic lines where wealth disparities have widened to levels comparable to the Great Depression. In 2013, for example, the average wealth of white households was 13 times higher than that of black households.
Fortunately, the news is not all bad. As explored further in a recent article published in The New York Times, the effect of geography can be a significant mitigating factor when determining life expectancy in the United States, particularly for the poor. For people in the lowest five percent income bracket, life spans varied substantially depending on where they lived. While some parts of the country, including regions within Michigan and Kentucky, continue to show declining life expectancies, in cities like New York, San Francisco and Birmingham, the poorest Americans are actually living longer. For comparison, New York City’s poorest residents are expected to live about six years longer than the poorest residents in Detroit. On the opposite end of the spectrum, the difference in life span when comparing the wealthiest people in these two cities was less than one year.
Lower gaps in life expectancy were found in cities with higher local government spending on social services, higher concentrations of college graduates, and lower incidences of obesity and smoking. These finding suggests that a variety of state and local initiatives to improve health can at least partially offset the effects of low income on life expectancy. The narrowing gaps in life expectancy – despite increasing income inequality – in cities like New York and San Francisco suggest a need for refocused efforts that go beyond access to medical care to also promote health more generally by addressing a wide range of social determinants.
In many ways, health equity is an exercise of distributive justice, where new or existing resources are allocated to help underserved populations achieve the best health outcomes possible, which is why Community Catalyst’s Center for Consumer Engagement in Health Innovation looks broadly towards wide scale system reform in efforts to reduce health disparities in its work on health system transformation.
In the next few weeks, we expect the Centers for Medicare and Medicaid Services (CMS) to release a proposed rule detailing their proposal for how physicians will be paid under the Medicare program. The new rules, authorized by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), will change how Medicare will pay physicians (and certain other providers) starting in 2019.
The current system for physician payment works in a relatively straightforward manner. A physician provides a service (such as an office visit) to a Medicare beneficiary, sends a bill to Medicare, and Medicare pays the physician the defined rate for that service (“fee for service”).
Under the new system, when a physician provides a service to a Medicare beneficiary, Medicare’s payment to the physician will depend on a number of additional factors, such as whether the physician meets certain quality benchmarks or participates in an “Alternative Payment Model,” such as an accountable care organization (ACO).
MACRA creates two payment pathways. The first is the Alternative Payment Model (APM) pathway. A physician can qualify for this pathway by having a certain percentage of payments under alternative payment model arrangements, to be defined by CMS. These alternative payment arrangements require physicians to take on some level of risk for the financial and quality outcomes of their patients’ care. The second is the Merit-based Incentive Payment System (MIPS) pathway, which retains more of the existing fee-for-service structure, but adds in quality incentives and penalties. The two different payment pathways are calibrated in order to push physicians into the APM pathway.
From the consumer perspective, MACRA matters because, if implemented carefully, it can promote more flexible care that is tailored to the needs of patients. And, because Medicare is the 800-pound gorilla in the health care system, MACRA’s payment incentives will likely drive physician and health care organization behavior nationwide. Specifically, by defining which APMs “count” toward the APM pathway participation requirements, MACRA will strongly influence the kinds of payment and care delivery models that are created in this country and define a set of quality measures that physicians need to meet.
While MACRA can drive the move toward “value-based payments,” the push for innovation must be carefully balanced against the need to smooth implementation. From a consumer perspective, the push toward risk-based payments must be balanced with strong consumer protections, and structures for meaningful consumer engagement in the design, implementation and oversight of these payment models. It is also important that the quality measures selected for both the MIPS and APM pathways reflect patient-centered priorities, such as patient experience and patient reported outcomes.
We have been keeping a close eye on MACRA developments. In December of 2015, CMS released a draft of its plan for developing the measures to be used under MIPS. We submitted comments, emphasizing the importance of measures that reflect patient experience and the importance of payment models that make sure providers who care for patients with complex social and medical needs will not be disadvantaged. We will be taking a close look at the forthcoming proposed rule which will be followed by a public comment period, to make sure that it is as consumer-protective as possible (our previous comments on MACRA can be found here). We expect a final rule in November of this year. We encourage Hub readers to keep an eye out for MACRA-related developments, to understand the impacts of this sweeping new program.
The second in our National Minority Health Month blog series.
In late March, the CMS Office of Minority Health released the Mapping Medicare Disparities (MMD) tool, an interactive map that displays differences in chronic disease prevalence and outcomes among Medicare beneficiaries. The tool uses Medicare claims data to present geographic differences down to the county level, searchable by parameters of sex, age, dual eligibility status, and race and ethnicity. This powerful resource can show measures of disease prevalence, Medicare spending, hospital and emergency department utilization, readmission rates, mortality rates and other health outcome measures for up to 18 chronic conditions. Users can compare outcomes between counties, racial and ethnic groups, and in comparison to national and state averages.
I decided to take the MMD Tool for a spin and checked out some of the data from the Boston area. I looked at how Black and White women in Suffolk County compared in terms of diabetes prevalence and emergency department visits. With a few clicks, I found the disturbing, but all too familiar, statistics: in 2014, 22 percent of White women enrolled in Medicare fee-for-service in the county had diabetes compared to 40 percent of Black women. And, the rates of emergency department visits among Black women were 22 percent higher than for White women.
Aside from confirming what we know – that people from racial and ethnic minority communities experience real and significant health disparities – the MMD Tool will help policymakers, researchers, advocates and consumers better understand the nature of these disparities. Most importantly, it can aid in decision-making around how to allocate resources to most effectively improve health equity, a priority area for Community Catalyst’s Center for Consumer Engagement in Health Innovation. Specifically, as we change the way we deliver and pay for care, this treasure trove of data will help us custom build new programs in order to ensure disparities do no persist or worsen in the process.
We encourage Hub readers to take the MMD Tool for a spin!
Please watch this space throughout April as we continue our Minority Health Month blog series.
First in a series throughout the month of April
April is National Minority Health Month, organized under the auspices of the Office of Minority Health (OMH) within the U.S. Department of Health and Human Services. This year's theme, Prevention is Power: Taking Action for Health Equity emphasizes the critical role of prevention in reducing health disparities. As the OMH page states, “It is a call to action, a charge for all of us to unite towards a common goal of improving the health of our communities. Everyone in America should have the chance to live a healthy life, regardless of who they are and where they live.”
Community Catalyst fully embraces this statement. We share a vision in which we all have the knowledge, skills, and resources to carefully consider promoting health equity in the way that we approach our work. We strive to keep a focus on increasing health equity in all of our programmatic work, and this goal is a key stated policy priority of our Center for Consumer Engagement in Health Innovation in its work on health system transformation.
In promoting the message of Minority Health Month throughout April, this blog kicks off a four-week series that will look both at aspects of health disparities as they currently exist and efforts to break down barriers to achieving equitable health outcomes. But before we turn our attention outward in next week’s post, we’d like to share some recent work our own staff has undertaken to look inward in order to further our understanding of ourselves, and of the challenge ahead in this work.
Health equity is understandably a broad concept. It encompasses a range of interactions that individuals have with the health care system, not only within the standard medical model, but also outside of it. Conditions such as racism, unsafe or unreliable housing, poverty and violence are just a few of the many social determinants of health. Because these conditions often persist across generations and have a profound impact on individual health decisions, it is increasingly difficult to conceptualize health equity without first constructing a social justice framework. In unraveling the complexities of these components, we must first look to address the interdependent social processes that influence health and health care delivery.
Last month, the Perception Institute facilitated a training at Community Catalyst to examine the systemic impact of implicit bias and equip staff with the tools to engage in meaningful discussions about the implications those biases have. Implicit biases are automatic associations that are expressed through attitudes and stereotypes, which then influence judgements and discriminatory behavior toward particular groups of people. These perceptions are often expressed separately from our conscious values and intentions. Through a series of exercises, each of us who participated in the training had the opportunity to personally reflect on how subtle and ingrained these biases can be.
Our conversations during the implicit bias training session reinforced the reality that implicit biases continue to have a pervasive impact in our healthcare system. Recently, there has been a flurry of media attention around implicit biases influencing the false beliefs some providers hold about biological differences between Blacks and Whites. There is also an extensive body of research demonstrating that implicit bias is a major source of disparities in delivery, access and the quality of care. The diagram below illustrates implicit bias during clinical encounters as a process for which we can conceptualize how biases influence health outcomes.
Using innovative tools like the Implicit Association Test (IAT) and other variations to detect the types of biases that individuals hold, researchers have frequently observed disparities in provider treatment recommendations.
- A recent study by the University of Virginia identified implicit bias in how medical students made recommendations to treat pain. Not only were black patients routinely under-treated for their pain compared with white patients with the same ailments, but some medical students actually held false beliefs that blacks felt less pain than whites.
- An analysis from the Journal of General Internal Medicine revealed that although providers explicitly indicated that they did not hold patient preferences, IATs consistently demonstrated implicit preferences toward white patients. Additionally, the more implicit bias providers had in favor of white patients, the more likely they were to recommend thrombolysis treatment for white patients while not recommending treatment for black patients.
- Researchers have also found that age bias resulted in an underutilization of breast conservation therapy, an alternative to a modified radical mastectomy for stage I and II breast cancers. Providers were found to recommend mastectomy more frequently for women who were older than 59 years old than for women who were younger than 31 years old. Furthermore, breast reconstruction was recommended for 96 percent of younger patients as opposed to 70 percent of older patients.
- More findings from the American Journal of Public Health determined that providers often expressed a preference for treating heterosexual patients over lesbian women and gay men.
Studies that identify such patient preferences are notable because compelling evidence suggests that negative perceptions of patients often lead to poor provider communication during medical visits, which in turn contribute to experiences of perceived discrimination and poor quality of care.
Compounded with a series of empirical evidence is the historical context of distrust that consumers and providers inevitably confront at various points along the healthcare continuum. Many early principles of medicine originated from the once dominant policies of discrimination that underscored racist, sexist, and heterosexist ideologies. A meaningful intervention must therefore be systemic and cross sectoral.
Understanding the impact of implicit bias is one step towards building and maintaining awareness with the hope that such awareness will lead to accountability and change. Community Catalyst will continue to build upon our internal capacity to understand implicit bias in health care and promote health equity in our outward-facing policy efforts.
Please watch this space throughout April as we continue our Minority Health Month blog series.
This week’s release by the Medicaid and CHIP Payment and Access Commission (MACPAC) of its Report to Congress highlighted the critical importance of Medicaid in the lives of so many low-income Americans. While the report focuses on Medicaid payments to safety-net hospitals and the future of children’s coverage, it was the chapter on integration of behavioral and physical health that particularly caught my eye.
It’s well documented that a disproportionately large number of Medicaid beneficiaries have a behavioral health diagnosis. The MACPAC report details the problems these beneficiaries encounter: siloed behavioral and physical health services lead to beneficiaries having multiple providers in multiple locations which, too often, results in declining health and soaring Medicaid costs. States are actively pursuing new programs to address these problems, but as MACPAC points out, the evidence base for this sort of integration is still in development.
As I read the chapter, I suddenly flashed back to a fascinating visit I made last year to the Coordinated Care Center at the Hennepin County Medical Center in Minneapolis. There, I had the privilege of sitting in on a team meeting made up of doctors, nurses, social workers, a psychologist and a substance use specialist. As the team reviewed its panel of high-need, high-cost patients, I was struck by the way the participants engaged in a conversation that flowed naturally among physical, behavioral and social issues. This holistic – and quite frankly, compassionate – approach has reduced both hospital admissions and unnecessary spending.
So, while MACPAC correctly notes that behavioral and physical health integration alone is not a panacea, our view at the Center for Consumer Engagement in Health Innovation is that continued investment in – and evaluation of – these approaches will move us toward a person-centered culture of care. Getting the details right and focusing on the whole person, as the good folks in Hennepin County are demonstrating, is the key.
This is the last in a series of blogs discussing the policy priorities of the Center for Consumer Engagement in Health Innovation. Previous blogs have discussed health equity, population health, consumer protection, payment models and person-centered care models.
At the launch of our Center for Consumer Engagement in Health Innovation in January 2016, panelist Amy Berman, RN, Senior Program Officer at The John A. Hartford Foundation, described our current health care system as a “pre-Copernican” model, where all of the planets float around the health care system, and the patient is just one of them.
We need to re-align the health care universe, to place the consumer at the center.
To achieve this, we need to actively and meaningfully engage consumers in every aspect of health system transformation. The refrain “nothing about us, without us,” the cornerstone of the disability rights movement, should become the standard in health system redesign.
We were pleased to see that the Institute of Medicine’s report, Vital Signs: Core Metrics for Health and Health Care Progress identified “engaged people,” referring to both individual and community engagement, as one of four key quality domains. “Engaged people,” along with “healthy people,” “care quality” and “care cost” were recommended as the four domains in a “parsimonious” but comprehensive set of health metrics that could be adopted by public and private health programs and organizations.
At the Center, one of our key policy priorities is to advocate for structures for meaningful consumer engagement. We believe that this engagement must happen at three distinct levels – individual, system and policy. In practice, these translate to the need for engagement in the clinical setting, in health care organizations, and in federal and state policymaking.
The table below summarizes the goals of engagement at each of the levels and gives examples of specific policies that can help support these goals.
In the clinical setting, there are a number of tools available to help clinicians and patients work together in the pursuit of better patient engagement in their own care. For example, the Stanford Patient Education Resource Center has developed a Chronic Disease Self Efficacy Scale. There is also a proprietary Patient Activation Measure (PAM 13) and a two-question health confidence measure. We note that the Institute of Medicine’s Vital Signs report considered health literacy to be the best measure of patient engagement. We support the continued adoption of patient engagement activities, including shared decision-making and evidence-based self-management programs, in light of the body of evidence that shows that patients who are more engaged or activated have better health outcomes. There is also some evidence that shows an association with lower cost. We note examples of practices that have used patient engagement as a focal point for care redesign.
At the health care organization level, we support including consumers in governance of organizations and programs. For example, plans participating in Ohio’s dual eligible demonstration project (MyCare Ohio) are required to have a Consumer Advisory Council (CAC) in each region the plan serves. Community Catalyst has supported the work of Ohio Consumer Voice for Integrated Care (OCVIC), a statewide coalition of aging and disability advocates that organizes and educates MyCare Ohio beneficiaries. OCVIC has been heavily involved throughout the MyCare rollout in building a voice for MyCare beneficiaries and advocating for policy changes going forward.
We believe that strong consumer representation like this is critically important in the governance and quality improvement activities of health care organizations, including Accountable Care Organizations and health plans, and that this representation must be supported through training and appropriate levels of funding.
Finally, we believe that consumers must have a seat at policymaking tables. As Massachusetts was developing its dual eligible demonstration, it sought input from diverse consumer perspectives through focus groups and outreach sessions. This process was essential to shaping the design of the state’s care delivery model and demonstration proposal to CMS. At the urging of state disability advocates, Massachusetts established an Implementation Council which was charged with monitoring program access and quality, promoting transparency in program implementation, and assessing Americans with Disabilities Act (ADA) compliance. The council’s members were identified through an open nomination process. At least half of the slots are required to be filled by MassHealth beneficiaries with disabilities or their family members and the remaining slots were filled by representatives of hospital, provider, collective bargaining and advocacy organizations. The Implementation Council holds monthly meetings that are open to the public and has a workgroup structure to examine specific issues such as long-term services and supports.
In addition to formal structures, we advocate for inclusion of consumers at “ad hoc” gatherings and meetings. For example, I was pleased to be able to join a roundtable that Sylvia Burwell, Secretary of HHS, convened in Washington, D.C. in January 2016 to discuss consumer engagement.
The roundtable was a powerful and validating step toward recognizing the importance of steering our nation’s health care onto a more consumer-centered course. We hope to see more such moves at the federal, state and local levels.
At the Center we are dedicated to advancing consumer engagement at all three levels, and to putting the sun back where it belongs: in the center of our Copernican universe.
This post in our Health System Transformation series is an update of the Jan. 26, 2016 blog post titled, “How America’s Social Structures Affect Our Health.” This updated post adds some key policy prescriptions that are central to the vision of Community Catalyst’s new Center for Consumer Engagement in Health Innovation.
In the initial blog post of this series, we mapped out Community Catalyst's policy agenda for Health System Transformation (HST). In order to achieve our goals of better value for our dollars and better health for all, we believe it is necessary to think beyond the delivery of medical services. Often the factors that have the greatest impact on health don’t involve the health care system at all. For example:
- If you did not have a home or a refrigerator to store your insulin, how well would you be able to control your diabetes? Being provided with a safe place to store your medications would be the better solution, compared to waiting until you got so sick from high blood sugars that you needed to be hospitalized.
- If your child’s asthma is made worse by air pollution in your neighborhood or the dust in your home, wouldn’t addressing the living conditions — by the provision of a home air filter or by public health measures to improve regional air quality — be more effective than increasing the number of your child’s medications and trips to the emergency room?
- If a family doesn’t have enough to eat, wouldn’t food be the most important medicine?
Traditionally, the health care system has not taken on these and many other social and environmental factors that contribute to poor health, but we believe that must change. Social determinants of health — which encompass social, environmental and behavioral influences like access to healthy food and water, safe housing, employment/working conditions, gender and culture — play an important role in promoting health and potentially lowering health care costs, and must be addressed by health system transformation efforts.
The County Health Rankings Model included in our report, The Path to a People-Centered System: Next Generation Consumer Health Advocacy, and reproduced below, nicely illustrates the many factors that contribute to health. Furthermore, a substantial body of research, including data compiled in The American Healthcare Paradox and “Leveraging the Social Determinants of Health: What Works?,” demonstrates that higher ratios of social-to-health care spending are associated with better health outcomes.
The U.S. health care system is the most costly in the world, but our population’s health outcomes are worse than those of most other Organization for Economic Cooperation and Development (OECD) countries. A driver behind this gap could be the relative “underspending” on social services compared to medical care: in the U.S., for every dollar spent on health care, only about $0.91 is spent on social services. In comparison, for every dollar spent on health care, OECD countries spend $2 on social services. Increasing spending on social services could help improve health, while decreasing health care costs. Across the country, there have been many examples of forward-looking programs that are working to direct resources to address social determinants of health:
- In Massachusetts, the Medical-Legal Partnership Boston, an interdisciplinary team of health care staff, attorneys and paralegals, provides direct legal assistance to low-income patients, ensuring their basic needs for housing and utilities are met. The impact of their services is significant: by connecting low-income families to utilities, food and housing services, they are able to demonstrate improved health outcomes for the population they serve.
- The Northwest Bronx Community and Clergy Coalition has a grant through the BUILD Health Challenge to work with Montefiore Hospital to address asthma in their community. The partners are working with tenant organizations in the Bronx to rehabilitate “sick” buildings to prevent and treat asthma that is linked to housing conditions.
- Maine Equal Justice Partners (MEJP), a legal aid organization, surveyed 1,000 low-income Maine residents to better understand their needs. The results showed that, by far, the greatest need was housing. Using this data, MEJP successfully advocated for increases in access to ongoing housing subsidies and is continuing to advocate, with the support of a newly-created Affordable Housing Working Group, to ensure greater access to affordable housing and therefore, a healthier population.
There are many more examples of initiatives that can improve the underlying health status of populations, but too often they lack adequate and stable funding. To address this problem, as health advocates, we need to broaden our partnerships to include organizations that work to secure affordable housing, promote access to healthy food, and address the other social and public health needs of a community. We also need to advance policies that can build support for addressing these issues right into the health care system, such as by:
- Ensuring that hospital community benefits programs (a requirement of non-profit hospitals in order to earn their tax-exempt status) help address the identified needs of their communities, including social supports and housing.
- Structuring new models of integrated health care delivery to include community-based organizations, who can then share in cost savings generated by achieving better health, as New Jersey has done with its Medicaid Accountable Care Organization model.
- Investing in organizations that assess patients’ needs and connect them to social support services in the community. One excellent example is Health Leads, which allows health care providers to prescribe basic resources like food and heat just as they do medications, then refers patients to advocates who help fill the prescriptions, working side-by-side with patients to connect them to the additional prescribed resources.
- Encouraging adequate payments for the housing, transportation, and social support services that people need to improve their health and ultimately reduce costs.
- Ensuring that payment models encourage prevention. One way to do this is to make sure that organizations delivering care are evaluated based on how well they are improving the health of the communities they serve, through the use of quality measures that assess community/population health. This can also be done by designing payment models like the all-payer model in Maryland that gives a fixed budget to hospitals, so that hospitals benefit if they keep people healthy.
- Directly supporting prevention and wellness activities. Massachusetts, as part of its 2012 comprehensive health care cost containment law, levied assessments on plans and providers to create a Prevention and Wellness Trust Fund to support population health interventions.
We have the most costly health care system in the world, but we don't get results commensurate with our level of spending. At the same time, relative to other countries we spend much less on addressing the social and environmental conditions that can lead to poor health. Addressing this imbalance must figure prominently in our Health System Transformation agenda if we are to be successful at improving the value we get for our health care dollars.
Note: Lauren Banks, was a contributing author to the earlier version of this blog post
This guest blog by Marcus Escobedo, Senior Program Officer at The John A. Hartford Foundation, was originally published February 18 in the foundation’s Health AGEnda blog.
To fulfill our mission of improving the care of older adults, it is critical to know what is working—and what is not—when it comes to health care for the nation’s growing number of older people. That is why The John A. Hartford Foundation supported a new report from the Dartmouth Atlas Project titled Our Parents, Ourselves: Health Care for an Aging Population.
“This report is really about success,” says Terry Fulmer, PhD, RN, FAAN, president of The John A. Hartford Foundation. “Life expectancy has almost doubled since the 1900s, from 40 years to 80 years today. The number of adults over age 65 also is projected to almost double in the coming decades, from 43.1 million in 2012 to 83.7 million by 2050. This is truly remarkable and something to celebrate. However, we now need to achieve the same level of success in meeting the care needs of this growing aging population.”
The Dartmouth Atlas report should help. In fact it should be required reading for health system leaders, advocates, and policymakers. It can help them understand the composition of Medicare beneficiaries in their communities, those beneficiaries’ experience of care, and whether they are receiving evidence-based health care along a number of dimensions directly meaningful to older adults and their families. For example, the report looks at the number of unique clinicians that patients see on average, as well as end-of-life treatments, such as late hospice referral and the number of days spent in intensive care.
Based on 2012 Medicare data, this report card is helpful because it breaks down by geographic region where the United States is making progress in patient-centered care for older adults and where improvements are needed. It also breaks new ground, sharing data that has never been public before, including:
- Older adults with two or more chronic conditions spent 33 days—or just over one month of the year—in contact with the health care system (in the hospital, at a doctor’s office, or at a lab visit).
- The average Medicare beneficiary was in contact with the health care system on 17 days. Looking at the data by geographic region, the range spanned from 10.2 days in Lebanon, N.H., to 24.9 days in East Long Island, N.Y.
- 18.4 percent of older adults filled at least one prescription for medication identified as high-risk by the National Committee for Quality Assurance. Again, the rates varied greatly depending on geographic region, from 9.8 percent in Rochester, Minn., to 29.1 percent in Monroe, La. Progress in this area is being made, as the percentage of Medicare beneficiaries who filled at least one high-risk medication prescription dropped 43 percent from 2006. But more work is needed to eliminate this dangerous practice.
- Preventable hospital readmissions have declined 23 percent, from 5.5 percent of Medicare beneficiaries in 2003 to 4.2 percent in 2012. Again, since these are by definition “preventable” readmissions, we must keep working to lower the rate to as close to zero as possible.
The John A. Hartford Foundation is very proud to support the work of the Dartmouth Atlas Project, and our commitment to patient-centered and patient-directed care for all older adults is only strengthened after reading about the large variations in quality of care that currently exist depending on where people live. This report describes both the real and potential care needs that we must address. The discussion we need to have in light of this eye-opening report must center on the kind of care that older adults want, need, and how they want that care delivered.
The John A. Hartford Foundation was one of the earliest supporters of Dartmouth’s work looking at regional variation in the 1980s. The resulting Dartmouth Atlas Project underscores that big data can make a big difference in our ability to improve the care of older adults. The Atlas provides a huge service to everyone who does research, makes policy, or cares about the health of older people. It is a great tool that we know our grantees and the field will find helpful.
Download and share Our Parents, Ourselves: Health Care for an Aging Population so that it will be referenced and used by hospitals, community providers, and others in their field to make important and needed changes in the care we deliver to older people in this country.
For more information, including links to The John A. Hartford Foundation’s full press release and key data tables, visit the foundation’s Our Parents, Ourselves page.
Senior Program Officer, The John A. Hartford Foundation
This is the next post in an inaugural blog series outlining the policy priorities of the Center for Consumer Engagement in Health Innovation. Each blog takes a deep dive into one of the six areas we believe must be addressed to achieve better care, better value and better health.
Transforming the way we deliver and pay for care holds the promise of better health outcomes and improved quality of life for the tens of millions of Americans who find themselves falling through the cracks of our disorganized and fragmented health care system. Among these populations are frail older adults, people with disabilities, those with multiple chronic conditions, children with special health care needs and people with mental illness or substance use disorders. Spurred by the Affordable Care Act, there are myriad demonstration projects, pilot programs and initiatives underway to achieve better care, better health and better value.
While the promise health system transformation initiatives may offer is considerable, so too are the risks to consumers. For some, the specter of 1990s-style managed care looms large, and any attempt to introduce payment reforms, especially changes that impact the most vulnerable populations, is viewed with great suspicion. The fear – particularly with any initiative that puts providers at risk – is that an inherent incentive is created to ration care or avoid patients who have complex care needs in order to reap greater profits. Others worry the use of limited networks (as a tool for achieving cost savings) will place unreasonable limits on choice or force patients to separate from providers with whom they have ongoing long-term relationships.
These are real concerns. It is incumbent on policymakers designing new initiatives to ensure that consumers enrolled in new programs are protected against plan or provider misconduct, as well as against unjust restrictions on choice. A traditional way of creating these protections is crafting a robust set of grievance and appeals procedures. And, to be sure, these rights are essential. These procedures must be easy to understand and utilize, there must be fair hearing protections, and plans or providers must continue to provide services to consumers throughout the course of an appeals process.
But building consumer protections into health system transformation is so much more, and in some cases requires advocacy around issues not typically seen as being part of the consumer “beat.” These include:
Payment: While normally seen as the province of plans and providers, payment rates – that is, getting them right – is fundamentally a consumer protection issue. Put simply, if payment rates are inadequate, the incentive to ration care is heightened. And the consumers most at risk are those with the greatest needs since they also account for the greatest costs. That’s why, to cite one example, we are pleased CMS is fine-tuning the risk adjustment system for plans participating in the demonstration projects aimed at improving care for those with both Medicare and Medicaid, often referred to as “dual eligibles.” A fair payment structure that takes into account the needs of the beneficiaries being served, especially those with the greatest needs, is truly the most foundational consumer protection.
Quality Measurement: Measuring what matters most to consumers is the way to get the most “bang for the buck” and serves to mitigate potentially negative effects of health system transformation. Among the measures that matter most is care consistent with patient’s goals, values and preferences. We also think the measures outlined in the Institute of Medicine’s Vital Signs report capture many key domains of health.
Meaningful Consumer Engagement: Ensuring a meaningful role for consumers, family members and advocates on advisory councils, for example, serves as a further means of protecting consumers. These types of bodies can serve as an early-warning system for problems arising in new systems of care, and provide the essential consumer-management feedback loop needed for ongoing service improvement.
Transparency: New payment and delivery systems require new levels of transparency with regard to design, implementation and reporting of outcomes. Reporting must be consumer-oriented so that results are understandable and data is offered in ways that reveal progress, or lack thereof, on achieving health equity. Additionally, beneficiaries must be fully informed and engaged on their choices, for example, to be part of an Accountable Care Organization or a Patient-Centered Medical Home.
It’s not an accident that these consumer protection priorities largely track the Center’s policy agenda. As our health system shifts away from fee-for-service and toward more risk-based payment arrangements for providers, our central task is to ensure that this transformation occurs in a way which benefits consumers, particularly those who are most vulnerable.
Join us on this journey!
There is increasing acknowledgement nationwide that the social and economic conditions in which people live play an enormous role in health. Clinicians and hospitals cannot make their patients healthier by solely focusing on what happens inside the clinic walls. Rather, improving health in a significant way means forging collaborations between clinicians and community-based organizations that address those social and economic conditions. The recent initiative announced by the Center for Medicare and Medicaid Innovation to establish Accountable Health Communities by funding clinical-community collaborations is evidence of the importance that policymakers are at long last attaching to these conditions.
This new emphasis is the reason we’re so excited about a new study from our friends at the Maryland Citizens Health Initiative (MCHI), a long-time Community Catalyst partner. Health Policy Hub readers may recall a guest blog we published last March about the steps MCHI has taken to transition their work to health system transformation. Since that post, MCHI has continued to expand its health system transformation work, and has focused on exploring programs that create collaborations between hospitals and faith/community-based organizations.
Specifically, MCHI is piloting a Faith Community Health Network in Maryland. The model is based on a program in Memphis, TN – the Congregational Health Network developed by Methodist Healthcare – in which the local hospital system and faith communities work together to keep congregants and the local community healthier. In Maryland, MCHI is working with LifeBridge Health to pilot a similar program in three LifeBridge hospitals, one urban, one rural, and one suburban. With a successful pilot, MCHI is hoping that this model can be refined and adopted by other hospitals in Maryland.
To inform their work, MCHI conducted a study—developed with support from Community Catalyst and in partnership with the Urban Institute Health Policy Center—that examines examples of collaborations between hospitals and faith/community-based organizations. The paper identifies five particular programs with proven track records. In one such project - Project RED (Re-Engineered Discharge) - adult patients in a Boston hospital were given access to Discharge Educators, who could be congregational or other volunteers who have received specialized training. The Discharge Educators followed a step-by-step program prior to discharge to be sure that both the patient and the physician understood the patient’s condition and what the patient should do when s/he returned home. Participants in Project RED had a 33 percent lower rate of emergency room (ER) visits and a 28 percent lower rate of readmission within 30 days of discharge as compared to patients receiving typical discharge care.
For more information about Project RED and the other four programs discussed in the paper, we invite advocates and others to take a look at the research MCHI has compiled, and to watch this space for updates on how advocates in Maryland and other states are working to address the social and economic determinants of health.
As we continue the conversation on what Community Catalyst believes are the key areas advocates should focus in health system transformation, up next on our list is: creating a person-centered culture of care.
The health system can be a challenge for anyone to navigate, particularly for those with frailties, multiple chronic conditions or complex disabilities. On average, Medicare beneficiaries with multiple chronic conditions have 13 or more physician visits, are more likely to visit the emergency room, and fill 49 prescriptions per year. Keeping track of doctors’ visits, medication changes, and provider recommendations is no simple task, making it easy for something to fall through the cracks. Health care providers must work as a team, with the patient at the center, in order to achieve safer and more effective care that is in line with patients’ goals, values and preferences.
A simple concept, and yet in practice it can be challenging to implement. For example, findings from a new survey conducted in collaboration with the Association for Community-Affiliated Plans revealed that many of the health plans serving Medicare/Medicaid beneficiaries under the Financial Alignment Initiative found it challenging to engage Primary Care Providers in the care team and found operational issues in the system, such as implementing an effective IT system that enables communication among care team members, as a barrier to coordinating care for their members. These findings were reinforced by a recent survey of beneficiaries enrolled in MyCare Ohio, the state’s dual eligible demonstration project. The survey uncovered many holes in the demonstration plans’ care coordination models, including that many consumers are not part of their own care planning process or that their care team did not include people they wanted.
To make care better and safer for patients, person-centered care has to be at the heart of what we do.
In order to improve care and reduce costs, health care providers, plans and policymakers must work toward the integration of physical and behavioral health services with community supports and services. The experience of health care organizations serving some of the most complex populations (patients who are dually eligible for Medicare and Medicaid), has helped identify core components for this kind of person-centered care:
- Timely, Comprehensive Health Risk Assessments
- Assessments should include functional status information, cultural and linguistic preferences and information about caregiver roles in order to create an individualized plan of care.
- Incorporation of a Patient Preferences into the Plan of Care
- A care plan must be developed in accordance with the patient’s values, goals and preferences, and with the patient at the center of the conversation. Care shaped by patient’s goals and preferences is important at every point in the care continuum but is particularly critical in palliative and end-of-life care.
- Seamless Care Transitions
- Transitions should be safe, seamless, and person-centered across care settings. When preparing for discharge from the hospital, for example, the patient must be central to the planning process. Instructions must be clear and understandable to the patient and family caregiver (where applicable). The discharge plan must be communicated to other members of the patient’s care team, and appropriate post-discharge care should be arranged for the patient.
- Culturally Competent Care Teams
- The care team should include diverse providers that understand the needs and preferences of the person being served. Aside from clinical providers, team members could include long-term service and supports providers, peer recovery counselors and/or community health workers.
We believe that these are just some of the key elements of achieving a person-centered culture of care, especially for three vulnerable populations: dual Medicare/Medicaid beneficiaries, people with substance use disorders and children and youth with special health care needs. Other considerations include building a strong payment structure that supports these elements, meaningful consumer engagement in the design, implementation, and evaluation of programs, and patient engagement in clinical decision making and care.
We know that putting these pieces of the puzzle together is not going to happen overnight, but there is a better way to better health, and consumers and their advocates have a critical role in pushing for structural changes that will get us there. We look forward to working with you on these important issues as we kick off our new Center for Consumer Engagement in Health Innovation.
Why Is This News?
2016 opened with yet another vote by the Republican controlled Congress to repeal the ACA coupled with more muttering about a replace agenda — we really really mean it this time. Maybe by the time we are celebrating the ACA’s 6th birthday we will see just how Congress proposed to avoid snatching coverage away from millions who now have it thanks to the ACA.
Truly the repeal rhetoric has long since passed the point of being a dead end. You can see that in the fact that conservative firebrand Gov. Matt Bevin (R-Kentucky) quickly backed away from his promise to repeal his state’s Medicaid expansion once it became clear that he might actually be in a position to carry it out. Recently he announced his intention to seek a waiver of some Medicaid rules while continuing to operate the program as is while negotiations proceed with CMS.
Resolutions for 2016
Instead of another year of empty rhetoric and gridlock, how about these for New Year’s resolutions for 2016:
Close the Medicaid Coverage Gap
A number of states, including LA, AL, NE, SD, and WY are having serious discussions about how to leverage federal funds to bring health and economic benefits to their state. Other states should not only join those debates but actually act to expand coverage for low income people. Given the demonstrated benefits of closing the gap, it is practically a crime not to do it.
Let’s Get Serious About Improving Affordability
Although the ACA has boosted access to health care and provided financial protection to millions of people, health care affordability remains a pressing problem that is in no way limited to people who get their coverage through the state marketplaces and Healthcare.gov. The affordability issue is multi-dimensional, but here are a few areas crying out for action:
- Premiums — The ACA does a lot to make premiums more affordable for those who lack employer sponsored insurance, but insurance still remains out of reach for too many.
- Out-of-pocket costs — Even those who have health insurance can often struggle to meet their cost-sharing obligations and face severe economic hardship as a result. Although in no way a complete solution, one place to start to tackle out-of-pocket costs is for states to address the problem of surprise out-of-network bills, which factor into a large share of the medical debt problems that people face.
- High drug prices — The rapidly escalating cost of prescription drugs contributes to both unaffordable premiums and to high out-of-pocket costs and medical debt. In 2016, both Congress and the states should take action to limit out-of-pocket costs for drugs, especially for those with chronic conditions, and also to rein in excessive drug prices for old and new medicines alike.
Reduce Gun Violence
Although Congressional Democrats were unable to lift the CDC research ban on the health implications of America’s gun epidemic during the budget debate, President Obama started the year off right with a commitment to use executive authority to expand background checks in gun sales .Governor Jay Inslee of Washington followed right behind. Already nearly 150 people in the U.S. have died in 2016 from gun related violence. If Congress and other states follow the president’s lead, we could reduce this tragic loss of life.
Here’s to a healthier 2016.
Consumer advocates across the country are increasingly developing expertise in payment reform and new models for health care delivery. The Center for Consumer Engagement in Health Innovation is eager to facilitate the sharing of information between advocates, particularly regarding ways they can participate in conversations in their states about health system transformation. We are, therefore, delighted to share the comprehensive recommendations on Medicaid Accountable Care Organizations (ACOs) developed by Health Care For All (HCFA) in Massachusetts. HCFA submitted these recommendations to MassHealth(Massachusetts’ Medicaid program) in December 2015.*
ACOs represent a new way to pay for and organize health care delivery by bringing together doctors, hospitals and other health care providers to provide coordinated, high quality care to their patients. States across the country are incentivizing the development of ACOs, and while these new structures do represent potential opportunities to improve care, there are also risks. Advocates must quickly get up to speed on both the opportunities and challenges presented by ACOs and identify opportunities to ensure robust consumer protections. HCFA’s recommendations may be helpful to advocates in many states developing and incentivizing ACOs and other new models. In their extensive comments HCFA emphasized:
- Member Protections
- Member Engagement
- Comprehensive Data Collection and Public Reporting
- Access to Services
- Population Health and Prevention
- Financial Incentives and Payment Methodologies
We encourage you to take a close look at HCFA’s excellent work.
Dr. Ann Hwang, Director of the Center for Consumer Engagement in Health Innovation, also provided brief testimony at a public hearing on Jan. 6, 2016 before the Massachusetts Health Policy Commission (HPC). The HPC, an independent state agency that develops policy to reduce health care cost growth and improve the quality of care, is presently developing standards for voluntary ACO certification for private sector providers in Massachusetts.
ACOs and other payment and delivery reform models provide opportunities to fundamentally transform the way health care is delivered. However, advocates must shape these new models so that they deliver high quality, high value, person-centered care, improve access to needed services, and lead to healthier communities. We hope these tools will help advocates across the country to make the most of these emerging opportunities.
*Similar comments werer submitted to the Health Policy Commission by HCFA.
Over the last few years, states have witnessed widespread failings within agencies charged with overseeing the well-being of children in foster care. And in many states, the tragedies have placed increased attention on how we care for foster children, who are among the most vulnerable members of a community. State and local agencies are struggling to show the public that they are able to provide quality care and safe homes for children in foster care and this extends to the health care they receive.
The unmet health needs of children and youth in foster care are rooted in their complex trauma histories and are compounded by the barriers to appropriate health services. Children and youth in foster care need more intensive and comprehensive care due to the additional challenges they face in physical and mental health, development, oral health and psychosocial adjustment. The American Academy of Pediatrics (AAP) is now weighing in on the issue, highlighting the need for more robust and deliberate attention to these children in the health care home.
The foster care population has demonstrated a significant disparity in health outcomes. According to the American Academy of Pediatrics’ 2015 policy statement:
- 30 to 80 percent of children come into foster care with at least one medical problem
- One-third of children in foster care have a chronic illness
- Up to 80 percent of children and adolescents enter foster care with a significant mental health need
- Nearly 40 percent of children in foster care have significant oral health issues
- 60 percent of children under age 5 in foster care have developmental health issues.
The data illustrates a clear need to reevaluate the health care practices when working with children and youth in foster care and to rethink how to provide high quality care.
One of the largest barriers to quality and comprehensive health care for these children is the lack of care coordination. The transient nature of life as a child in foster care and the shared and transferred authority among caregivers and professionals leads to fragmented care. Additionally, the health care services they receive are often reactive instead of preventive.
As the health industry begins to rethink delivery systems and quality of care, there is an opportunity to change our approach and provide more holistic care for children in the foster care system. One part of quality health care for children and youth in foster care is creating a “foster care-friendly office.” Ensuring that pediatricians and caregivers have a comprehensive understanding of childhood trauma is incredibly important and all of the adults in the child’s life need to focus on providing a trauma-informed environment. Additionally, pediatricians should be using appointments to screen for signs of child abuse or neglect as this small adjustment has the potential for positive changes for the children.
Advocates can address these barriers by calling change in the training and education of our pediatricians and caregivers. Additionally, advocates can partner with child-focused agencies that support the needs of foster children, educating them on the importance of the provider visit and important screenings required by Medicaid.
As advocates shift the conversation to health system transformation and delivery system reform, we should not lose sight of the critical needs of children experiencing trauma. Advocating for comprehensive training, care coordination and active communication between caregivers, pediatricians and professionals will help improve the health care services for children and youth in foster care.
-Katherine Fukumoto, Intern, New England Alliance for Children's Health
In a recent blog we shared reflections on our health equity journey and identified health system transformation (HST) as the next frontier of health care advocacy. Promoting health equity is an organizational priority at Community Catalyst and one of the fundamental pillars of our HST policy agenda outlined in our initial blog post in this series. While we believe a health equity lens must be a part of all of our work, bringing that focus to HST deserves special attention because of both the opportunity and the risk. On the one hand, changing how we finance and deliver care creates a golden opportunity to tackle disparities in health care and health. On the other hand, if those efforts don’t focus on addressing health equity, health disparities are likely to persist or widen as system reform unfolds.
When we use the term “health equity,” we’re speaking of a society in which everyone has a fair opportunity to achieve their full health potential. Advocates need to be particularly sensitive to potential harms to people with greater — or different — health care needs as some new policies may have differential impacts on different populations. For instance, some policies may lower costs for some while raising them for others, or they may have a negative health impact on some but not on others. In our work to promote health equity, Community Catalyst is exploring the following areas:
As providers are increasingly placed at risk for the cost of care, risk-adjustment becomes critical to ensure that there is not an incentive to avoid or under-treat sicker or harder to treat populations. While the need to adjust payment based on clinical factors is widely accepted, we have begun looking into risk-adjustment based on population health measures such as socioeconomic status (SES) that also address non-clinical factors that impact cost and health outcomes. People in lower socioeconomic brackets tend to face greater challenges maintaining their health and are more likely to require expensive interventions or have adverse outcomes. Without SES risk-adjustment, providers who serve lower SES patients have a significant amount of unaccounted risk and fewer resources to provide care because of unfairly designed incentive payments. Conversely, providers giving an identical level of care to higher SES patients will show better results and receive an unfair advantage in payments.
2. Health Data Collection
Health data collection policies that do not stratify data by race, ethnicity, primary language, and gender identity and sexual orientation lack the detail and information providers, patients, advocates and the public need to understand and address health disparities. Inadequate health data can mask unique patient and population needs and undermine effective interventions. Consumer advocates, such as the Data Equity Legislative Coalition in Oregon, are building support for strategies that improve data collection policies, and Community Catalyst is working to collect and share those strategies with advocates and policymakers across the country
3. Community-Based Providers
As the health system evolves to serve individuals with a variety of physical, behavioral, social and economic needs, we need to ensure that the health care workforce is also evolving to ensure that individuals receive appropriate, culturally competent care. We believe that expanding the role of Community Health Workers within multidisciplinary care teams and as part of population health interventions can facilitate the effective provision of services and make quality health more accessible and equitable.
4. Cultural Competence and Implicit Bias
Community Catalyst is examining proactive approaches at the policy, delivery system and individual levels for improving cultural competence and reducing implicit bias in health care delivery. Community Catalyst has been promoting networks with culturally and linguistically competent providers and urging emerging alternative payment models to ensure that individuals are guaranteed a choice of providers who speak and understand their culture and language. In recent years, substantial attention has been paid to the possibility that implicit bias among health professionals contributes to health disparities. Community Catalyst is exploring the role implicit bias plays in perpetuating health disparities in treatment outcomes and opportunities to incorporate quality metrics that can assess implicit bias in health care and create incentives and support systems to reward providers who undergo implicit bias trainings.
5. Population Health
We identified poor population health as a principle driver of poor value in our health care system. In an effort to address this driver, population health is prioritized in our HST agenda, and we are working to promote programs and policies that aim to redirect resources to address major population health determinants beyond the delivery of medical care, such as education, the built environment and housing.
As we move forward in this new era of health care reform, these health equity priorities are meant to guide consumers and their advocates towards a path that will transform how we pay for and deliver care to the most vulnerable populations. In the coming week and months, we will drill down on each of the areas highlighted above and examine the best ways to achieve the promise of better care, better value and better health.
In a blog two weeks ago, we sketched out a multi-part agenda addressing what Community Catalyst believes are the key areas on which consumer advocates should focus in the midst of the current changes in the organization of health services. This week and in the weeks ahead, we will take a little closer look at each element of that agenda, starting with payment reform.
As consumer advocates approach the topic of payment reform we should bear in mind the following adages:
"Every system is perfectly designed to achieve exactly the results it gets."
--Don Berwick, founder of the Institute for Healthcare Improvement and former administrator of the Center for Medicare and Medicaid Services (CMS)
"Insanity: doing the same thing over and over again and expecting different results"
--Albert Einstein, Nobel prize-winning physicist, philosopher and humanitarian
"You get what you pay for."
In other words, if we want different results from our health care system, we have to change the way we pay for health care goods and services.
The development of a pro-consumer agenda on payment reform requires us to look at the issue from three distinct points of view: What is that we are trying to achieve? What is it that we are worried about? What are the available opportunities to move the system forward?
What are we trying to achieve through payment reform?
The goal of consumer advocacy around payment should be to maximize the potential benefits of new payment approaches while minimizing the downside risks. At the same time, consumer groups are not operating in a vacuum. The best way to enter into the debate will be to identify promising opportunities as they unfold in the states, as well as in Washington.
To maximize the benefits of payment reform we should identify and seek to rectify the key weaknesses in the current financing system that relies mainly on fee-for-service (FFS) reimbursement. (Note, this continues to be true notwithstanding the spread of "managed care," since most providers continue to be paid substantially on a fee-for-service basis.)
Those weaknesses are:
- Too much focus on treatment of discreet episodes of acute illness without adequate attention to management of increasingly prevalent chronic conditions and disabilities
- Unequal treatment and outcomes for low-income populations, racial and ethnic minorities and other historically marginalized groups
- Over-reliance on heroic medical interventions (too often in the last stages of life when there is little left to be gained) and underinvestment in interventions to prevent illness, including addressing the social determinants of health
- High levels of spending on health care services relative to other advanced industrial countries without a concomitant improvement in outcomes
What are we concerned about?
Reversing the financial incentives inherent in FFS does not automatically bring about the results we are seeking. Ironically, the very populations who have the most to gain from a shift away from FFS also have a lot to lose if financial incentives are not carefully constructed. That's because it may be easier for provider systems subject to cost and quality targets to meet those goals by avoiding or under-serving high need/high cost patients rather than by reengineering care processes.
What is the opportunity?
The ACA accelerated a movement to payment reform that was already underway prior to passage. Through the creation and funding of the Center for Medicare and Medicaid Innovation, CMS has been testing new models of payment and care delivery. More recently, HHS has adopted a goal of shifting 90 percent of Medicare FFS payments "from volume to value" by the end of 2018. This emphasis on payment reform is turning Medicare into an engine of reform. Other initiatives, including the State Innovation Model grants (SIM) and Medicaid Delivery System Reform Incentive Payment (DSRIP) waivers are increasingly bringing states into the act. Changes in how Medicare pays physicians, adopted as part of the legislation replacing the Medicare Sustainable Growth Rate formula, are likely to add yet more momentum to the shift because under the new formula, physicians' ability to get pay increases will be directly tied to their participation in "Alternative Payment Models" that are accepting financial risk.
Toward a pro-consumer agenda
Relatively speaking, altering the incentives of FFS is the easy part. HHS has identified a continuum of payment reforms starting with enhanced payments for care-coordination at one end of the spectrum, and proceeding to creating fully capitated integrated delivery systems responsible for a defined population of patients.
Making sure that new financial incentives achieve their intended purpose is much more challenging. To realize the benefits of payment reform, we must do three key things:
First, we must tie financial incentives directly to improvements in outcomes with particular focus on improving care for high-need/high-cost populations, reducing health disparities and adjusting payments to recognize the greater needs in low-income communities. The failure to recognize that caring for low-income groups presents challenges not fully captured in clinical risk adjustment methods is more likely to undermine the delivery system for disadvantaged groups than it is to improve it. This problem has been observed in the operation of Medicare's Readmission Reduction Program (and CMS has recently acknowledged that its system of risk-adjustment was underpaying Medicare Advantage plans with a high proportion of enrollees eligible for both Medicare and Medicaid).
Second, we must also capture a portion of current spending on medical care and redirect those resources to address the social determinants of health. Mechanisms for achieving this include hospital community benefits programs, assessment on payers or providers such as the Prevention and Wellness Trust Fund in Massachusetts, or engaging communities in allocating a portion of any shared savings realized by the health care system to meet needs the community itself identifies.
Finally, we cannot ignore excessively high prices. With respect to aggregate system savings, the shift along the spectrum toward capitation will reduce the incentive to boost the overall volume of services, but high unit prices will remain a significant issue that require consumer activism. Two places in particular merit close attention from consumer advocates because the prices paid in the US outstrip payments in other countries. One of these areas is prescription drugs where US consumers pay more than people in other countries for the very same product. Another is hospital outpatient charges. This has become a significant problem as the volume of outpatient services has increased, particularly as hospitals continue to acquire physician practices.
There is a lot of momentum behind payment reform. Because the current arrangements lead to excessive cost relative to outcomes and fail to meet the needs of the most vulnerable populations, consumers should welcome rather than seek to obstruct this shift. At the same time, vigorous consumer advocacy is urgently needed to ensure that the benefits of payment reform are realized and the pitfalls avoided.
Obviously much more detail is needed in order to create an actionable policy agenda. But for now it is important to emphasize that while changing financial incentives are necessary, they alone cannot do the work of positive system transformation. Changes in payment must be accompanied by:
- structural changes to promote team-based care
- meaningful consumer engagement
- better, more person-centered and outcomes-based quality measurement
- robust consumer-protections, including support for complaint resolution and easy-to-navigate appeal rights to guard against under-service, and
- proactive efforts to advance health equity such as expanding data collection and promoting a culturally competent workforce.
These topics will be taken up in future blogs.
The Dual Agenda, the bi-weekly newsletter of our Voices for Better Health project, periodically features “Eldercare Voices” guest columns, sharing contributions from providers or researchers directly involved in improving care delivery to older adults. This week’s column, Affordable Senior Housing and Services: A Coordinated Approach to Serving Vulnerable Older Adults, is from Robyn I. Stone, Ph.D., Executive Director of the LeadingAge Center for Applied Research and Senior Vice President of Research at LeadingAge. Dr. Stone shares exciting progress being made in forging partnerships between senior housing facilities and health organizations, with significant implications for health system transformation efforts. We know that where one lives plays a large role in health, both in access to services and in a variety of upstream social determinants of health. The cutting edge work described in this piece highlights the opportunities to deliver coordinated care and services, with a meaningful role played by service coordinators in affordable senior housing facilities, helping foster good health while promoting health equity through culturally competent relationships with residents.
Affordable Senior Housing and Services: A Coordinated Approach to Serving Vulnerable Older Adults
Guest contributor Robyn I. Stone, Ph.D.
Executive Director, LeadingAge Center for Applied Research
An estimated two million older adults currently live in publicly subsidized housing properties located in urban, suburban and rural communities nationwide. Findings from a recent federally-funded study of affordable senior housing properties in 12 jurisdictions across the country, conducted by researchers at the LeadingAge Center for Applied Research (CFAR) and the Lewin Group, indicate that elderly residents of low-income housing properties have more chronic conditions, take more medications, are more functionally disabled and have higher emergency department (ED) and hospital visits than their peers living in the community. Approximately 70 percent of these elderly residents are dually eligible Medicare and Medicaid beneficiaries, underscoring their high-risk status and suggesting that publicly subsidized housing may serve as a locus for better management and coordination of services for vulnerable older adults.
Multiple efforts are underway at the federal and state levels, and in the private sector, to reform our health and long-term care delivery systems to better address the country’s care needs, particularly among vulnerable populations. These efforts focus on lowering Medicare and Medicaid expenditures by providing timely preventive care; improving care coordination and service integration; reducing over-utilization; and providing overall population health management at the community level.
The current reform climate, focused on transformation of our health care system, provides a unique opportunity for senior housing/health care organization partnerships to achieve common goals. Since residents of affordable senior housing communities are an ideal demographic for implementing population-based health reforms, they present especially conducive opportunities for the forging of such partnerships.
Continue reading this edition of Elder Care Voices here.
To mark Older Americans Month, the Voices for Better Health project has debuted a new video highlighting an important strategy to improve the health and well-being of vulnerable older adults. “Building Bridges to Better Health” tells the story of an innovative collaboration between consumer advocates and providers to infuse geriatrics best practices into the Demonstration Projects for people with both Medicare and Medicaid (dual eligibles).
Working nationally and with Voices for Better Health state partners, this powerful partnership draws on the expertise of leaders in the geriatrics community – physicians, gerontologists, nurses, social workers and other providers and researchers – sharing best practices to improve efficiency, quality and outcomes in the demonstration projects. This collaboration has increased the effectiveness of state advocacy efforts around these demonstrations. With people of color making up a disproportionately large percentage of the dually eligible population, we also see this work as helping to build another important bridge – to health equity for all.
While “Building Bridges” focuses on the dual demonstration projects, it affirms that breaking down silos and strengthening alliances with providers is an indispensable approach to creating a path to a people-centered health system, both for older Americans, and those of all ages.
In July, the Ocean State became the thirteenth state to sign a Memorandum of Understanding (MOU) with the Centers for Medicare and Medicaid Services (CMS) to move forward with integrating services and financing for its Medicare-Medicaid population (dual eligible). While many challenges have surfaced with the twelve demonstrations already underway, we see some improvements in this MOU. For instance, the Rhode Island MOU:
- includes the strongest provisions of any MOU to promote rebalancing from nursing homes to community care
- is the only MOU that, from the start, offers protections in the form of risk corridors for all three years
- contains strong policies on assisting enrollees with transitions between care settings.
Still, as with the other ongoing demonstration projects, “the devil is in the details.” And there are still a lot of details to get right for Rhode Island, as outlined in this fact sheet. Rhode Island advocates are hard at work nailing down these details, including ensuring that enrollment goes smoothly and that older adult enrollees receive geriatric-competent care, as our state partners emphasized in a recent Op-Ed in the Providence Journal. These details will be part of a three-way contract which is currently under negotiation between CMS, the State and the participating health plan (Neighborhood Health Plan of Rhode Island). Most of all, their work ensures that consumers and their advocates are at the table as these decisions are being made.
As we’ve learned over the past two years, getting these demonstrations right takes time, vigilance and course corrections. The RI MOU signifies a cautious step in the right direction. But the hard work starts now. The readiness review process and details of the three-way contract will be important to watch. As with any new health system transformation initiative, ongoing transparent collaboration with consumers and their advocates will be vital to getting it right.
This is the first in a blog series outlining Community Catalyst’s policy priorities for Health System Transformation. Each subsequent blog will take a deeper dive into one of the six areas we believe must be addressed to achieve better care, better value and better health.
Although much work remains to fully realize the coverage vision embodied in the Affordable Care Act (ACA), another aspect of the ACA—how we deliver and pay for health care—is receiving increasing attention. To date, the bulk of this attention has come from providers and public and private payers. But consumer advocates are coming to the table, increasingly recognizing that critical decisions about access, quality and affordability are being made.
With support from The Atlantic Philanthropies, Robert Wood Johnson Foundation, The John A. Hartford Foundation and others, and working closely with other national and state partners, Community Catalyst has committed itself to supporting an effective consumer voice in the debate over “Health System Transformation.” A necessary (though not sufficient) step in this direction is to clarify what we hope to get out of Health System Transformation, what the risks are to consumers in a reorganized system, and consequently, what our agenda for change should look like.
What We Hope to Achieve
The Institute for Healthcare Improvement’s "triple aim”—better care/better health/lower cost—provides a good starting point to develop a framework for transforming our health system. But it can be made more specific by answering three questions:
Better care for whom? Primarily, for two intersecting groups:
- people with multiple chronic conditions and disabilities who account for the bulk of our national health care spending and who are often poorly served by a system that is better designed to address discrete episodes of acute illness
- low-income people, racial and ethnic minorities and other marginalized populations
Better health how? Better health will be achieved not only by improving clinical processes to get better health outcomes, but also by redirecting wasted resources in an inefficient medical care system to improve the social and economic conditions that generate a lot of acute and chronic health spending.
Finally, better value how? By addressing those features of the U.S. health care financing and delivery system that inflate our spending relative to other advanced industrial democracies but fail to improve clinical outcomes (see The Path to a People-Centered Health System for more discussion of these drivers of low-value care).
What Are the Risks?
- The push to achieve cost savings will come at the expense of better care and better health. We see this risk in the alarming trend toward higher patient cost-sharing, which can lower health spending but also puts the greatest economic burden on people with chronic conditions and low-income people.
- Plans and providers will seek to achieve results by avoiding or underserving high-need/high-cost patients. Reengineering care is hard. Relatively speaking, avoiding patients who might drag down quality scores or bust through budget caps is easy.
What Policy Agenda Can Help Us Realize Our Positive Goals, While Minimizing the Risks?
Community Catalyst has identified six areas we believe are critical to address in order to ensure that the promise of better care, better value and better health is realized and the pitfalls avoided.
1. Advance consumer engagement at three critical levels: individual, health system and policy development. At the individual level, the goals and experience of each patient should inform the caregiving process. At the delivery system level, there should be organized systems to integrate patients and patient advocates into the process of continuous quality improvement. Finally, at the policy development and monitoring level, consumer advocates must have a seat at the table along with payers and providers (and not just token representation).
2. Implement pro-consumer payment policies. This should encourage providers and health systems to address the needs of high-need/high-cost patients, reduce payments for overpriced goods or services and reward providers for improving outcomes.
3. Strengthen consumer protections. While patient engagement and appropriate payment policies are important consumer protections, they are likely not sufficient in a system that puts providers at risk for the cost of care. In order to guard against under-service, a robust set of consumer protections, including grievance and appeal rights, and consumer-oriented quality measurement and reporting is needed.
4. Place care coordination at the heart of delivery system reform. In order to improve care and outcomes, especially for people with multiple chronic conditions, consumer advocates will have to ensure that care delivery models, such as patient-centered medical homes and accountable care organizations, incorporate team-based care approaches and integrate physical and behavioral health services.
5. Redirect resources to address social determinants of health. Many factors that lead to high spending and poor outcomes lie outside the delivery of medical care per se. Indeed, when spending on health and social services is combined, the U.S. is less of an outlier compared to other countries. It focuses more of its spending on medical care and less on primary prevention, so people don't get sick in the first place. Part of the goal of system change should be to correct this imbalance.
6. Promote health equity. Many important strategies to promote health equity are addressed under other priorities, but the topic deserves special attention because health disparities are likely to persist or even widen as system reform unfolds. Racial and ethnic health disparities impose significant costs both from avoidable health spending and from lost productivity. A multi-faceted strategy must include data collection, adequate funding for currently underserved communities and populations, diversifying the health care workforce and promoting culturally competent care.
Obviously, much more detail is needed to fill in this ambitious agenda and make it actionable. In the weeks ahead, we will use this blog series to drill down on each one of these topics.
We also recognize that all of this change will not happen overnight. Placing these priorities at the heart of efforts to transform the way we pay for and deliver health care and how we promote health more broadly will require sustained advocacy over many years. We welcome feedback on this agenda from our state and national colleagues and from other stakeholders, and look forward to making the promise of better care, better value and better health a reality.
Since partnering with the Voices for Better Health project in 2014, I have spoken to nearly 500 older adults and people with disabilities. The stories I have heard are compelling, often heartbreaking, accounts of people struggling to stay healthy and in their community. It is these stories that we are working to bring to policymakers to make fundamental changes to Rhode Island’s health care system, especially for the most frail and vulnerable populations who are often overlooked and underrepresented in the health care debate. With the recent announcement of the Memorandum of Understanding between the federal Centers for Medicare and Medicaid Services and Rhode Island’s Medicaid program to begin a demonstration project to coordinate care for beneficiaries with both Medicaid and Medicare, there is change ahead. The stories below share some of the challenges that need to be addressed.
Stories from the Field
The most pervasive and profound stories I hear relate to isolation, the lack of family support, and loneliness. Today’s families are often fragmented and far-flung, making it impossible for many older adults and people with disabilities to depend on relatives for support. This is why the health care system and community-based services network is so vitally needed to work in a coordinated way to provide support services.
Mary is 90 years old and owns a small duplex in need of repair. I met her through a Meals on Wheels (MOW) outreach campaign. She is bright and talkative. She was overjoyed when I came to her home to chat. Mary hadn’t spoken to another human being in over two weeks; that’s when her “friend” and caretaker left for vacation, canceling Mary’s MOW delivery service during her absence. Someone was supposed to come and help her with her daily activities, but never showed up, leaving Mary to fend for herself. Mary’s limited mobility makes it impossible for her to take public transportation. She desperately needs dependable social services, but she’s afraid she will lose her house if she applies. Mary lives on less than $750.00 a month, however, she receives no Medicaid, LTSS nor is she on the SNAP program. Meals on Wheels is the only program she participates in. Mary admitted that the food is just okay, it’s the daily interaction with the volunteers that Mary craves and is her saving grace.
Many other older adults I have met with are similarly struggling to cope with loneliness, isolation and lack of a support system. They live in private single or multi-family housing, have no means of transportation or family support. Many live with undiagnosed mental illness or dementia. They rarely get out, don’t belong to any civic group, organization, church or senior center, and as a result, many crave human interaction. The real challenge has been how to make an initial contact with more people like Mary. Many seniors live in private housing where their isolation may go totally unnoticed until a tragedy occurs. Reaching this population would give us a more complete understanding of the most fundamental needs of those aging in the community.
Discharge plans are another area where poor, often isolated, older adults all too easily fall through the cracks.
Amanda is recovering from an unusual mid-brain stroke. She spent more than week in the hospital and then several more in rehab. Although she was told she would be receiving at-home care, it never materialized. It took countless calls for Amanda to obtain durable medical supplies such as a bath seat, grab bars and a walker that were essential for her to live safely at home. By the time she was contacted regarding Home Based Health Care after nearly four months, she was well on her way to recovery. Discharge planning requires good communication between the patient, a family caregiver or friend, if available, and all health care providers involved to ensure the best possible outcomes for the patient.
Relationship-based Organizing as an Effective Tool in Health System Transformation
So why is reaching isolated consumers so important in transforming our health care system? What are effective ways to do this kind of outreach? Here are strategies I’ve used in my work:
- Relationship-based Organizing is an approach that starts by building connections between individual members of a community or interest group, such as a church congregation, senior centers and residences. Its initial building blocks are house meetings. These are purposeful public sessions where participants share their stories of important events in their lives. This is the first step in building trust and deeper relationships around common values. The second step after a series of house meetings is a research phase, which turns broad, often-voiced concerns into specific, immediate and winnable issues and develops proposals to address those issues.
- The final step is to organize public action meetings with turnout of consumers and allies, where decision-makers are asked to give a public response to our proposals.
Organizing is distinct from advocacy in that you are teaching the community how to effectively come together to advocate for itself to change social policy. For poor and minority seniors, providing avenues for participation and ways to gain a “seat at the table” with those who have the authority to make change can be a new and empowering experience. Small victories build the community’s confidence that they indeed have power and encourage them to take on bigger challenges.
The Rhode Island Organizing Project (RIOP) is a community organization dedicated to promoting justice and the common good. RIOP’s organizing strategy places a premium on community outreach, participation and empowerment, leadership development, and grassroots organizing. RIOP’s most significant achievements include expanding state funding for affordable housing and leading an effort to redevelop one of Rhode Island’s poorest neighborhoods. RIOP began working on elder issues in 2009 and began conducting house meetings, listening to low-income seniors talk about their health care experiences and desire to age in place.
Marjorie L. Waters
Rhode Island Organizing Project
Under the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) is assisting states in integrating care for people who are eligible for both Medicare and Medicaid – primarily low-income people over age 65 and working-age adults with disabilities. In 2011 CMS invited states to submit proposals to operate three-year demonstration projects that would better integrate care for their dually eligible beneficiaries by aligning the financing of Medicare and Medicaid. Massachusetts was the first state to launch its demonstration in 2013, and as of mid-2015, twelve states have begun implementing demonstrations. This population, which is by definition low-income and also disproportionately from racial and ethnic minority communities, has historically received very poor health care, and the status quo is not working for them. The hope for these demonstration projects is that they will be able to provide better coordinated care at lower costs, including integrated higher-quality primary care, behavioral health care and long-term services and supports. Are the projects achieving those goals?
Over the last few months, both the trade and mainstream press coverage has painted a dire picture for the projects. Modern Healthcare, for example, ran a story in April with a headline suggesting that the future of the demonstrations was in question. In July, the industry publication Crain’s New York Business ran an article headlined “Problems Plague Program for Dual Eligibles” (subscription required to view). In early August the Boston Globe reported on the financial losses sustained by health plans participating in the Massachusetts demonstration, One Care.
Each of these articles has identified some real difficulties that exist in the demonstrations. State advocate partners in our Voices for Better Health project also report a myriad of concerns such as lower than anticipated enrollment numbers, poor communication with primary care providers about the demonstrations, cases of disrupted care for enrollees, inadequate readiness review, inadequate financing and risk adjustment provisions, and financial losses for plans. Consumer advocates are working energetically together with beneficiaries, to identify and implement solutions in collaboration with plans, states and CMS.
What’s largely been missing in the press coverage, however, is the impact of the demonstrations on the people they are aiming to help. Responses to the Boston Globe article from an enrollee, a provider and a plan attempt to balance out the picture with real stories of people with complex conditions getting measurably improved care. This is not to say that such successes are yet as widespread as we would like across the demonstrations. But any balanced evaluation of the projects must acknowledge successes, and also be measured against the failings and unsustainability of the current health care system. The existing system is expensive, uncoordinated and inadequate. Too many of these enrollees have been falling through the cracks for decades, and the problems with the demonstrations can only be fairly viewed through that lens.
Most importantly, we must take the long view and give these demonstrations time to work. This is hard. It is far too soon to pronounce either failure or success. Coordinated care can provide better care at lower costs, but reaching this goal will take time. While mid-course corrections are needed, that in no way means we should give up on the project, since we know that the status quo doesn’t work. The kinds of things the demonstrations are trying to do – and in some cases are already doing – are the right things. There is a proven track record in Massachusetts, for example, of improved care for low-income older adults in the Senior Care Options program. The same is true of PACE (Program of All-inclusive Care for the Elderly) sites around the country. These and other working models show that well-integrated coordinated care results in higher-quality care that can reduce preventable hospitalizations and unnecessary nursing home admissions. Given ample time to work, robust state and federal oversight and meaningful consumer input, the dual eligible demonstrations can be just as successful as these models.
Changing how we care for the dual eligibles is not like altering course in a speedboat. It’s more like turning a tanker. It won’t always be smooth sailing, but commitment to the long-term goals of the demonstrations and to fixing problems as they arise, will help us stay the course.
With April being National Minority Health Month and May Older Americans Month, the time is now to stand against the barriers that create the social, health and economic disparities experienced by the older adult population – a population that demographic data clearly tells us is becoming more and more diverse. That’s why we were struck by the most recent issue of Generations, the quarterly journal of the American Society on Aging, which is entirely devoted to these timely and critical issues.
First Let's Talk About the Landscape
African Americans, Latinos and Native Americans in the U.S. receive lower quality health care and experience disproportionately high rates of mortality and health status disparities compared to other high-income countries, say Alberto Palloni and James Yonker. And as author Steven P. Wallace states in his article, “Health inequities are the result of avoidable differences between populations that affect less powerful groups in society. They stem from a pattern of health determinants, outcomes and resources associated with broader social inequities.”
Several other authors in Generations argue that we need public policies and institutions that create healthy environments for older adults with diverse backgrounds, that make the “healthy choice the easy choice.” Determinants such as economic status, safety and adequate housing, are important as these facilitate healthy behaviors.
Valuing caregivers can also help address disparities, author Nancy R. Hooyman argues. Most caregivers and care recipients are women. Hooyman's article points out that gender inequities experienced by women are inextricably linked to the widespread undervaluing of caregiving, saying, “These disparities are reinforced by social institutions of the family and the labor market.” The solution lies in viewing caregiving as a “public value” rather than a private duty, as is often the attitude in the U.S.
Taking a Closer Look: LGBT Older Adults
Generations features a number of articles focused on particular populations, including one about lesbian, gay, bisexual or transgender (LGBT) older adults. According to Karen I. Fredriksen-Goldsen, there are 2.4 million adults 50 and older in the U.S. who identify as LGBT, accounting for 2.4 percent of the population in that age range. She goes on to say that “LGBT adults who are middle-age and older experience significant health disparities, defined as variations in health attributable to systemic environmental, economic and social barriers that place individuals at a disadvantage in the larger society.”
It is critical to ensure comprehensive support services for mid-life and older LGBT adults. Adequate resources will ensure that this population does not experience social isolation and poor health outcomes. The Affordable Care Act (ACA) provides important steps forward in advancing policies that address the needs of LGBT older adults, such as establishing the non-discrimination protections in health care services based on sexual orientation or gender identity.
Taking Advocacy to the Next Level
So, which strategies and advocacy approaches can take this movement to the next level? Generations authors highlight initiatives underway through the Administration on Aging (AOA), including the Administration for Community Living and the Older Americans Act. For example, authors Boutaugh et al, suggest that these initiatives offer lessons that can help address the issues of access for racial and ethnic minorities. One such initiative the AOA has supported bolsters evidence based health and prevention programs such as the Chronic Disease Self-Management Program. Other initiatives, made possible through the ACA, can also advance health equity for vulnerable, diverse older adult populations, such as the demonstrations to integrate care for those dually eligible for Medicare and Medicaid.
The Bottom Line
The latest Generations issue* keenly reminds us that the transformation of our health care system must fully recognize the diversity of America’s aging population and tackle, head on, the social and health disparities it experiences. Fortunately, the ACA offers myriad opportunities to take on this challenge and, critically, to make older adults’ voices central to the decisions being made about their health.
*This issue is available to ASA members or for single-issue purchase here.
Spring is a great time to think about transformation, and everywhere you look these days, more initiatives are sprouting to improve the health system. Medicaid is no exception, showing again that it is a program willing and able to help states lead the way toward more effective and efficient care.
Recently, Medicaid officially launched a program of web-based support to speed states' efforts to improve health and health care for Medicaid beneficiaries. The initial focus is on new ways to pay for and deliver services for people with drug and alcohol problems, also called substance use disorders. It's a welcome spotlight on an area of care that has long been in the shadows.
Later this spring, Medicaid plans to roll out a second part of its Medicaid Innovation Accelerator Program (IAP) that will focus on super-utilizers of health care services, followed by other segments on community integration to support long-term services and supports, and on integration of care for physical health and mental health. These areas – all critical for better care for consumers -- were chosen with help from stakeholders using criteria that included need, opportunity and synergy with other federally supported innovations, including the State Innovation Models Initiative and the demonstrations for Medicaid-Medicare beneficiaries (dual eligibles). The IAP is being run jointly by the Center for Medicaid and CHIP Services and the Center for Medicare and Medicaid Innovation. Advocates and other stakeholders can respond to federal officials' request for comments on the three new issue areas at MedicaidIAP@cms.hhs.gov.
For each of these issue areas, Medicaid is providing a year of intensive, tailored technical assistance to a small group of states that is already moving forward, and a series of webinars and resources to any state Medicaid program just getting started on innovations to improve care and outcomes. Both the tailored coaching and the webinars focus on expanding new models, improving quality measures, payment and contract strategies that yield better value, and ways to share lessons quickly across states and the nation. The shape of those innovations will vary greatly state to state.
The states getting high-intensity coaching for substance use disorders work were selected in February: Kentucky, Louisiana, Michigan, Minnesota, Pennsylvania, Texas and Washington. It's great to see that states of all political persuasions signed up. Details of their planned innovations have not yet been released.
Medicaid has also started the web-based support for 19 other states who applied for the IAP. These SUD learning sessions will be grouped by topic areas, such as benefit design, managed care contracting, and integration of primary care and substance use services. The first session dealt with increasing provider capacity, a critical issue for substance use disorders, since only about 10 percent of those with problems get treatment. There's no limit on state participation in the web support, so Medicaid officials say more are welcome. A map of the learning community states and an outline of the topics will be posted on the IAP website in the next few weeks.
If your state is one of those in the intensive group, now's the time to reach out to the state official who is the lead on this. A good place to start is whoever directs substance use disorders services in your state's Medicaid administration. If your state hasn’t already jumped in, you can encourage Medicaid or Health Department officials to check out the opportunities. While advocates aren’t part of the project’s learning community, federal officials are expecting states to engage stakeholders, including consumer advocates. It's critical that consumers be at the discussion tables to make sure the new care models work for everyone.
Why are they starting with substance use? No surprise that it's partly about the money. The top diagnoses among Medicaid beneficiaries that lead to frequent, costly and potentially avoidable re-hospitalizations include substance use and mental illness. Studies increasingly show that screening for substance use and providing effective treatments –such as combining medications and counseling -- saves money and lives. But too few people are screened, many don't get the care they need, and others get fragmented care where treatment for substance use is segregated from care for other illnesses.
The Medicaid IAP seeks to help states learn from each other, eliminate federal and state barriers to better, less costly care, and improve outcomes for consumers. Sounds like a model we know works. The issues are critical: substance use disorders, super-utilizers of health care services, community integration to support long-term services and supports, and integration of care for physical health and mental health. Let's get involved.
The passage of the ACA was a monumental achievement for individuals and organizations across the country. Here at Community Catalyst, we continue to be incredibly proud of all our state partners who have worked tirelessly to implement the law in their own states and as part of a national effort.
Consumer health advocates have made the law work by:
- Setting up State Marketplaces or working with federal policymakers to improve the Federal Marketplace.
- Training thousands of in-person assisters who sit down with consumers and help them understand not only how to enroll in health care coverage but what it means to have coverage.
- Ensuring that individuals who are dually eligible for Medicare and Medicaid have high-quality care that is coordinated and comprehensive.
- Closing the coverage gap in 28 states (plus the District of Columbia) so everyone can benefit from the full intent of the ACA.
- Releasing nationwide information about drug and device manufacturer payments to doctors and teaching hospitals, beginning a new era of sunshine and transparency. The information, which is made public under a provision of the Affordable Care Act, shows the millions of ways that drug and device manufacturers try to influence doctors using gifts, free meals, free travel and other payments of some value.
We know there is much more to do, but the ACA is a really strong start toward creating a system where everyone can receive and afford high quality care. Repeated efforts to repeal the law as a whole or take it apart piece by piece have not been successful. However the threats are not over, and we are committed to protecting the law and working to improve it every step along the way. We cannot return to the days when young adults could not stay on their parents’ plans, when women were charged more for their care than men, and when insurers could deny people coverage because of a pre-existing condition.
Today is a day to celebrate what our partners have achieved and, more importantly, what consumers have gained. Happy 5th Birthday ACA!