Health Innovation Highlights: August 10, 2017

Full Edition

FROM THE CENTER & OUR PARTNERS

A Suggested Recess Reading Item

A message from Ann Hwang, MD

We will likely remember for a long time the Senate’s historic early morning health care repeal vote nearly two weeks ago. Yet for many of us, our sense of relief has co-existed with continuing unease. Even with Congress on recess, we remain concerned about efforts to sabotage health care coverage and destabilize insurance markets. And there is a sense of uncertainty about how and whether we will be able to move forward in our mission of better health—for everyone. In these uncertain times, I found this short Forbes piece on leadership a helpful and thoughtful read. I hope you will also find it useful. See you in September—and onward!

A New Center Leadership in Action Program Connects Respected Health Care Experts with Consumer Advocates

In a recent blog post, Center Senior Advisor Carol Regan, discusses the launch of the Center’s new Leadership in Action (LIA) program for our Consumer Voices for Innovation (CVI) grantees. LIA will connect our CVI grantees’ staff with distinguished senior leaders in the health care field to enhance their policy expertise and foster strategic relationships. LIA builds on the successful Geriatrics Provider Collaboration program that Community Catalyst and the Center have been running for nearly four years.  

Helping our consumer advocate partners build new connections will be vital as we collectively work to create a health system that makes care better for vulnerable people and populations. The LIA program is the next step in the Center’s work of supporting advocates on the ground to ensure a movement toward person-centered care.

Center Blog Post on MACRA Quality Payment Plan Year Two Rule

On June 20, the Centers for Medicare and Medicaid Services released a proposed regulation laying out updated rules for year two of the Quality Payment Program, created by the 2015 passage of the Medicare Access and CHIP Reauthorization Act (MACRA). This rule changes how Medicare pays physicians to shift the focus of their care delivery from volume to value. The release of this rule was much anticipated, as it provides some of the earliest indications of whether, and how, the Trump administration plans on advancing value-based payments. In a blog post, Center Strategic Policy Manager Danielle Garrett focuses on four areas in the 1,000-page rule that are of particular importance to consumer advocates and anyone working with populations with complex health and social needs

ELDERCARE VOICES

Championing Oral Health for Older Adults

Deborah Jacobi, RDH, MA

Dr. Sarah Crane is board certified in Internal Medicine and Geriatric Medicine and practices in Rochester, Minnesota. She, along with a mentor, Dr. Linda A. Ward, are also oral health champions. 

Dr. Crane shared with me one of several cases from early in her career that drove her to pursue a solution to meeting the dental needs of her vulnerable older patients. On rounds one day when she was a fellow at the Mayo Clinic under the supervision of Dr. Ward, a nurse reminded them that dental examinations were required under a new regulation. The elderly patient had been prescribed repeated rounds of antibiotics and hospitalized for fever of unknown origin. Donning gloves and running a finger along the patient’s teeth, the underlying problem became immediately clear: multiple broken and infected remnants of teeth.

In addition to the human cost of avoidable pain and infection in cases such as this one, the dollar amount required to pay for timely preventive dental care is a fraction of that required to treat the consequences of undiagnosed dental disease. Unbelievably to Drs. Crane and Ward, learning the source of infection was just the start of a many-month struggle to obtain care for this patient, and ultimately for many other older adults in the Rochester area.

When Drs. Crane and Ward began to make calls to find a dentist to remove the infected teeth, they discovered how few area dental offices accepted Medicaid. Also, most general dentists were not prepared to address the patient’s medical complexity. Determined searching was required before they found someone willing and able to remove the teeth, months later. How could this happen in Rochester, Minnesota, known internationally for high-quality health care delivery?

Barriers: cost, coverage, workforce and accessibility

The most often cited barrier to dental care is the cost. After years of employer-based coverage for routine preventive care and treatment, many older adults are dismayed to learn that dental services are not included in Medicare coverage. For those reliant upon Medicaid, dental benefits are optional, meaning they are determined by each state’s Medicaid program. In practice, they are limited in scope or significantly under-funded in most states. Beyond, and often exceeding the cost of care, are “hidden co-pays” such as transportation costs, including the cost of nursing staff time to accompany the patient to an office appointment from a nursing facility, and medical transportation fees. The nine recognized dental specialties do not include geriatrics or special needs. Most dental care is delivered in private offices, which are typically not well-equipped to treat medically complex patients with physical or cognitive disabilities.

Why does oral health matter for older adults?

The lack of both coverage and access to affordable oral health care comes at exactly the wrong time for older adults in this country. Through advances in dentistry over their lifetimes, more adults have kept more of their teeth than those in previous generations and, therefore, have higher expectations for their oral health as they age. They also are living to older ages, and therefore more likely to have developed chronic diseases such as diabetes and heart disease. Commonly prescribed medications for these and other conditions may cause dry mouth, reducing the natural cleansing flow of saliva, and leading to new decay along fillings, crowns and bridges. Decreased dexterity makes daily mouth care more difficult, increasing bacteria-laden plaque. The resulting mouth infections, tooth decay and periodontal disease can spread to other parts of the body, complicating the control of high-cost chronic diseases. Research shows that people receiving appropriate dental care have significantly lower overall health care costs.

Unwilling to watch the system fail their patients, Drs. Crane and Ward sought a lasting solution to meet the oral health care needs of vulnerable older adults in their community. Their search led them to Dr. Michael Helgeson, CEO and co-founder of Apple Tree Dental, a non-profit group dental practice established in 1985 to provide dental care to residents of nursing facilities in the Minneapolis/St. Paul area. Apple Tree now serves people of all ages and abilities in communities across Minnesota.

Drs. Crane and Ward were undeterred when Dr. Helgeson explained that, as a result of deep cuts to Minnesota’s Medicaid adult dental benefits, the non-profit was focused on sustaining existing programs and not in a position to expand. Not giving up, they convened medical, dental, philanthropic and civic leaders to highlight the problem and raise needed funds to bring Apple Tree to Rochester.

Apple Tree utilizes a proactive, prevention-oriented, patient-centered approach, called Community Collaborative Practice to advance its mission “to improve the oral health of all people, including those with special dental access needs who face barriers to care.” For older adults, dental hygienists visit long-term care facilities each month to provide mandated oral assessments and work with individual residents and direct-care staff to ensure appropriate daily mouth care. Dentists and dental therapists (a new mid-level provider in Minnesota,) provide examinations and treatment onsite using mobile dental offices for those residents choosing Apple Tree as their dental home. The team includes care coordinators who, using a cloud-based electronic health record, schedule appointments and needed consultations with medical providers. A dental liaison at each facility acts as point person and alerts Apple Tree of dental emergencies. Together, they are able to ensure that long-term care residents receive the preventive and restorative dental services needed for a healthy mouth.

Doctors Crane and Ward’s efforts led to the establishment of Apple Tree’s Rochester program in 2008 which today serves 13 assisted living facilities and nursing homes, two group homes and a behavioral health center, as well as community members of all ages. As a direct result, over 10,000 patients including 2,602 people over age 65 have received dental care since services began.

Does your community need an oral health champion, too?

Deborah Jacobi, RDH, MA is the policy director for Apple Tree Dental, a nationally recognized innovative nonprofit. Apple Tree operates six regional Minnesota dental programs, delivering comprehensive dental care in clinics and on-site care at more than 130 collaborating urban and rural community sites including Head Start Centers, schools, group homes, and long-term care facilities. In addition to her clinical dental hygiene background, she holds a Bachelor’s in Sociology and a Master’s in Public Policy and Health Administration from the University of Wisconsin - Madison.

NOTEWORTHY NEWS & RESOURCES

New Payment Models Must Account for Patients’ Social Needs

An article in Modern Healthcare reports on a study in the Journal of the American Medical Association that found that physician practices serving a high proportion of dually eligible patients, as well as practices serving patients with complex medical needs, may be more likely to incur financial penalties under a new Medicare pay-for-performance program. The study indicates that such physician practices struggle with registering and reporting performance data and also perform more poorly on quality outcomes. The authors note that lower quality outcomes could relate to the fact that these practices’ patients often face challenges with transportation, food and housing.

Two CMS Comment Opportunities: Behavioral Health, Home Health Care Agency Payments

The CMS Innovation Center is seeking comments on new payment models for behavioral health services for beneficiaries in the Medicare, Medicaid and CHIP programs at a September 8, 2017 meeting in Baltimore. The new models can focus on substance use disorders, mental illness, and/or dementia. CMS has also opened a public comment period, which ends September 25, 2017, on its proposed new rule to reduce payments to home health care agencies.

Two NQF Comment Opportunities: Medicaid Innovator Accelerator Project, Disparities Report

The National Quality Forum (NQF) is accepting comments until August 21, 2017 on quality measures for the Medicaid Innovation Accelerator Project. The NQF’s Disparities Standing Committee also posted its draft report: A Roadmap to Reduce Health and Healthcare Disparities through Measurement for public comment. The report outlines the Committee’s final roadmap to reduce health and health care disparities through performance measurement and associated policy levers. The roadmap seeks to capitalize on the current care delivery and payment model transformation while recognizing the persistent and pervasive nature of healthcare disparities.

Study Demonstrates the Importance of Investments in Social Needs

A new study from the Commonwealth Fund finds a high degree of variability across states in the care experiences of adults with chronic health care needs. Of particular interest is the finding that high-need adults, defined as those with two or more chronic conditions and a “…functional limitation in their ability to care for themselves or perform routine daily tasks” were far more likely to delay needed care than adults with chronic conditions and no functional limitations. High-need adults tended to be older and more likely to be insured than the total adult population in almost every state studied. High-need individuals also tended to have lower incomes and were more likely to have health insurance through state Medicaid programs than other adults in the same state. Citing Colorado, Oregon and Minnesota as leaders, the study’s authors point states toward investments in delivery reform initiatives and investments in addressing the social and economic determinants of health and integrating  behavioral and medical health in order to improve care for high-need populations.

STATE HIGHLIGHTS

Alabama

The Alabama Medicaid Agency has cancelled plans to implement the Regional Care Organization (RCO) model that was started in 2014. The Medicaid Agency reports that due to changes that were being proposed by the Trump administration and Congress, the state has decided to pursue alternatives. The program was slated to start October 2017.

Colorado

The Colorado Department of Health Care Financing and Policy issued a request for proposals to secure Regional Accountable Entities (RAE) for the Accountable Care Collaborative, which is part of the state’s Medicaid program. The goals of this next phase of RAEs are to improve health and life outcomes for members and effectively use the state’s resources. The deadline to submit proposals was July 28.

Washington

The Medicare-Medicaid Coordination Office released the Washington Final Demonstration Year One and Preliminary Demonstration Year Two Medicare savings report on Medicare savings results of the Washington Health Home Managed Fee-for-Service model dual eligible demonstration project. This managed fee-for-service model demonstration launched in 2013 to integrate care for high-cost, high-risk, full-benefit Medicare-Medicaid beneficiaries. The final results for Demonstration Year One show total gross Medicare savings of almost $35 million. The preliminary savings results for Demonstration Year Two show total gross Medicare savings of $32 million, for a combined two-year total gross Medicare savings of $67 million. The report does not include information about Medicaid savings.  

KEY DATES

Wednesday, Aug. 16 (2-3 p.m. Eastern) – Webinar: Home and Community- Based Services (HCBS) Quality Measure Development, presented by the Administration for Community Living.

Please register for the webinar.


Monday, Aug. 21 (Deadline Extended from Aug.7) – Deadline for health care consumers to apply for a Consumer Grant to attend the National Center for Complex Health and Social Needs’ Putting Care at the Center conference taking place in November 2017

Wednesday, Aug. 23 (2 p.m. Eastern) – Webinar: Assessing Organizational Ability To Provide Navigation Services, presented by The CMS Medicare-Medicaid Coordination Office, in collaboration with The Lewin Group.

Please register for the webinar.

Monday, Aug. 28 (2 p.m. Eastern) – Webinar: Providing Navigation Services to Clients with Serious Mental Illness and Chronic Physical Health Conditions, presented by The CMS Medicare-Medicaid Coordination Office, in collaboration with The Lewin Group.

Please register for the webinar.

Thursday, Sept. 7 (12-1:30 p.m. Eastern) – Webinar: Organizational Buy-In: Making Member Engagement A Top Priority, presented by The CMS Medicare-Medicaid Coordination Office, in collaboration with The Lewin Group and the Center for Consumer Engagement in Health Innovation.

Please register for the webinar.

Thursday, Sept. 7 (1-2 p.m. Eastern) – Webinar: Managing Social Determinants of Health: A Framework for Identifying, Addressing Disparities in Medicaid Populations, presented by Health Management Associates.

Please register for the webinar.

Sunday, Sept. 10 – Application Deadline for the Jewish Healthcare Foundation and Health Careers Futures 2017 Jonas Salk Health Activist Fellowship – an incubator for emerging health activists. We encourage undergraduate students, graduate students, or employees in health-related disciplines to apply by completing the online application at www.qitcenter.org/2017-salk-fellowship.

Thursday, Sept. 14 (12-1:30 p.m. Eastern) – Webinar: Involving and Supporting Family Caregivers in Care Planning and Delivery, presented by The CMS Medicare-Medicaid Coordination Office, in collaboration with The Lewin Group, the American Geriatrics Society and the Center for Consumer Engagement in Health Innovation.

Please register for the webinar.