Health Innovation Highlights: July 13, 2017

Full Edition


DIRECTOR'S CORNER

 Photo: Julie Turkewitz, 2014

The National Academy of Medicine Points the Way to Improved Care for High-Needs Patients


Ann Hwang, MD
Director, Center for Consumer Engagement in Health Innovation

Last week, I had the honor of speaking at the National Academy of Medicine in Washington, D.C., at the release of the Academy’s new special report, “Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health.” This report focuses on patients with high medical needs, and advances insights and perspectives on how to improve their care. I had the opportunity to respond to the report and I wanted to share a few of my reflections.

First, the report calls attention to an important fact: the health care system is failing the very people who need it most. The report notes that high-need individuals are more likely to suffer from care that is not coordinated and to have unmet medical needs. For those of us who spend a lot of time in the health care system, whether as patients, caregivers or providers, this is not surprising. Trying to get appropriate care when you or a loved one (or your patient) has a complex set of needs exposes all of the gaps and shortcomings in our health care system. We must do better, and this report provides a tremendous amount of data and evidence to guide our way forward.

Second, an important step for improving care is to identify the patients with high needs who are suffering from poor care. The report presents a starter “taxonomy” of high-needs patients. But one of the report’s findings – that health care consumers know when the system is failing them – presents the possibility of an alternative approach. Instead of starting from the claims data in the hopes of getting to the person, why not start with the person? This means identifying a simple set of two or three questions that could allow providers, patients and caregivers to identify who has high needs and is at high risk for getting inadequate care. These questions – perhaps derived from measures of patient activation, patient confidence, health status and care quality –could serve to identify those consumers who might benefit from an intervention, such as enrollment into an enhanced-care coordination program. This, to me, seems a much more direct method to identify who is at risk, and one that can be applied at any point of contact with the system.

Third, in order to be successful, the work to improve care for people with complex needs must have a laser-like focus on consumers and caregivers. While the report identifies organizational attributes of successful care models for consumers with complex needs – including leadership, customization, team relationships, training, continuous assessment and data use – I would argue that these are the strategies, not the vision. A clear and shared vision of patient-centered care is necessary to carry out the hard work of transformation, otherwise we risk this vital endeavor becoming reduced to a “check the box” exercise without fundamentally changing the culture of health care so that it focuses on taking care of a person, in partnership with that patient and their caregivers.

Fourth, consumers should be full and engaged partners in the development and implementation of these models of care. We have seen some of this great work by our consumer advocates and community partners working on their states’ the dual eligible demonstration projects, and in the Center’s Consumer Voices for Innovation program. We’d love to see this focus on engagement become standard practice. In the same way that policymakers now routinely incorporate technical assistance and outreach to providers as they adopt new models of care, I would like to see technical assistance and outreach to consumers as they participate in these models. In this work, we must be mindful that some people and communities face greater barriers to engagement, and focus on addressing disparities in engagement and access.

Finally, the publication of this report in the midst of a pitched battle about health care coverage in this country raises a pointed question: what will happen to care for people with complex needs if they lose health care coverage? Just as we see this great progress toward improving care for those who are most at risk – frail elders, people with complex conditions, people who face social as well as health challenges – there are tremendous changes proposed to health coverage and the funding of Medicaid in this country that threaten the care for exactly these populations.

We can and should work to improve care for those with high needs and protect the coverage that is the foundation of this care. This report is a wonderful acknowledgement of the work done to date and an encouragement to all of us as we forge the path forward. I believe that the expertise of consumers – particularly those with complex needs and their caregivers – can help our country collectively write the next chapter in this journey toward better care, for everyone.

FROM THE CENTER & OUR PARTNERS

New Blog Post Quantifies Impact of Proposed Capping of Medicaid on Family Caregiver Burden

A new blog post authored by Center research director Marc Cohen and program and policy associate Kris Wiitala, delves into the severe implications a move to a per capita cap funding system for Medicaid would have on caregiving for adults and children who depend on  home-based care. The analysis examines both the reduction of state funding for paid caregiver services and the resultant major increase in the burden on family caregivers.

Rhode Island General Assembly Restores ‘No-Fare Bus Pass’ Program - A Major Win for the Rhode Island Organizing Project and the Senior Agenda Coalition

Center partner, the Rhode Island Organizing Project, along with the Senior Agenda Coalition and the broader Coalition to Preserve No-Fare Bus Passes, celebrated a major victory as the Rhode Island General Assembly restored the No-Fare Bus Pass Program providing free travel for low-income seniors and people with disabilities. The Gray Panthers and the Rhode Island Handicapped Action Committee led a successful campaign 40 years ago, which resulted in the state implementing the no-fare bus pass program. During the 2015 legislative session, the House of Representatives added a budget provision that would allow the Rhode Island Public Transit Authority (RIPTA) to eliminate the program. Over the past two years, Rhode Island advocates have been fighting to preserve the program, and when RIPTA officially eliminated the program in February 2017, the advocates pushed even harder to highlight how disastrous this change was for 13,000 no-fare riders. As a result of the coalition’s tenacious advocacy, the General Assembly restored the program, which included a $3.4 million annual RIPTA subsidy for the next two years and a mandate that RIPTA establish a process to develop a sustainable funding solution for the program.

NOTEWORTHY NEWS & RESOURCES

Health System Transformation Imperiled By Proposed Massive Cuts to Medicaid

As the United States Senate continues to debate a health care bill that would strip coverage from millions of people, a new article from NEJM Catalyst reminds us that there can be no delivery system reform without coverage expansion. Care coordination and the technology that makes it possible require up-front investments, and patient engagement requires a patient population that has access to care outside of the emergency room. The Medicaid program, which has been a hotbed of innovation, will not continue to transform care if millions of people get kicked off the Medicaid rolls. 

Movement to Focus on High-Cost “Super Users” of Health Care Services Making Gains

A recent article in The Atlantic discusses the growth of programs focused on high-need, high-cost “super users” of health care. Building upon Dr. Jeffrey Brenner’s pioneering identification of “hot spots” of such super users in Camden, New Jersey, many health systems and providers around the country are now developing innovative programs to serve this population in ways that both improve care and reduce costs. Among the highlighted systems is the Commonwealth Care Alliance, which serves people with disabilities through the One Care dual eligible demonstration project in Massachusetts. While each  health system’s or program’s approach is unique, the common goals are keeping people out of the emergency room and reducing hospital admissions, which in some cases have resulted in savings of up to 40 percent. 

Holes in the Health Care Workforce

Workforce issues continue to hamper efforts to transform the health system. As the delivery system changes to focus on patient-centered care and high utilizers, and the payment system focuses on value rather than volume, having the right workforce in place to implement those changes is critical. One provocative article suggests that, when it comes to physicians, the focus should be on the shortage of geriatricians rather than on primary care physicians more broadly. Drawing increasing attention is also the growing shortage of home care workers, without whom we will not be able to keep people out of nursing homes. Without significant improvements to wages and working conditions, these low-wage jobs are becoming more and more difficult to fill and shortages will only worsen if major cuts to Medicaid funding go into effect.

STATE HIGHLIGHTS

Colorado

Colorado’s managed fee-for-service dual elgible demonstration project is scheduled to end on Dec. 31, and the state has submitted a transition plan to CMS describing what will happen to members currently enrolled in the demonstration.  Under this plan, current enrollees will be transitioned into the state’s broader Accountable Care Collaborative. Other key components of the transition plan include:

  • Members will be able to continue to stay enrolled in their regional care collaborative organization and keep their primary care provider
  • Members will still be able to access all services and supports beyond December
  • The state will continue to engage stakeholders on an ongoing basis.

Hawaii

On July 6, Hawaii’s Legislature passed The Kupuna Caregivers Act, making Hawaii the first state in the nation to offer money to caregivers who also work full-time. [Kupuna is the Hawaiian word for elder or grandparent.] Under the act, full-time working caregivers can earn up to $70 per day to help ease financial stress so they won't have to give up their primary jobs. According to AARP, there are about 154,000 unpaid family caregivers in the state, and Hawaii's aging population is on the rise.

Caregivers who work at least 30 hours per week could use the money toward health care, meals, transportation and other home services for their dependents over 60. The landmark legislation took 21 years to pass and is being closely watched by national organizations to see if it can benefit other states.

Massachusetts

MassHealth, the commonwealth’s Medicaid program, provided the latest enrollment updates to the One Care dual eligible demonstration project. A detailed report is available here.

Michigan

The Michigan Department of Health and Human Services provided the latest enrollment updates to the MI Health Link dual eligible demonstration project. A detailed report is available here

KEY DATES

Thursday, July 27 ( 12-1:15 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 Community Catalyst.

Register for the event here.

Thursday, July 27 ( 2-3 p.m. Eastern) – Virtual Event: Recovery LIVE! Increasing the Accessibility of Recovery Support for People with Disabilities presented by SAMHSA.

Register for the event here.

Monday, 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 2017 conference taking place in November 2017