Health Innovation Highlights: June 12, 2019

full edition

DIRECTOR'S CORNER

Person-Centered Care – Sharing Evaluation Results, Progress and Threats

 


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

Last week, I had the pleasure of joining health care and public health leaders at a Kaiser Permanente-sponsored Washington Post Live event to talk about how health care can better address social needs and social determinants of health. I was gratified that the conversation acknowledged the need to change policy and to build the leadership of diverse communities in this effort: two topics that we cover in this month’s issue of Health Innovation Highlights.

First, on consumer leadership, I’m honored to share the results of the final evaluation of our Consumer Voices for Innovation (CVI) program. Two years ago, we set out to understand how we could engage consumers with complex health and social needs and best support them in developing powerful voices in the shaping of delivery system reform. We supported consumer advocacy organizations in six states in identifying, organizing and supporting consumer leaders, particularly people from low-income communities, people of color and/or older adults. Advocates and consumer leaders worked to influence delivery system reform efforts happening in their community or state – to make these programs more person-centered.

Over two years:

  • Nearly 30,000 consumers were reached
  • Over 1,000 new consumer leaders were trained and engaged in leadership activities
  • Programs in all participating states incorporated changes recommended by consumers

I am grateful to the advocates and consumer leaders who made this work such a success, and I hope you’ll take a few minutes to read the report and share your feedback.

Second, on policy change – the (potentially) good kind:

This month we feature a post I authored for The Commonwealth Fund’s “To The Point” blog on improving care for people who are enrolled in both Medicare and Medicaid (dual eligibles), as well as an article in the American Journal of Managed Care about how the Medicare Star ratings system – a “report card” for Medicare health plans – measures patient-centered care.

And if you’re having trouble keeping up with all of the news related to care for dual eligibles, you’re not alone! In the past few weeks, we’ve seen new rules for the Program of All-Inclusive Care for the Elderly (PACE), read new evaluation reports for the Financial Alignment Initiative demonstrations in Texas and Massachusetts, and submitted comments on a proposal by the Center for Medicare and Medicaid Innovation to create regional organizations to serve Medicare beneficiaries, including dual eligibles.

To help make sense of what’s happening in policies affecting the dually eligible population, we’ll be co-hosting a webinar on June 20 with The Commonwealth Fund, Melanie Bella from Cityblock Health, Cheryl Phillips from the SNP Alliance, and Michelle Herman-Soper from the Center for Healthcare Strategies. You can register here.

Finally, policy change – the bad kind. It’s important to recognize that all of our work to improve care is happening in a context of ongoing attacks on access to health care and social services, particularly for people with complex health and social needs. I want to highlight three harmful recent proposals and the current efforts to fight them:

  1. Redefining Poverty: The White House Office of Management and Budget proposes to reduce the number of people defined as “poor” by changing the inflation measure used to periodically update the poverty level. This change would make it harder to qualify for Medicaid, Medicare Part D Extra Help, SNAP, and other basic needs programs and would reduce the amount of Supplemental Security Income benefits people receive. See this blog post from Community Catalyst and read more here. Comments are due June 21.

  2. Evicting Immigrant Families: Earlier this month, the Department of Housing & Urban Development issued a proposed rule that would force 25,000 families with mixed immigration statuses in public housing and Section 8 programs to separate or face eviction. These housing assistance programs support 1.9 million older adults who would otherwise be unable to afford the cost of shelter. If enacted, this proposed rule could cause many of them, both U.S. citizens and noncitizens, to become homeless. Read more here. Comments are due July 9.

  3. Allowing Discrimination in Health Care Programs: At the end of May, the Department of Health & Human Services issued a proposed rule rolling back protections against discrimination in health care programs, established in Section 1557 of the Affordable Care Act. The proposal threatens the rights of LGBTQ people, rolls back protections for older adults with limited English proficiency and limits the way that victims of any type of discrimination can seek redress under the law. See Community Catalyst’s statement. The due date for comments will be announced when the proposed rule is published in the Federal Register.

What do you see happening in consumer leadership and in policy change that is important for person-centered care for people with complex needs? Tweet us at @CCEHI or email us at healthinnovation@communitycatalyst.org.

FROM THE CENTER & OUR PARTNERS

Final Evaluation Report on Phase One of Center’s Consumer Voices for Innovation Program

Two years ago, the Center set out to understand whether and how we could engage consumers with complex health and social needs and support them in becoming powerful voices in shaping delivery system reform. Through the Consumer Voices for Innovation (CVI) program, the Center supported consumer advocacy organizations in several states to identify, organize and support consumer leaders, particularly people from low-income communities, people of color and/or older adults. We charged the advocates and leaders to influence delivery system reform efforts happening in their community or state – to make these programs more person-centered. And we provided them with funding and technical assistance to help them achieve their goals.

In a final report of outcomes of the program, the Institute for Community Health found that our partner advocates – among other accomplishments – reached nearly 30,000 consumers, trained over 1,000 of those for leadership activities and that programs in every state incorporated changes recommended by consumers. Read more about the outstanding work our advocates did.

The Center and The Commonwealth Fund Unite on Duals Projects

The Center is partnering with The Commonwealth Fund to help guide the design of programs to improve care for dual eligibles. In a recent “To The Point” blog post, “Designing the Future of Care for Dually Eligible Medicare-Medicaid Enrollees,” Center Director Ann Hwang, MD, identifies the initiatives that are likely to result in the most expansive improvements in cost containment and quality care, including those that:

  • Improve alignment between Medicare and Medicaid by integrating financing and delivery
  • Scale up and increase usership in integrated models
  • Continue to increase the health system’s emphasis on value

Ann will also moderate an upcoming Commonwealth Fund webinar on the implications of recent CMS announcements regarding dual eligibles, at which panelists will discuss state and health system responses and share strategies for improving care. “What Do New Changes for Medicare-Medicaid Enrollees Mean for Health Systems, Providers, and Patients? will take place Thursday, June 20 from 1:30-2:30 p.m. EST. Other presenters include Melanie Bella, chief of new business and policy at Cityblock; Michelle Herman Soper, Director of Integrated Care at the Center for Health Care Strategies; and Dr. Cheryl Phillips, President and CEO of SNP Alliance.

Is Improvement of Person-Centered Care “In the Stars?”

In an article in the American Journal of Managed Care, “Will 2019 Kick Off a New Era in Person-Centered Care?,Center Director Ann Hwang, MD, and Center Research Director Marc Cohen discuss both the implications and limitations of Medicare’s star rating system. Having analyzed the person-centered care measures in the current star rating system, the authors found many opportunities for improvement in this area and further found that the current measures do not adequately capture what providing this care actually involves. Taking a somewhat hopeful tack, the authors highlight the improvements made in creating a new star rating system that pushes plans to refocus and reallocate resources to person-centered ends, while recognizing that there is still much work to be done in this area.

ICYMI: Older Americans Month Blog Series

Center staff marked Older Americans Month in May with a blog series that gave a shout-out to older adult consumer leaders, highlighted new work being done by our partners, offered resources for geriatric-competent care, and underscored the importance of asking older adult patients "what matters" to making the health care system “age-friendly.” Check out our #OAM19 blog series below:

Upcoming Webinar: Delivering Dementia-Capable Care Within Health Plans

The Center’s next webinar in the Geriatric-Competent Care (GCC) series, presented in collaboration with the Medicare-Medicaid Coordination Office and The Lewin Group will be “Delivering Dementia Capable Care Within Health Plans: Why and How?,” covering ongoing work and achieved outcomes in filling gaps in dementia care. The webinar is scheduled for Wednesday June 19 from 12:00-1:30 p.m. EST. Click here for more information and to register.

The GCC webinar series helps providers in all settings and disciplines expand their knowledge and skills related to the unique aspects of caring for older adults and working with their caregivers.

NOTEWORTHY NEWS & FEATURES

CMS Announces Final Rule on PACE

On May 28, CMS announced a new Final Rule that updates the standard of care for the Program of All-Inclusive Care for the Elderly (PACE). This rule is meant to strengthen patient protections, improve care coordination and provide administrative flexibility. Changes are anticipated to reduce administrative burden, increase transparency around enrollment and quality improvement and expand the role of PACE interdisciplinary care teams. A CMS fact sheet on the proposed rule can be found here and the complete final rule can be found here.

New Tool for States Looking to Advance Medicare-Medicaid Integration

The Integrated Care Resource Center has released a new tool, State Pathways to Integrated Care, to help states further Medicare-Medicaid integration. The tool outlines steps states can take to achieve integration based on state policy goals and delivery system structures while better understanding their dually eligible populations.

The tool provides key considerations and resources related to:

  • Understanding the dually eligible beneficiary population
  • Assessing environmental factors and opportunities to integrate care
  • Addressing foundational issues in integrating care
  • A variety of integrated care paths including managed fee-for-service and capitated managed care options

New Framework to Help Primary Care Providers Screen for SDOH

The United Hospital Fund released a framework designed to help primary care providers screen for social determinants of health and partner with community-based organizations (CBOs) to respond to those needs. The report identifies four complex challenges to successful and sustainable partnerships between primary care providers and CBOs. Challenges include developing standardized information technology systems, ensuring CBOs can accommodate the increased demand for services and creating payment systems that generate the revenue needed to respond to the volume of need identified. The full report can be found here.

Health Systems and Communities Working Together to Eliminate Disparities

In a June 7 “Viewpoint” column posted on the JAMA Network online – “Building Trust in Health Systems to Eliminate Health Disparities” – authors Donald E. Wesson, MD, MBA, Catherine R. Lucey, MD and Lisa A. Cooper, MD, MPH, argue that health care systems need to take a much more proactive role in building and earning the trust of communities experiencing high levels of disparities. Forging these partnerships will help to overcome decades of eroded confidence, and make progress toward eliminating those disparities. The authors explain that this “mistrust stems from historical events, structural racism, disparities in care, and personal experiences of discrimination.”

The authors acknowledge the necessity of strong community and consumer partnerships in order to truly begin addressing all the drivers of health, using their analysis to focus in on the vital role of trust in these relationships. 

STATE HIGHLIGHTS 

California

Plans participating in Cal MediConnect (CMC), California’s dual eligible demonstration program, recently examined the ways they have integrated behavioral health services. The state’s Department of Health Care Services outlined these findings and lessons learned in a summary report entitled “Improving Behavioral Health Integration and Coordination for Cal MediConnect (CMC) Members.” The following are some of the lessons learned:

  • Identifying Members’ Behavioral Health Service Needs – Strategies include reviewing Health Risk Assessments, analyzing hospital admission data and measures, and tracking referrals from providers, county offices and CMC members.
  • Developing Relationships and Strengthening Communication Channels – A trusted relationship between plans and county partners (who provide specialty mental health services) is a key factor in their ability to successfully coordinate care for CMC members. Plans develop and strengthen these relationships through plan liaisons, memorandums of understanding, educational and training opportunities, and regular meetings with county staff.
  • Promoting Data Sharing –Most plans have established data sharing agreements with county partners to facilitate sharing of members’ information, although this continues to be a challenge in some counties.
  • Enhancing Care Coordination –Some plans integrate resources to provide behavioral health services while others delegate the provision of services to the county or contracted vendors with behavioral health expertise.

In other news, last month the University of California, San Francisco (UCSF) released “2019 Findings from the Cal MediConnect Rapid Cycle Polling Project. The SCAN Foundation-funded report compares Cal MediConnect beneficiary data by several member characteristics including county, race, language and disability based on responses of just over 2,900 dual eligibles in 2018. Overall, UCSF researchers found that CMC members are satisfied with their care but had different experiences navigating and accessing health services. A few of the key findings are highlighted below:

  • CMC members’ experiences differed by race. White and Black CMC members were significantly more likely than Latinos or Asians to say they were confident in knowing how to manage their health conditions.
  • There were major differences by language in CMC members’ confidence managing health care. English-speaking CMC members were more confident they knew how to manage their health conditions, knew who to call if they had a health need or questions and knew they could get their questions answered as compared to Spanish and Chinese speakers.
  • CMC members with personal care needs were slightly less likely to feel very confident that they could get their questions answered, compared to those with no needs or just routine needs.

    Plans participating in Cal MediConnect, California’s dual eligible demonstration program, recently examined the ways they have integrated behavioral health services. The state’s Department of Health Care Services outlined these findings and lessons learned in a summary report. In other news, last month the University of California, San Francisco released “2019 Findings from the Cal MediConnect Rapid Cycle Polling Project which included differences in the experiences of beneficiaries by race, language and need for personal care services.

Massachusetts

In May, the Massachusetts Executive Office of Health and Human Services issued an amended and restated request for responses for One Care Plans which serve dual eligible beneficiaries between ages 18 and 64. Implementation is still set to begin Jan. 1, 2021.

In related news, the Medicare-Medicaid Coordination Office released the second and third year evaluation reports for the One Care program from RTI International. Key highlights from the second year report include:

  • Improved assessment processes reported by both of the participating plans due to lessons learned from early implementation experiences and, in part, due to lack of passive enrollment in 2015
  • No savings or losses were identified in either demonstration year 1 or demonstration year 2 on the Medicare side; no Medicaid data is yet available
  • Most enrolled in the program reported being satisfied, particularly with some of the expanded services like dental care, though transportation remains a major issue

Key highlights from the third year report include:

  • Focus group participants reported that services received from One Care had helped them to engage, or re-engage, in life activities or hobbies they enjoyed
  • Similar to the second year report, no savings or losses were found on the Medicare side
  • One Care plans still report some operational design features that lack integration between Medicare and Medicaid such as submission of encounter data

New York

The Citizens Budget Commission (CBC) released a report highlighting options for the state’s dual eligible demonstration project, which is set to end in December 2019 and may not be extended. The report considers enhancements to the demonstration model and alternatives for serving those with long-term care needs and also identifies options to reach dual eligible enrollees with other needs who could benefit from greater care coordination.

Texas

The Medicare-Medicaid Coordination Office released RTI International’s first evaluation report for the Texas dual eligible demonstration project. The demonstration operates in the six counties with the largest populations of Medicare-Medicaid enrollees, with five health plans serving this population. In this first report, the evaluators describe the early implementation and analysis of the demonstration’s impact. A few highlights from the report are:

  • State agency reorganization created a number of operational and stakeholder engagement challenges
  • Of the more than 155,000 Medicare-Medicaid enrollees eligible for the demonstration, only 43,000, or 28 % were in the demonstration as of 2017
  • Most focus group participants in 2016 and 2017 indicated that their health or quality of life had improved in the previous two years though in-depth interviews with enrollees found that the plans had little or no impact on their lives

Washington

Modern Healthcare reported in May that Washington Gov. Jay Inslee signed into law a program to help offset the costs of long-term care. Washington is the first state in the nation to introduce a long-term care program. Starting in 2025, the program promises a benefit for those who pay into the program, with a lifetime maximum of $36,500 per person, indexed to inflation, paid for by an employee payroll premium. People who need assistance with at least three "activities of daily living" such as bathing, dressing or taking medication could tap into the fund to pay for things like in-home care, home modifications like a wheelchair ramp and rides to the doctor. To be eligible, workers must have paid the premium working at least 500 hours per year for three of the previous six years in which they're seeking the benefit or for a total of 10 years, with at least five of those paid without interruption.

KEY DATES

Friday, June 14 (2-3 p.m. Eastern) - Webinar: City- and County-Wide Community Health Needs Assessments: Community Efforts that Go Above and Beyond, presented by Altarum Healthcare Value Hub. Please register for the webinar.

Sunday, June 16 - Application Deadline: The National Center for Complex Health and Social Needs is currently accepting applications for its 2019-2020 National Consumer Scholar program.

Wednesday, June 19 (12-1:30 p.m. Eastern) - Webinar: Delivering Dementia Capable Care Within Health Plans: Why and How?, 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, June 20 (1:30-2:30 p.m. Eastern) - Webinar: New CMS Programs to Improve Care for Dual-Eligibles, presented by The Commonwealth Fund and the Center for Consumer Engagement in Health Innovation. Please register for the webinar.    

Thursday, June 20 (1-2 p.m. Eastern) - Webinar: Patient Acceptability of Social Risk Screening, presented by SIREN (Social Interventions & Research Network). Please register for the webinar.

Thursday, June 27 (11:30-1 p.m. Eastern) - Webinar: Promising Practices for Supporting Dually Eligible Older Adults with Complex Pain Needs, presented by The Lewin Group in collaboration with the Academy of Certified Social Workers. Please register for the webinar.

Wednesday, July 10 - Nomination Deadline: The National Center for Complex Health and Social Needs is currently accepting nominations for a new working group to develop a set of core competencies for the field of complex care. To ensure a working group that is diverse in sector, geographic location, and lived experience, an open call to the field for nominations of working group members is being extended.