« Health Innovation Highlights: November 15, 2018 Issue

Full Edition

DIRECTOR’S CORNER

Counting Chads: A Post-Election Recap

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

It’s been over a week since election day, and final counts (and, in some cases, recounts) are still underway. But the broad outlines have come into view: the Senate will remain under Republican control, the Democrats have gained a clear majority in the House, and seven states have flipped from having Republican governors to Democratic ones. And voters made it overwhelmingly clear that health care was a major driver of their decisions in the voting booth. While it’s still early, we’ve been thinking about what the future might hold for person-centered care, especially for people with complex health and social needs. Here are four things advocates for person-centered care innovation should watch for:

  1. The end of “repeal and replace:” We sincerely hope the days of “now it’s dead, now it’s not” efforts to repeal and replace the Affordable Care Act or severely cut Medicaid coverage through Congressional actions are a thing of the past. Although we shouldn’t completely let our guard down, for better and worse, a divided Congress means it will be challenging to get major legislation passed over the next two years. There are a few areas where there seems to be some bipartisan interest, including controlling prescription drug prices, supporting substance use disorder prevention and treatment, and advancing value-based payment initiatives. We’ll be keeping a close watch on any proposals that might impact access or care for people with complex health and social needs.

  2. A mixed-bag of increased administrative activity: A gridlocked Congress means that most federal action will happen through regulation – and the Administration is not wasting any time. The votes were barely tallied before HHS issued rules that could limit women’s access to contraceptive coverage, published a major regulation on Medicaid managed care, and announced the return of mandatory bundled payment models. We’re keeping an especially close eye on actions that further erode the Medicaid safety net. The Administration has supported the adoption of policies such as work requirements and lock-out periods that have resulted in many low-income people losing their health coverage. In addition, the Office of Management and Budget posted an announcement about a proposed rule hinting at flexibility for states to no longer cover non-emergency medical transportation (NEMT) for Medicaid enrollees. NEMT has not only been shown to be critically important for health, but has also been shown to reduce costs, and we’ve been working with partners to try to preserve and improve this vital service.

  3. State-level opportunities to expand coverage and improve care: We’ve always been bullish on states, but we believe that over the next two years, states are going to be the major sites of innovation in health care coverage, access and care delivery. With seven governorships changing to Democratic, the shift of party control in a number of state legislatures, and the success of Medicaid expansion initiatives, we expect greater opportunities to expand and improve Medicaid. We‘d love to see more states invest in opportunities to tackle social determinants of health, such as Pennsylvania’s investment in supportive housing for people with complex needs (with kudos to the Pennsylvania Health Access Network!) and North Carolina’s recently approved Medicaid waiver that includes a strong focus on social services.

  4. Long-term care: While Maine’s ballot measure for universal home care was defeated, the need to address current and future gaps in long-term care financing and service delivery remains ever present. The aging population, shortage of caregivers and the erosion of the private insurance market for long-term care create conditions that may push more states to seek solutions for the growing number of people who need long-term services and supports. We hope to see more states take on this challenge and look forward to the forthcoming report of a National Academy of Social Insurance study panel on this topic, co-chaired by our research director, Marc Cohen.

Finally, in case you missed it, in the middle of election week, the Centers for Medicare and Medicaid Services (CMS) released its final Medicare physician fee schedule for calendar year 2019. The proposed rule included a provision that would greatly reduce the amount that physicians are paid for office visits with people with the most complex needs. We were concerned that this could have seriously compromised care for such individuals. We are relieved that CMS pared back this proposal in the final rule, which also delays implementation of these changes.

What are you hoping for or worried about after this election? Tweet us @CCEHI.

Editor's note: An earlier version of this article incorrectly stated the number of states that shifted from having Republican Governors to Democratic Governors. The correct number is 7 (IL, KS, ME, MI, NM, NV, WI).

FROM THE CENTER & OUR PARTNERS

New Center Report Focuses on the Transformative Potential of Primary Care

The Center released a new report, “Policies to Transform Primary Care: The Gateway to Better Health and Health Care” that gives advocates several federal and state level avenues for pursuing primary care reform as a proactive means of addressing poor health outcomes for consumers and high costs for all.    

More people receive care from a primary care provider each month than any other health professional. They often serve as an entry point in the health care system – connecting patients to the other specialists, treatment options and even social services needed to get and stay healthy. Additionally, we know that primary care is associated with better health outcomes and lower costs – particularly for patients with complex health needs. But there are a number of problems consumers experience in trying to access this high-value care. It’s often hard for consumer to find a primary care provider, consumers still face affordability barriers to accessing primary care, and when they can access primary care, that care often doesn’t meet their health care needs.

Because primary care is the gateway to the health system, a transformed health system that meets the health needs of all people must start with re-envisioning how we deliver primary care.

Center Work Featured in RWJF Lessons on Consumer Engagement

A recent blog post from the Robert Wood Johnson Foundation highlights seven strategies to better engage Medicaid enrollees in the policy development and delivery reform implementation process. The Foundation identified these strategies in collaboration with its national partners, including the Center and Community Catalyst. The post also highlights the work of the Massachusetts One Care Implementation Council as a best practice and pointing to the Center’s case study of the Council.

ELDERCARE VOICES

Spotlight: Learning to Appreciate Integrated Care to Address Mental Health Needs

Gregg Warshaw, MD

Dr. Warshaw, an academic family physician/geriatrician, is a clinical professor in the Departments of Family Medicine and Internal Medicine, Geriatrics Division, School of Medicine, at the University of North Carolina-Chapel Hill. Dr. Warshaw is a Senior Advisor to the Center for Consumer Engagement in Health Innovation.

The practice of geriatric medicine is characterized by an inter-professional approach. During my career I’ve been fortunate to practice in settings with comprehensive team-based care.  Most recently, for the past three years, I have been working in the University of North Carolina – Chapel Hill’s Health System.  I care for older adults in two out-patient offices affiliated with the Departments of Family Medicine and Internal Medicine, Geriatrics Division.  Primary care is the primary mission of both practices. These busy, high-quality teaching practices are supported by an array of clinical team members including, physicians, clinical nurse specialists, nurses, pharmacists, physical therapists, nutritionists, social workers, and medical assistants.  New to me has been the inclusion of mental health expertise integrated into these practices, including psychiatrists, psychologists, and skilled social work counselors.  These mental health professionals work in my office and are available for informal or formal consultation.

Primary care settings are the most common pathway to the behavioral health system, and primary care providers need support and resources to screen and treat individuals with behavioral and general healthcare needs. My current experience reinforces my belief that integrated care, the systematic coordination of general and behavioral healthcare, may be the best solution for these twin care needs.

For example, Mr. R is a 78-year-old man in my practice who has Lewy Body Dementia (LBD).  LBD is associated with significant behavioral symptoms including psychosis.  These patients are also very sensitive to psychotropic medications and frequently have adverse reactions to them.  Mr. R is cared for in his home by his wife who is increasing overwhelmed by her caregiving responsibilities.  In my care for this patient, I have regularly conferred with the psychiatrist in my practice for advice on managing behaviors and have asked the social worker to assist me in providing support for Mr. R’s wife/caregiver.  This on-site team-based model reduces communications problems between clinical providers and reduces stress on Mrs. S who is responsible for organizing Mr. R’s care. This additional expertise has improved the overall quality of care for this patient and it has all been possible without referral to outside resources.

There are many ways to integrate care, and they may go by different names, including “Collaborative Care” or “Health Homes.” This is an important model of care because:

  • Primary care settings, like a doctor’s office, provide about half of all mental health care for common psychiatric disorders
  • Adults with serious mental illnesses and substance use disorders also have higher rates of chronic physical illnesses and die earlier than the general population
  • People with common physical health conditions also have higher rates of mental health issues.

Coordinating primary care and mental health care in this way can help address the physical health problems of people with serious mental illnesses.

How Does It Work?  There are different levels of services integration. The Substance Abuse and Mental Health Service Administration (SAMHSA) designed a framework to help health care providers plan and support an integrated system.  That framework has three main categories:

  • Coordinated Care, which concentrates on communication
  • Co-located Care, which focuses on physical proximity
  • Integrated Care, which emphasizes practice change.

Within each category, there are varying degrees of collaboration between care providers. These levels range from minimal to full integration. Minimal integration is when medical and mental health care providers work in separate facilities, have separate systems, and rarely communicate. Full integration involves a single health system’s medical and mental health care providers working simultaneously to treat a patient’s behavioral and medical needs with shared medical record access.

Why Is It Important? Addressing the whole person and his or her physical and behavioral health is essential for positive health outcomes and cost-effective care. Many people may not have ready access to mental health care providers, or even if they do, may still prefer to visit their primary health care provider. While most primary care providers can treat straightforward mental disorders, particularly through medication, that may not be enough for some patients, or their cases may be unusual or complex. For these reasons, it historically has been difficult for a primary care provider to offer effective, high-quality mental health care when working alone.

Combining mental health provider services and expertise in a team-setting with primary care can reduce costs, increase the quality of care, and, ultimately, improve lives.

This post by Dr. Warshaw first appeared in the blog of Eldercare Workforce Alliance on October 31, 2018.

NOTEWORTHY NEWS & RESOURCES

Doctors, Patients and Computers: “Something’s Gone Terribly Wrong”

A New Yorker feature article by Atul Gawande discusses computerized systems – designed with the best of intentions to help physicians better care for their patients – and the difficulties these systems are increasingly causing in doctors’ practices. While outlining the challenges that occur when human systems and technological systems meet in any sphere, Gawande focuses on the impacts they have on patient care, and the changes being wrought in doctor-patient relationships, as physicians spend an ever-increasing percentage of their time looking at screens instead of interacting with their patients. Spoiler alert, one quote from the article: “Something’s gone terribly wrong.”

CMS Calls for Nominations for Health Equity Awards

The Centers for Medicare and Medicaid Services is accepting nominations for the CMS Health Equity Award until Dec. 7. This award recognizes an organization “closing gaps in health care quality, access, or outcomes for our priority populations." The inaugural award was presented to Novant Health and Kaiser Permanente in February of this year.

MMCO Relaunches "Monthly Enrollment Snapshots"

The Medicare-Medicaid Coordination Office has resumed issuing a monthly report showing the number of individuals with both Medicare and Medicaid. The report shows that as of Dec. 2017, there was a total of just over 10.7 million dual eligible beneficiaries across the country.

STATE HIGHLIGHTS

Maine

Voters in Maine rejected Question 1, which would have established a first-in-the-nation universal home care program in the state. The initiative would have increased the training and pay for home health care workers by levying 3.8 percent tax on income over $128,400 and would have provided at-home services for anyone in the state needing long-term care. Maine’s population is the oldest in the country, and about half of all Maine residents require home health services or have provided them for family. Despite its defeat in Maine, the national interest in the measure may inspire similar efforts in coming election cycles across the nation, as well as catch the attention of state and federal policymakers.

Michigan

Six Michigan cities have joined AARP’s Age Friendly Communities initiative in an effort to more adequately address the needs of their growing senior populations. Taking a page from the World Health Organization’s guide for age-friendly communities, AARP has identified eight areas in which to assess a city’s age-friendly status, including access to affordable housing, social inclusion and health services. In addition to city-led public meetings to discuss infrastructure and service gaps for older adults, some community centers have taken it upon themselves to offer a wider range of health and wellness programs aimed at increasing access to care, developing community networks, and establishing mechanisms for older adults to identify barriers. Another offshoot of this initiative is a program developed at St. Joseph Mercy Hospital called the Senior E.R., a medical wing built to respond directly to the health needs of older adult populations.

Virginia

According to a new analysis from Catalyst for Payment Reform, more than two-thirds of commercial and Medicaid contracts in the Commonwealth of Virginia include ties to value. Catalyst for Payment Reform has produced value-oriented scorecards for both commercial payments and Medicaid payments in the state, hoping to establish a baseline for future value assessments and highlight the state’s work to improve value-based care. Among the findings is data showing that the vast majority of commercial value-oriented payments were to hospitals, while the state’s value-oriented Medicaid payments went more often to primary care providers.

KEY DATES

Tuesday, Nov. 27 (1-2 p.m. Eastern) - Webinar: Innovations in Member Engagement in Rural Areas, presented by the The Centers for Medicare and Medicaid. Please register for the webinar.

Wednesday, Nov. 28 (12:30-4:30 p.m. Eastern) - Symposium Livestream: “The Dual Imperative," presented by the Center for Consumer Engagement in Health Innovation. Please register for the livestream.  

Wednesday, Dec. 5 (12-1:30 p.m. Eastern) - Webinar: Palliative Care for Older Adults Dually Eligible for Medicare and Medicaid, presented by The American Geriatrics Society. Please register for the webinar.    

Wednesday, Dec. 5 (1-2 p.m. Eastern) - Webinar: ASA Webinar: Fall Prevention, presented by The American Society on Aging. Please register for the webinar.