Hospital systems across the nation are buying up physician practices, and policymakers are concerned about the impact that this trend — called vertical integration — could have on the health care system. On June 12, the US Senate Judiciary Subcommittee on Antitrust, Competition Policy, and Consumer Rights held a hearing on the competitive implications of vertical integration in the health care industry.

Vertical integration occurs when entities at different levels of the health care supply chain combine, such as when hospitals acquire physician practices or health plans acquire pharmacy benefit managers. This type of consolidation is different from horizontal integration, which occurs when entities operating in the same market come together — when one physician group buys another or hospitals merge with other hospitals.

Academic and political interest in vertical integration has increased as the rate of independent practices being acquired by hospitals has accelerated. An analysis (PDF) by the Physicians Advocacy Institute and Avalere Health found that the total share of physician practices owned by hospitals increased from 14% in 2012 to 31% in 2018. And a study published in the California theme issue of Health Affairs found that between 2010 and 2016, the percentage of California physicians in practices owned by a hospital increased from 25% to over 40%.

“These deals are, in many respects, reshaping the way patients receive and pay for health care,” said subcommittee Chairman Michael S. Lee (R-UT) at the hearing. “We hope that these transactions might improve the quality and reduce the cost of health care, perhaps by eliminating inefficiencies and aligning incentives. But vertical integration can also easily enable market power to be used in an anticompetitive manner, allowing the merged firm to use its new structure to the disadvantage of others, and in some cases, to the harm of consumers.”

The Potential for Cost Containment

Theoretically, vertical integration in health care can promote economic efficiencies, thereby improving the quality of care while reducing costs. At the Senate hearing, Craig Garthwaite, PhD, associate professor of strategy at Northwestern University’s Kellogg School of Management, pointed to the closely watched acquisition of health insurance company Aetna by drugstore chain / pharmacy benefit manager CVS Health as a “compelling merger,” writes Steven Porter in HealthLeaders. Garthwaite argued that the alignment of interests between the companies might help control chronic conditions and spending. “Now they at least have the incentive to [make patients healthier]; the incentives are aligned correctly,” he said.

Fiona Scott Morton, PhD, the Theodore Nierenberg Professor of Economics at the Yale University School of Management, said the acquisition of pharmacy benefit managers by health plans could yield notable efficiencies, FierceHealthcare reports. As spending on physician-administered drugs increases, “combining the pharma and medical benefit together will allow us to get a handle on those costs,” Scott Morton said.

Not All Mergers Are Created Equal

But witnesses also emphasized that vertical mergers can lead to anticompetitive behavior and higher costs. According to FierceHealthcare, tradition holds that vertical integration is categorically safe, but Scott Morton said that evaluating mergers should be done on a case-by-case basis, especially as health care accounts for such a large part of the economy.

Increased scrutiny may be necessary in light of research linking higher costs to vertical integration involving hospital-owned physician groups. A study of US hospitals by Stanford University researchers found that “hospital ownership of physician practices leads to higher prices and higher levels of hospital spending.” This finding was consistent with the researchers’ hypothesis that vertical integration increases hospitals’ bargaining power with insurers.

Studies of this type of vertical integration in California have reached similar conclusions. Physician groups owned by large hospital systems were more than 50% more expensive than those owned exclusively by physicians, according to an analysis published in the Journal of the American Medical Association. And the Health Affairs study concluded that recent increases in vertical integration in California were associated with higher prices for primary care, more expensive specialty care, and higher health insurance premiums.

Research from Rice University’s Baker Institute for Public Policy shows vertical integration has little to no impact on care quality, Jacqueline LaPointe reports in Rev Cycle Intelligence. “Physician-hospital integration did not improve the quality of care for the overwhelming majority of [quality] measures,” said study author Vivian Ho, PhD, director of the Center for Health and Biosciences at the Baker Institute. “If patient welfare doesn’t improve after integration, there may be other reasons why physicians and hospitals are forming closer relationships — perhaps to raise profits.”

Preserving a Competitive Market

For these reasons and more, both federal and state governments seem to be paying closer attention to vertical integration’s effects on competition. At the federal level, the Department of Justice and the Federal Trade Commission are responsible for investigating antitrust issues. In 2014, the FTC intervened in a case against St. Luke’s Health System in Idaho. More recently, the attorney general in Washington State privately settled a case against Franciscan Health System.

When asked how the federal government should respond to the vertical integration trend, witnesses at the Senate hearing recommended clarifying and expanding guidelines for antitrust regulators to follow during investigations. But even with clearer guidelines for both federal agencies, Scott Morton warned, there are not enough resources to keep pace with vertical integration in health care.

How has vertical integration affected your local health care market? Tweet at me with #EssentialCoverage or email me.

The post Is Vertical Integration Bad for Health Care Consumers? appeared first on California Health Care Foundation.

New data released by the state Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) show mixed results for California’s health insurance enrollment in 2018. Total enrollment stood at 32.8 million, down 269,000 (or 0.8%) from 2017, with declines in Medi-Cal managed care and the individual market nearly offset by increases in employer-sponsored small and large group coverage.

The enrollment data are also available under Document Downloads (Table 1).

Net Increase in Employer Coverage: Rise in Group Coverage Greater than Drop in ASO

Assisted by a strong economy, group enrollment increased in 2018 by about 350,000 (2.9%). Both the small group (1.5%) and large group (3.3%) markets expanded. Large group growth was partially explained by 2018 reporting improvements, which shifted roughly 250,000 enrollees from administrative services only (ASO) arrangements ¹ provided to self-insured employers to large group. Enrollment in ASO services was down by 219,818 (3.8%) to 5.5 million.

Taking both group and self-insured ASO changes into account, enrollment in employment-related categories increased by about 130,000 in 2018, trailing the nearly 284,300 California jobs added (PDF) during that time. The fact that enrollment is not keeping pace with job growth could be due to many factors, including an increasing number of jobs in the gig economy, which often lack benefits, and fewer employers offering coverage.

Medi-Cal Managed Care Enrollment Declines

Public managed care enrollment declined overall by nearly 300,000 (2.3%) to 12.9 million, driven by reductions in Medi-Cal managed care. Medi-Cal managed care enrollment dropped 3.5% to 10.4 million, while Medicare managed care grew by 3.1% to 2.5 million. Declines in Medi-Cal managed care have also been reported independently by the state Department of Health Care Services (PDF), confirming the downward trend in regulators’ data. Factors contributing to this trend may have included an improved economy, increasing minimum wage, and federal immigration policies that have discouraged enrollment in public programs.

Individual Market Enrollment Falls, Driven by 15% Decline Off Exchange

At the end of 2018 the individual market had 2.1 million enrollees (down 4.6%), posting its third consecutive year of losses (Figure 3). The 2018 individual market declines were spurred by accelerating losses outside Covered California, in the unsubsidized “off-exchange” market (9.5%, 6.8%, 15.0% respectively in 2016, 2017, and 2018). The full data set is available under Document Downloads (see Table 3).

These persistent off-exchange losses are likely influenced by multiple factors, including:

• Affordability — Off-exchange enrollees receive no premium subsidies and, unlike most Covered California enrollees, must absorb the full cost of premium increases.
• Elimination of individual mandate penalty — In December 2017 Congress eliminated the Affordable Care Act’s financial penalty for not carrying health insurance. Although this didn’t go into effect until 2019, it may have reduced incentives for both new signups and renewals in 2018. In the Covered California population, the full elimination of the mandate penalty in 2019 has already been shown to discourage new enrollments.

Why Off-Exchange Losses Matter

The off-exchange losses create problems for the entire individual market, because rates are set based on the pool of all individual enrollees. A broad-based pool, which includes the healthy as well as the sick, is needed for the long-term stability of the market. When a market or a portion of the market erodes, the healthy are most likely to give up coverage, driving up average medical costs and premiums. While Covered California’s enrollment totals are strong, their premiums could be hurt by trouble in the off-exchange portion of the market. Although most enrollees on Covered California are shielded from the full weight of premium increases by their premium subsidies, rising premiums put pressure on the benefit structure,² on the unsubsidized, and on anyone “buying up,” for example to a gold plan.

DMHC Continues to Regulate Vast Majority of Commercial Enrollment

The overall distribution of commercial enrollment (individual and group) between California’s two regulators remained unchanged in 2018. Health plans regulated by DMHC accounted for 93% of commercial enrollment in 2018; plans regulated by CDI accounted for 7%. (See Table 2 in Document Downloads for the full data set.)

Looking Ahead

Affordability is key to the long-term health of all California health insurance markets, especially the individual market. Recent state legislation, specifically the enactment of an individual mandate penalty and state-sponsored premium subsidies for enrollees earning 400% to 600% of the Federal Poverty Level, could improve participation and promote stability in the individual market. Even so, broad, long-term strategies to control costs and limit premium increases remain essential to maintaining high levels of coverage across all markets in the state.

Finally, we need to better understand if the decline in Medi-Cal managed care (and Medi-Cal overall) represents mainly transitions to other coverage or a new stream of uninsured (data on the state’s uninsured rate in 2018 is not yet available).

The post State Releases Data on 2018 Health Insurance Enrollment appeared first on California Health Care Foundation.

In a case that could eventually reduce funding for federal programs in California, a split US Supreme Court has temporarily blocked the Trump administration from adding a citizenship question to the 2020 census. In the 5-4 ruling on June 27, Chief Justice John G. Roberts Jr. joined the court’s liberal justices in finding that the Census Bureau’s justification for adding the question was inadequate. The case was sent back to a lower court for further proceedings. Because federal funding to states is determined partly by census counts, the stakes are significant for the health care system in California, which has a large immigrant population.

In March 2018, Secretary of Commerce Wilbur Ross, citing a request from the US Department of Justice, announced his intent to add this question to the 2020 census: “Is this person a citizen of the United States?”

However, earlier this year, US District Judge Jesse M. Furman of the Southern District of New York found that Ross violated federal law by misleading the public and his own department about the reasons for adding the question, Vox’s Dara Lind reported. Chief Justice Roberts upheld Judge Furman’s ruling after recent evidence (PDF), publicized by the nonprofit watchdog group Common Cause, suggested that Ross’s justification for the change was an after-the-fact rationalization. “We are presented . . . with an explanation for agency action that is incongruent with what the record reveals about the agency’s priorities and decision-making process,” Roberts wrote (PDF).

A Chilling Effect

Experts worry that the citizenship question would create a chilling effect in immigrant communities. Households with immigrant or minority family members might fear deportation as a result of filling out census forms, resulting in an undercount of 6.5 million people, according to the administration’s own estimate. “That could cause states with big immigrant populations like California to lose House seats and money for everything from infrastructure to food stamps,” wrote Patricia Leigh Brown in the New York Times.

Despite the Supreme Court’s ruling, California will remain vigilant to ensure a complete count, said Governor Gavin Newsom. President Trump “is desperately trying to stop immigrants from participating in our democracy and American society,” Newsom said in a statement. The state is “meeting this unprecedented census challenge with an unprecedented investment of $187 million in outreach efforts to ensure an accurate and fair count,” he said.

CHCF President and CEO Sandra R. Hernández noted on Twitter that while the decision is “good news for our democracy, it is critical for leaders from philanthropy, state and local government, and the community to continue working closely to ensure an accurate census. The future we share depends on it.”

An inaccurate census would mean that government health and social service programs whose funding is tied to census data would lose billions of dollars and struggle to meet community needs. According to the Public Policy Institute of California (PPIC), “more than half of the state’s population-based federal funding goes to Medi-Cal, which provides health insurance to low-income residents.” In federal fiscal year 2015, California received $44.2 billion in federal funding for Medi-Cal alone.

Additionally, health researchers who use census data would have a much harder time providing state leaders with the information they need to understand local challenges, target resources, and plan for the future, according to a PPIC fact sheet.

Immigration Question Could Resurface Soon

What comes next for the census and the legal case is unclear. “While the question is barred for now, it is at least possible that the administration will be able to offer adequate justifications for it,” Adam Liptak wrote in the New York Times.

Mere hours after the Supreme Court blocked the citizenship question, Trump stated his intent to delay the census to give administration officials more time to justify the addition of the question, the Washington Post reported. However, the administration does not have time on its side — it has previously said that a high court decision was needed by June 30 so that it could begin printing census forms.

How has your community responded to the Supreme Court decision? Tweet at me with #EssentialCoverage or email me.

The post Supreme Court Temporarily Blocks Census Question About Citizenship Status appeared first on California Health Care Foundation.

With the 2020 presidential race now underway, health care is one of the top concerns of American voters. At the first Democratic primary debate, held on June 26 and 27 in Miami, many of the 20 candidates addressed health care with various plans, goals, and ideas. Immediately following that event, CNN polled a nationally representative sample of 1,613 adults. The survey offers a snapshot of public attitudes (PDF) about health policy related to coverage. Here are some highlights:

National Health Insurance Program

When asked whether the US government should provide a national health insurance program for all Americans even if it results in higher taxes, 56% of respondents said it should, while 40% said it shouldn’t.

That split hasn’t shifted much since the same question was asked in January. However, support has waxed and waned over the years: In 1991, 67% supported a national health insurance program, dropping to 55% in 1995 and rising to 64% in 2007.

Not surprisingly, there was a significant divide among self-described Democrats, Independents, and Republicans on this question. A majority of Democrats (87%) and Independents (56%) were in favor of a national health insurance program for all Americans, while only 20% of Republicans supported it. Younger adults were also more likely to approve of a national health insurance program: 65% of respondents under the age of 45 approved, while 50% of respondents age 45 and over approved.

Replacing Private Insurance

The 807 survey respondents who said they support a national health insurance plan for all Americans were asked whether it should completely replace private health insurance. The survey found 37% said it should, while 57% said it should not. That is a slight drop in support for ending private insurance compared with six months ago.

Among all 1,613 adults who participated in the poll, “just 21% say they favor national health insurance and that it should completely replace private health insurance. Among potential Democratic voters, just 30% feel that way,” wrote CNN Polling Director Jennifer Agiesta.

Understanding “Medicare for All”

The concept of “Medicare for All” has received a great deal of attention in the media and on the campaign trail. Despite that interest, there may not be any broad, shared understanding of precisely what the term means and how it would work. CNN asked survey participants how well they understand what presidential candidates mean when they use the term “Medicare for All.” A total of 74% of respondents said they understand what the candidates mean “very well” or “somewhat well,” while 24% said “not too well” or “not at all well.”

For a primer on some of the Democratic plans for expanding health care — how they work and what they encompass — see Sarah Kliff and Dylan Scott’s comprehensive piece in Vox.

The CNN Poll (PDF) was conducted by SSRS from June 28 to 30 among a random national sample of adults reached on landlines or cellphones by a live interviewer. Results for the full sample have a margin of error of plus or minus 3 percentage points. For the subsample of 656 Democrats and Democratic-leaning independents who are registered to vote, the margin of error is 4.7 points.

Did any of the poll results surprise you? Tweet at me with #EssentialCoverage or email me.

The post As 2020 Race Revs Up, CNN Asks Americans About Health Care appeared first on California Health Care Foundation.

The Trump administration is seeking to modify federal regulations with harmful changes that could dramatically affect immigrants’ access to health care and other public benefits and weaken the health and social safety net. These policies affect access to health coverage, food assistance, housing, protections against discrimination, and more. These proposed changes could have major consequences for the health and well-being of immigrants across the country and especially in California, which has more immigrants than any other state.

Taken together, the administration’s proposals could damage the health and well-being of significant numbers of people. Experts suggest a recent enrollment decline in Medi-Cal among immigrant children may be partly driven by rising fear and uncertainty among immigrant families about federal immigration policy. Even as federal officials try to make life tougher for immigrants, California last month became the first state in the nation to offer full Medicaid benefits to undocumented adults up to age 25.

Many of the federal proposals affecting immigrants have not yet been finalized. Here is an overview of several key proposed rule changes, including opportunities to file public comments.

Public Charge Admissibility

Agency: Department of Homeland Security (DHS)

Release date of proposed regulation: October 10, 2018

Public comment period: Closed on December 10, 2018 (more than 260,000 comments were filed)

Release date of final regulation: Unknown but expected September 2019

Last year, DHS proposed altering public charge admissibility criteria under which an immigrant with legal status can enter the country or be allowed to become a legal permanent resident. Under the proposal, the definition of “public charge” would be expanded significantly, and an immigrant could be deemed a “public charge” — and therefore be denied entry to the US or a green card — if enrolled in one or more of a wide range of safety-net programs. These include full-scope Medicaid (called Medi-Cal in California), the Supplemental Nutrition Assistance Program (called CalFresh in California), and others. The draft rule includes criteria giving preference to immigrants who speak English, are formally educated, and have financial means while deeming the absence of these things as negative factors that put immigrants at a disadvantage if they have health challenges they can’t afford to treat. Our earlier blog dives into details, as does a California-specific report from the Insure the Uninsured Project (PDF).

Although the rule will not take effect until finalized, cannot be implemented retroactively, and applies only to certain immigration status categories, it has created a chilling effect that is driving individuals and families to withdraw from health and safety-net programs for which they are eligible. If implemented, the changes could cost California billions of dollars and thousands of jobs, according to an analysis performed by the UCLA Center for Health Policy Research, the UC Berkeley Labor Center, and California Food Policy Advocates. According to a recent report from the Urban Institute (data), as many as one in seven adults in immigrant families reported that they or someone in their family avoided public benefit programs in 2018 in anticipation of the DHS proposed rule. The negative impact reported thus far will be exacerbated when the rule is finalized. Legal challenges will likely delay implementation, but immigrant disenrollment from key safety-net programs will likely continue.

Public Charge Deportability

Agency: Department of Justice (DOJ)

Release date of proposed regulation: Unknown

Public comment period: 60 days following release

Release date of finalized regulation: Unknown

DOJ is pursuing a related rule regarding public charge deportability that would alter the criteria under which the government can remove an immigrant from the country if that person is deemed a public charge. Journalists obtained a copy of the draft rule in May. The proposed rule is now at the Office of Management and Budget for review. It is expected to be published soon in the Federal Register, after which a 60-day opportunity to provide public input will begin. Protecting Immigrant Families (Community Resources, Take Action) offers a range of resources for people and organizations interested in commenting.

Housing Protections for Immigrant Families

Agency: Department of Housing and Urban Development (HUD)

Release date of proposed regulation: May 10, 2019

Public comment period: Closed July 9, 2019

Release date of finalized regulation: Unknown

Housing is key to good health. HUD is proposing to alter the public housing assistance eligibility rules for “mixed status families,” meaning families with mothers, fathers, siblings, or other relatives whose immigration status has not been verified by the government. Currently, these families receive prorated housing assistance based on the number of individuals in the family who have citizenship or verified immigration status and who fall within immigration classifications eligible for government housing programs, such as Section 8. The head of household or spouse in a mixed family is currently not required to have verified immigration status to qualify for housing assistance.

Under the proposed regulations, no one in a family could get assistance unless everyone in the family has verified immigration status. Once implemented, this means that if a parent’s status is not verified, they cannot be “head of household” and thus cannot apply for housing assistance for their family — even for citizen children. This is a marked change from current statutory interpretation. If the rule is finalized, it will put access to safe, stable housing — a key social determinant of health — in jeopardy for citizen children and their mixed status families. The Center on Budget and Policy Priorities has more details about who would be affected by the rule.

The 2020 Census

There has been extensive debate and litigation about a question regarding citizenship that the administration seeks to include in the 2020 Census. Opponents argue that this question would scare immigrants and undocumented people away from responding to the census, thus leading to an undercount. The Supreme Court recently ruled that the Trump administration did not adequately disclose its reasoning for including the citizenship question on the upcoming census. Because of the tight timeline for printing the census questionnaires, the administration at first decided to go forward without the citizenship question. But after that information was given to the court that was hearing the case, the White House abruptly changed course, and the administration has declared its intention to continue seeking a legal pathway to place the question on the form.

The Urban Institute recently released a report and interactive graphic assessing potential miscounts in the 2020 census (overview, full report, interactive graphic) and identifying communities at greatest risk of being undercounted. California’s population is projected to be undercounted by 379,000 to 792,000 people due to such factors as demographic changes, underfunding, process changes, and the citizenship question. The undercount would largely occur in historically underrepresented communities, including Latinos, who account for about 40% of California’s population. Because federal funding and congressional representation are proportional to population, California could end up with fewer members in the House of Representatives and could experience a reduction in federal funding for the Children’s Health Insurance Program, CalFresh, and other programs.

The post These Four Federal Proposals Would Have Major Health Implications for Immigrants appeared first on California Health Care Foundation.

Dolly Lucio Sevier, MD, grew up so close to the US-Mexico border in Brownsville, Texas, that she had American classmates who lived in Mexico and commuted across the border daily for school. Brownsville is one of the poorest places in the country, with limited access to health care and healthy food. After completing her pediatric residency at the University of Texas Southwestern Medical Center, Sevier felt a responsibility to return to her hometown, where she now finds herself on the front lines of the nation’s historic child migrant crisis.

Sevier told The Atlantic’s Jeremy Raff that her role as a pediatrician includes “being the voice for the kid, the advocate.” She never could have predicted that would include being an advocate for migrant children held in squalid conditions in a US Customs and Border Protection detention center known as Ursula.

In a medical declaration obtained by ABC News, Sevier wrote, “The conditions within which [the children] are held could be compared to torture facilities.”

More than 1,000 migrant children are being held in Ursula, a retrofitted warehouse in McAllen, Texas. A team of immigration lawyers — alarmed by what they saw during a recent visit — asked Sevier to visit the detention center and evaluate the young inmates. Children were being held in overcrowded facilities (PDF) with limited food, blankets made of Mylar sheets, and no access to showers.

After examining as many children as she could, Sevier found “evidence of sleep deprivation, dehydration, and malnutrition.” Most troubling, she witnessed unusual behavior that she attributed to psychological trauma. Most of the children Sevier sees in her pediatric clinic resist or cry when they are frightened. But the children she examined at Ursula were submissive — at first “totally fearful, but then entirely subdued.” She told Raff, “I can only explain it by trauma, because that is such unusual behavior.”

Pictures of Children’s Pain

On July 3, the American Academy of Pediatrics (AAP) released disturbing drawings made by migrant children after their release from detention. Time magazine reports that three drawings, “created by a 10-year-old Guatemalan boy, an 11-year-old Guatemalan child, and a third child identified only as 10 years old,” were sent to Sara Goza, MD, president-elect of the AAP, by a mental health clinician and social worker.

The children were asked to draw their experiences in Border Patrol detention centers like Ursula (the AAP does not know which detention centers these three children were held in). One drawing depicts five caged stick figures lying on the ground, covered by blankets. A guard wearing a hat watches from above, while two others stand at the exits.

Migrant kids were living in isolated cellblock units, subject to pepper spray and other forms of force or discipline, and allowed outside only for limited periods of time. —Michelle Wiley, KQED

“The fact that the drawings are so realistic and horrific gives us a view into what these children have experienced,” Colleen Kraft, MD, immediate past president of the AAP, told CNN. “When a child draws this, it’s telling us that child felt like he or she was in jail.”

These troubling conditions are not limited to detention centers in Texas. KQED’s Michelle Wiley reports that immigration facilities across California are failing detained children with disabilities. Investigators with Disability Rights California, the nation’s largest disability rights group, in the past year visited nine California facilities run by the Office of Refugee Resettlement, which is responsible for housing unaccompanied migrant children in the US. They found that the agency fails to provide children with disabilities with necessary special education services, adequate health care services, and facilities appropriate for their mental health needs. “For example, migrant kids were living in isolated cellblock units, subject to pepper spray and other forms of force or discipline, and allowed outside only for limited periods of time,” Wiley writes. Many of the children have post-traumatic stress disorder, self-injurious behavior, suicidal ideation, or other mental health concerns.

Serious Threat to Long-Term Health

Reports about conditions at migrant detention centers have alarmed pediatricians and human rights advocates around the world. California Surgeon General Nadine Burke Harris, MD, MPH, an expert on childhood trauma, tweeted, “Traumatic events, like forcible separation from a parent, put children at risk for long-term health problems. . . . The harmful conditions documented in federal detention centers are a serious health threat that demands action.”

Michelle Bachelet, United Nations high commissioner for human rights, condemned the US for detaining children, saying that it “may constitute cruel, inhuman, or degrading treatment that is prohibited by international law,” according to Vox. “Detaining a child even for short periods under good conditions can have a serious impact on their health and development — consider the damage being done every day by allowing this alarming situation to continue,” Bachelet said in a statement.

A systematic review of studies on the relationship between immigration detention and mental health found “profound and far-reaching mental health difficulties” among detained children and young people. The review, published in BMC Psychiatry, concluded that “detention should be viewed as a traumatic experience in and of itself.”

Additionally, the US policy of family separation subjects children to multiple types of adverse childhood experiences (ACEs), according to a JAMA Viewpoint article written by the commissioner and chief of staff of the New York State Department of Health. Migrant children who are forcibly separated from their parents experience emotional neglect, parental separation, scenes of violence, and parental incarceration. And, while incarceration of children is not an official ACE, the authors argue that “simply being held in [detention] facilities may become an ACE for some” of the migrant children.

In an interview with the Greater Good Science Center at UC Berkeley, Burke Harris said that ACEs are “associated with changes in the structure and function of children’s developing brains, in their developing hormonal systems, and even in the way their DNA is read and transcribed.” A landmark study of more than 17,000 Kaiser Permanente members linked higher ACE scores with higher risk for poor health outcomes.

Time Is of the Essence

These studies strongly suggest that now is a critical time to mitigate the physical and mental harm suffered by migrant children in US detention centers. The authors of the BMC Psychiatry study stress the importance of minimizing the length of detention. Multiple studies have found a significant positive correlation between detention duration and negative mental health consequences. The AAP also tweeted that “no amount of detention is safe for a child.”

A study published in BMJ Pediatrics calls for the US and other countries that detain immigrant children to “reduce harm and promote the resilience and recovery of traumatized children by developing post-migration policies and processes.” Immigrant families must be reunited as quickly as possible, and children must be given access to trauma-informed health services, including culturally competent psychological and psychiatric support, the study concluded.

Some officials in Washington, DC, are paying attention to the studies. Congress has called Department of Homeland Security (DHS) officials to testify about the overcrowded conditions at detention centers. On July 12, the House Committee on Oversight and Reform heard from Jennifer L. Costello, the acting inspector general of DHS, about the “substantiated allegations of mistreatment” at detention centers. Kevin McAleenan, the acting secretary of DHS, has agreed to testify before the committee on July 18.

Sevier’s time at Ursula was spent working in a makeshift clinic as efficiently as she could, examining children one by one as they were brought in by Border Patrol agents. She examined 38 children on that day, taking meticulous notes such as “Underweight, fearful child in no acute distress. Only concern is severe trauma being suffered from being removed from primary caregiver.” She gave those notes to the immigration lawyers, who will use them to pressure the government to improve conditions in Texas detention centers.

The pediatrician told ABC News that the facility “felt worse than jail. . . . It just felt, you know, lawless. . . . I can’t imagine my child being there and not being broken.”

What have you read about the conditions at migrant detention facilities? Tweet at me with #EssentialCoverage or email me.

The post A Doctor’s Eye-Opening House Call at a Lockup for Migrant Children appeared first on California Health Care Foundation.

For more than a decade, many state and federal policymakers have argued for greater health care price transparency, and their efforts received a push in recent weeks. In late June, President Donald Trump signed an executive order that would publicly disclose the prices paid by insurers to health care providers for “shoppable services.” A few days later, a key US Senate health committee voted to send a bill with several major price transparency provisions to the floor for consideration. Here at home, the stakeholder committee tasked with developing California’s cost transparency Healthcare Payments Database neared the halfway point in its yearlong deliberation on what data to collect and how to distribute it. (The state’s effort is part of a category generally referred to as all-payer claims databases.)

What Is Becoming More Transparent?

Efforts vary on what type of prices would be made more transparent. In some cases, policymakers have pushed health care providers to publish their chargemasters, or list prices for services. (While few patients pay these prices, they are far from meaningless.) Most private health insurers and vendors such as Castlight now provide patients with estimates of out-of-pocket costs for different services. And some state and federal efforts have promoted disclosure of the rates negotiated between providers and insurers.

Support for this last type of transparency is the most controversial. Some stakeholders argue that negotiated prices are proprietary — that is, legally protected trade secrets. Other observers maintain that publishing these secrets could foster collusion among providers, enabling competitors to tacitly work together to boost negotiated rates. This tactic is known as “shadow pricing.” “Publicly disclosing competitively negotiated, proprietary rates will reduce competition and push prices higher — not lower — for consumers, patients, and taxpayers,” said Matt Eyles, president and CEO of America’s Health Insurance Plans.

What Should Become More Transparent?

A new CHCF report from legal and policy experts at UC Hastings School of Law, The Secret of Health Care Prices: Why Transparency Is in the Public Interest, examines this debate. After a thorough review of federal and state legal precedent, the authors found that no court has definitively held that negotiated rates between health care providers and insurers constitute trade secrets. Even if a court did find price data to be a trade secret, that protection is not absolute. States are legally permitted to disclose information in the public interest if they establish the conditions and policies for disclosure at the time of data collection.

Currently, 14 states collect and disclose price information in some form in publicly available databases that policymakers, researchers, and other parties can access. In all cases, data include prices negotiated between health plans and providers. States such as Maine and New Hampshire operate consumer-friendly, publicly accessible websites that list the amounts that specific plans and providers have agreed on for the most commonly used health care services.

In practical terms, the report authors find that price transparency does not automatically lead to collusion among companies. In contrast to commodity markets, health care prices are set annually, negotiations are complex, providers compete on more than cost, and patients often remain loyal to their providers. Economists argue that collusion — if any were to occur — would show up in the data being collected by the absence of evidence of inflationary pressure in other markets with databases.

To date, no state with a health care price database has experienced the feared competitive harms. In fact, a decade of public disclosure of negotiated rates in New Hampshire resulted in increased competition and reduced prices for “shoppable” health care services. University of Michigan economist Zach Brown (PDF) found that five years after prices for services like x-rays, CT scans, and MRIs were published on New Hampshire’s HealthCost website, patient out-of-pocket costs for these services declined 11%. Individuals and insurers in the state collectively saved an estimated $44 million over the study period.

Transparency as Cost-Containment Strategy

Californians are desperate for relief from the high cost of health care. Health insurance premiums now consume one-third of the state’s median family income. Premiums have increased 234% for the average family since 2002, while workers’ wages have increased only 30%. Californians are now more worried about paying for health care than for housing, transportation, and other necessities. While not a panacea, increased price transparency can be part of the solution to our health care cost conundrum.

Many different stakeholders would benefit from increased transparency. When consumers know how much providers charge for services, they may be able to make more value-based decisions. When researchers know what happens to prices charged by expanding systems, that information can help inform antitrust law. When regulators know where patients are getting care and what they are paying, they can ensure that insurance companies have adequate networks. When policymakers know exactly where dollars are flowing within the system, they can better target cost-containment efforts.

A major step toward greater price transparency is California’s Healthcare Payments Database. The Office of Statewide Health Planning and Development has brought together providers, payers, consumers, and other stakeholders to help make important decisions about which spending data will be collected, who must report, and how much of it will be publicly disclosed.

To ensure that California implements its database in ways that advance the cause of price transparency, the authors of the CHCF report made a series of recommendations based on the experience of other states with price transparency initiatives. These recommendations include:

• Developing clear policies regarding data release prior to data collection
• Establishing a committee to create guidelines, policies, and agreements for data access that balance competition and the public interest
• Monitoring annual claims data for anticompetitive behavior

With the right policies, governments can shine a light on the prices being paid by various stakeholders in our health care system. Such transparency could finally help achieve the holy grail of more accessible and lower-cost health care for all Californians.

The post How California Can Finally Close In on Meaningful Health Price Transparency appeared first on California Health Care Foundation.

The Trump administration’s recent changes to the Title X Family Planning Program are expected to severely reduce access to reproductive health services across the country. Title X is the $286 million federal program that ensures that low-income or uninsured women can obtain contraceptive and related services. Since the program was created in 1970, Congress has prohibited the use of Title X funds for abortion. The administration further distanced the program from abortion when it announced on July 15 that it had immediately cut off federal funding of health clinics that perform or refer patients for abortion. On July 20, the government gave clinics a two-month grace period to comply with the rule changes before facing penalties, the Washington Post reported. According to the Associated Press, “the latest timetable from the administration says clinics must submit a compliance plan next month, and by mid-September must show they are carrying out most of the new requirements.”

The rule changes are a huge setback for Planned Parenthood, the nation’s largest provider of reproductive health services (including abortion) and the largest recipient of Title X funding, at about $60 million. Planned Parenthood serves 41% of the four million Title X patients nationwide, providing basic primary and preventive services like wellness exams, breast and cervical cancer screenings, and testing and treatment for sexually transmitted diseases. In California, 26% of the more than 360 Title X clinics are no longer eligible for federal funding because they are Planned Parenthood clinics or because they provide abortions, according to KFF (Kaiser Family Foundation). Only Vermont, Utah, and Alaska have higher proportions of Title X clinics that are affected by the new rule.

Politco reported that Planned Parenthood will withdraw from the Title X program. To continue providing family planning services, it will tap emergency reserves while challenging the administration in court. “Since day one, the Trump-Pence administration has aggressively targeted the health, rights, and bodily autonomy of people of color, people with low incomes, and women,” said Emily Stewart, vice president of public policy for the Planned Parenthood Federation of America, in a statement. “We’re going to fight this rule through every possible avenue.”

These regulations put politics over quality patient care. They go against clinical best practices and medical ethics. — Julie Rabinovitz, Essential Access Health

Reproductive rights groups and nearly two dozen states, including California, have filed numerous lawsuits to block the Title X changes. In March, California Attorney General Xavier Becerra sued the Trump administration in the federal court for the Northern District of California. Oregon and Washington filed similar lawsuits. The challenges won temporary injunctions in April blocking implementation of the rule, but the Department of Health and Human Services appealed. On June 20, a three-judge panel of the US Court of Appeals for the Ninth Circuit in San Francisco ruled that the Trump administration’s Title X rule could go into effect immediately. Soon after, Becerra petitioned the Ninth Circuit to have all 27 of its judges reconsider the panel’s ruling.

Role of Reproductive Services in Reducing Poverty

Title X, passed with bipartisan support and signed into law by President Richard Nixon, provides a family planning safety net for millions of low-income women. Nearly 70% of patients who rely on Title X live in poverty, Jessica Mason Pieklo reported in Rewire.News. Additionally, “about one-third of Title X patients are Latinx and approximately 22% are Black, meaning a disproportionate number of Title X patients are people of color.”

Research shows that family planning plays a pivotal role in reducing poverty, in addition to numerous benefits, including “maternal and infant survival, nutrition, educational attainment, the status of girls and women at home and in society, human immunodeficiency virus (HIV) prevention, and environmental conservation efforts.”

It’s not surprising that a majority of Americans are concerned about access to reproductive health services under the new rule. A national poll conducted by KFF found that 69% of Americans and 76% of women ages 18 to 44 share this concern. Seventy-six percent say it is important for the federal government to fund reproductive health services, including family planning and birth control for women with low incomes. A national poll conducted by Morning Consult for the National Family Planning & Reproductive Health Association (NFPRHA) found 81% of Americans believe the public needs access to health care and health education — mainstays of the Title X program — to prevent unintended pregnancy. [Disclosure: Carlina Hansen, senior program officer for CHCF’s Improving Access team, serves on NFPRHA’s board of directors.]

California Not Immune to the Threat

In California, the nonprofit Essential Access Health is responsible for distributing Title X funds to over 360 health clinics in 38 counties. After the Trump administration released its final rule for Title X in March (implementation has been delayed by the legal challenges), Essential Access Health president Julie Rabinovitz said that she anticipated there would be clinic closures and 200 layoffs of federally funded positions under the rule, Sammy Caiola reported for Capital Public Radio.

In an email interview, Rabinovitz told me that “these regulations put politics over quality patient care. They go against clinical best practices and medical ethics. We are very disappointed that the Department of Health and Human Services decided to begin implementation of the regulations and jeopardize access to care while we are still in the early stages of the judicial process.” Essential Access Health has sued the Trump administration to block the Title X rule from taking effect.

The California Medical Association (CMA) also strongly opposed the final rule, saying in a statement, “These new regulations will limit access to critically needed care and services for millions of individuals who depend upon the Title X program for their care and will result in harm to patients and the public health.” CMA cited the finding by the Guttmacher Institute, a research organization committed to advancing reproductive health and rights, that $1.3 billion is saved annually in California due to public investment in family planning services at Title X–funded health clinics.

A Chaotic Time for Planned Parenthood

Roiled by the uncertainty and controversy surrounding the Title X changes, Planned Parenthood is also facing upheaval. After eight months at the organization’s helm, Leana Wen, MD, was ousted by the board of directors. On July 16, Wen announced via Twitter that the Planned Parenthood board had ended her employment because of “philosophical differences over the direction and future of Planned Parenthood.” Wen followed up with another tweet emphasizing her belief “that the best way to protect abortion care is to be clear that it is not a political issue but a health care one.”

Planned Parenthood appointed Alexis McGill Johnson as acting president. McGill Johnson, who co-founded the antibias research group Perception Institute, has served on Planned Parenthood’s board for nearly a decade. In a statement, Planned Parenthood described McGill Johnson as a “renowned social justice leader, lifelong political organizer, and a tireless advocate for reproductive rights and access to quality, affordable health care.”

At a time of growing threats to reproductive health services for women and families with low incomes, stable access to care is critical.

Essential Coverage will be on break next week and return on August 5. Tweet at me with #EssentialCoverage or email me.

The post Will Low-Income Women Lose Access to the Reproductive Health Care They Need? appeared first on California Health Care Foundation.

After five years leading the California Health Care Foundation’s High-Value Care Team and its opioid safety portfolio, Kelly Pfeifer, MD, is leaving Oakland for Sacramento to become deputy director of mental health and substance use disorder services for the California Department of Health Care Services (DHCS). In the last four years, CHCF has invested $7 million in innovative opioid safety work. I asked Pfeifer to reflect on California’s response to the opioid crisis and what she’s looking forward to accomplishing in her new role. Our conversation has been edited for length and clarity.

Q: When you started at CHCF in 2014, there were counties in California with opioid overdose death rates among the worst in the country. How did CHCF help to address this crisis?

A: It seemed like everything needed to change at once. Because too many areas of the state were awash in prescription opioids, we needed policies to reduce overprescribing while simultaneously increasing access to medication-assisted treatment (MAT) and the overdose antidote naloxone. We helped create local opioid safety coalitions to activate leaders and to change hearts and minds about solutions. We teamed with health plans, hospitals, clinics, and provider groups to integrate MAT into all points of care. And we worked with state leaders to align the many efforts around the state and help us pull in the same direction.

For people with substance use disorders, fragmented health care services are life-threatening. The only way to reverse the opioid epidemic and pave the way for better treatment of all brain disease is to get the local care system to work together cooperatively. That means primary care practices, mental health clinics, and treatment programs; hospitals, emergency departments, and paramedics; health plans and pharmacies; law enforcement and correctional facilities; schools; advocates; and many others. These relationships are all local.

Q: Where did the idea for these local coalitions originate?

A: We learned a lot from San Diego and Marin Counties. They brought these players around a table to review local data, create a plan, and take action. It became clear that stopping overdose deaths involved changing local culture and making sure everyone dealing with the overdose crisis had the most up-to-date information and understood that addiction is a disease, not a moral failing. We soon realized we would need local coalitions like this all over the state. That’s how they became a centerpiece of CHCF’s opioid safety initiative. Today, 45 of California’s 58 counties have coalitions, and they are linked together through the California Opioid Safety Network. The Center for Health Leadership and Practice at the Public Health Institute provides education and training to the network, with CHCF support.

Collaboration at the state level was equally important. Covered California [the health insurance marketplace],  CalPERS [the California Public Employees’ Retirement System], and DHCS [which runs Medi-Cal] — organizations that collectively purchase health care for 16 million people — started coordinating their opioid safety efforts under the umbrella of Smart Care California. These activities included disseminating an opioid safety toolkit for health plans so the plans could develop their own initiatives.

In 2014, the California Department of Public Health convened the Statewide Opioid Safety workgroup, which brought together more than 40 state and nongovernment organizations to improve coordination and to expand joint efforts to address opioid misuse, addiction, and overdose deaths.

The overdose crisis challenged all of us to work together in new ways. In the long run, the biggest legacy of our coalition work might be that local communities were empowered to leverage these new relationships to tackle other public health problems.

Q: How would you characterize California’s progress against unsafe opioid practices?

A: The good news is that opioid prescribing has declined 38% in the last four years and that California’s opioid overdose death rate is substantially lower than the national rate. The national opioid overdose death rate increased by 66% from 2014 to 2017, while California’s rate rose 6%. In the same period, overdose deaths for all drugs increased by almost 50% in the US, while increasing by 5% in California. We also are seeing increased access to treatment. For example, the number of Medi-Cal enrollees who received the opioid addiction medication buprenorphine almost quadrupled between 2014 and 2018. The number of Medi-Cal enrollees receiving the opioid overdose antidote naloxone went up almost 30-fold between 2014 and 2018, reflecting the much greater availability of this rescue drug.

But now there is some worrisome news for California too. Earlier this month, the US Centers for Disease Control and Prevention released provisional data for 2018 showing the first decline in the national all-drug overdose death rate since the 1990s. Meanwhile, California’s rate is estimated to have risen nearly 7%, the second consecutive year of increases. This is troubling.

The uptick in the overdose death rate shows the work is not done. We are still losing too many before their time, and we have the growing threat of methamphetamine, as well as the ongoing problems of alcohol and other drugs. California needs to continue to focus on the multipronged strategy that has kept our death rate comparatively low. The state has more tools, resources, and networks in place to build on its progress.

Q: The opioid crisis required California to innovate quickly, and you launched or supported many new ideas. Is there one pilot project you consider especially successful?

A: People with addiction may show up in many different places asking for help. Opioid overdoses continue to happen after people have reached out for help in health care or corrections settings, and that’s often a tragic missed opportunity. We wanted to change that. CHCF helped emergency departments and hospitals to start using MAT more routinely, and today 31 hospitals in 27 counties are part of the California Bridge Program, which uses a medication-first model for opioid addiction. They promptly treat the craving and withdrawal symptoms, then connect patients to resources for ongoing recovery. This is one of dozens of DHCS integration programs in the MAT Expansion Project, and it’s supported by over $240 million in federal funds. I am especially proud that our work helped inspire 30 counties to commit to providing MAT in jails. Some counties have already started, and others will soon. Most people in jail – 65%, according to one study – have substance use issues, but effective treatment for opioid addiction wasn’t available before.

Q: What did we learn from the opioid safety effort that can help California address other substance use disorders?

A: California has been smart about using federal funds to build infrastructure that can help people with any kind of addiction. As a society, we can’t afford to build a one-drug system. The opioid epidemic gets headlines partly because one wrong dose can kill you in minutes, but California also has a surging methamphetamine problem. And let’s not forget that alcohol causes more deaths than either meth or opioids. California needs a system that doesn’t pick winners and losers among the misused substances. Everyone deserves compassionate treatment.

CHCF has been very involved in helping DHCS and counties overhaul Medi-Cal’s program for substance use disorder services, known as the Drug Medi-Cal Organized Delivery System. It’s up and running in 30 counties so far. These new programs are building local capacity for treatment that spans the full spectrum of evidence-based care of addictions. It was the first expansion of its kind in the nation, and other states are watching and learning from it.

Q: CHCF is very focused on behavioral health integration. Why?

A: With everything we know about brain science and the interconnection of physical health, mental health, and substance use, our fragmented systems of care don’t make sense anymore. That’s why CHCF made it a priority to bring a whole-person approach to behavioral health in Medi-Cal.

CHCF convened meetings with a wide range of stakeholders last year to find ways to improve outcomes for people in Medi-Cal struggling with mental health challenges. CHCF recently published a blueprint for integration based on that work. The blueprint calls for every person in Medi-Cal to be associated with a single accountable entity that can arrange physical and behavioral health. That doesn’t mean one entity provides all the care and treatment, and it doesn’t mean that every county or region does it the same way. It does mean that at the end of the day, there is someone responsible for making all the different parts of the system work together for a patient’s total health.

Q: What are your hopes for your work in Sacramento?

A: This is an exciting time to be joining state government. We have a governor committed to universal coverage and to a better system for people with mental health and substance use disorders. We have a bold and innovative health and human services secretary, Dr. Mark Ghaly, a leader in integrating care for vulnerable populations. And for the first time in California history, we have a mental health czar, Tom Insel. It’s an incredible opportunity to contribute to the improved well-being of millions of Californians and to help the state set a positive example for the nation.
 

The post Opioid Safety Lessons Put Physician on Path to State Policymaking appeared first on California Health Care Foundation.

When babies are born dependent on opioids, typically they are whisked away from their mothers, put into the neonatal intensive care unit (NICU), dosed with morphine to get them through withdrawal, and gradually weaned off the drug—a process that can take weeks.

Research now suggests that this long-established standard of care may be the worst way to care for a newborn with opioid dependency, or neonatal abstinence syndrome (NAS). The NICU is busy, noisy, and bright, filled with beeping machines, other crying babies, and bustling nurses. Infants are fed not when they’re hungry but every three hours on a schedule. When they cry, there may be no one to hold them if the nurses are busy attending to other babies. And when they finally can sleep, they may be awakened to be poked and prodded for medical tests and treatments.

A new initiative is turning NAS treatment on its head with a shockingly simple concept: treat the baby like a baby and the mom like a mom. Keep the baby and the mother together. Keep the baby out of the NICU. And don’t give the baby opioids unless absolutely necessary.

This approach is known as “Eat, Sleep, Console,” meaning let the babies eat and sleep when they want and console them when they cry. With this protocol, hospitals treating members of Partnership HealthPlan of California — a Northern California Medi-Cal managed care organization — reduced the average hospitalization of babies with NAS from 18 days to 11 days. Partnership said that in just the first three months of implementing the new approach, it saved $389,000. Studies at other institutions have shown newborns experience no adverse effects from this new protocol.

When the Standard of Care Is Wrong

To anyone who’s taken care of an infant, Eat, Sleep, Console may sound obvious, but to physicians and nurses who treat babies with NAS, it’s a revolutionary departure from decades of practice recommended by experts.

“Taking these babies from their moms and putting them in a nursery where it’s noisy and lights are on has always seemed a little counterintuitive to what’s best for them,” said Susan Johnson, RNC, the NICU clinical coordinator at St. Joseph Hospital in Eureka. “But it was what the standard was and what we were told to do.”

Since the 1970s, the standard of care for NAS has been pharmacologic therapy — typically methadone or morphine — guided by the Finnegan Neonatal Abstinence Scoring System. The Finnegan system tests for symptoms of opioid withdrawal, such as shaking, fever, sweating, high-pitched crying, gastrointestinal problems, sneezing, and yawning. Babies are assessed every three hours, and if they score eight or more on the Finnegan three times in a row, they are given medication. Once they’re on the drug, it takes three to four weeks to wean them off, during which time they must remain in the hospital.

The problem is, many of the signs of opioid withdrawal look like typical newborn behaviors. “It really pathologizes a lot of the symptoms that are normal in any given newborn,” said Carrie Griffin, DO, a family medicine physician in Humboldt County who specializes in perinatal substance use and treats moms and babies. “All babies yawn, all babies have some amount of a tremble response. And what happens is, when we know that there’s been opioid exposure in utero, it’s a different lens through which we’re looking at these babies.”

Learning That Mom Is Medicine

Eat, Sleep, Console gets rid of the subjective Finnegan scoring system and only gives weight to a newborn’s essential functions. Can the baby drink an ounce of milk? Sleep for an hour undisturbed? Be consoled within 10 minutes? If the baby is functioning normally, then regardless of opioid exposure in the womb, the withdrawal isn’t severe enough to warrant treatment with drugs.

The protocol was developed by Matthew Grossman, MD, an assistant professor of pediatrics at Yale School of Medicine. While caring for babies with NAS, he noticed that the infant’s environment — and particularly whether the infant was kept with its mother — had more impact on how quickly the baby was released from the hospital than the pharmacologic treatment did. So instead of automatically turning to opioids, Grossman decided that the first-line treatment would be the mom.

It turns out that when the babies are given mom instead of morphine, they do better. With Eat, Sleep, Console, the average length of stay for infants born with NAS at Yale New Haven Children’s Hospital dropped from 22 days to 4 days. What’s more, only 12% of newborns treated with Eat, Sleep, Console required opioids compared with 62% of babies scored using the Finnegan model. These changes cut the cost of care per infant by more than 70%.

Watch this presentation about Eat, Sleep, Console by Yale pediatrician Matt Grossman, MD.

A Mother’s Touch

Nicole Merschdorf was one of the first women to go through the new protocol with her daughter Penny Lou at Mad River Community Hospital in Arcata, California. Merschdorf had been using intravenous drugs for five years, and she was on buprenorphine to treat her addiction when the baby was delivered. Buprenorphine is a first-line treatment for opioid addiction, and while it can lead to NAS in babies born to pregnant women taking the medication, the NAS is usually less severe. Buprenorphine helps the women maintain a more stable life without experiencing withdrawal and cravings while in treatment.

When Penny Lou was born, she showed signs of NAS, like restlessness, jerkiness, sneezing, and overactive sucking. But Merschdorf said that as soon as she did skin-to-skin contact with her baby, “It was really all the difference in the world,” she said. “She’d be fussing in her bassinet, and as soon as you picked her up and she felt a body, she’d instantly be soothed.”

Merschdorf and her daughter were able to stay in a private room in the nursery for seven days before Penny Lou was deemed healthy enough to go home. The baby girl required only a single dose of morphine on the second day. The one-off treatment — another departure from the Finnegan model — was enough to get her through the worst of her withdrawal without requiring a full course of the drug. Now Penny Lou is a happy, healthy six-month-old baby.

“When the baby is born, there’s a massive amount of guilt and regret,” Merschdorf said. “But the doctors and nurses are there to help you. And getting the best medical treatment for your child is what’s going to be best for them in the long run.”

Changing Clinicians’ Minds

In rural Humboldt County along California’s northern coast, more than 10% of newborns are diagnosed with NAS, the second highest rate in the state. Griffin, the family medicine physician, has spearheaded the rollout of Eat, Sleep, Console in several Humboldt hospitals, including St. Joseph Hospital and Mad River Community Hospital. Since the program started, most of the babies have gone home after four days, and Penny Lou was the only one who required pharmacologic treatment.

Most babies and children would rather be cuddled by their parents when they’re feeling sick than have somebody sedate them and make them sleep through the symptoms. —Candy Stockton, MD

Griffin said that while she is excited by their initial success, she’s still working to get buy-in from all the care providers. “There’s been a lot of resistance from pediatricians here because they feel like the babies are suffering, and we’re not doing anything to mitigate it,” she said. “It is hard to unwind those years of training and assessing and clinical pattern development and reorient around the idea that this is a healthy baby. The baby is experiencing withdrawal from the substance, but if we support them as we would want to support any newborn, they do really well.”

To help get more of the doctors and nurses on board, Griffin and Candy Stockton, MD, a family physician at the Humboldt Independent Practice Association and head of the county’s perinatal substance use task force, have been trying to reframe what the true source of suffering is for these children.

“Most babies and children would rather be cuddled by their parents when they’re feeling sick than have somebody sedate them and make them sleep through the symptoms,” Stockton said. “Putting the baby in a brightly lit, noisy, chaotic environment in the neonatal intensive care unit, separating them from their parents and caregivers to provide this care — all of those things are more traumatic to an infant who doesn’t understand what’s happening than it is for them to be a little shaky with a little bit of nausea and some muscle aches.”

Education Is Key

This type of clinician education is critical as Partnership HealthPlan of California works to get more hospitals to roll out Eat, Sleep, Console. The initiative began with a one-day conference on maternal opioid use in October 2018, at which Grossman presented the protocol. His talk had a dramatic and immediate effect on many of the care providers at the 22 hospitals in Partnership’s network. While the average reduction in length of stay was from 18 to 11 days, the hospitals that were most committed to Eat, Sleep, Console got their average stay down to just 4 days. As more hospitals adopt the program, the average length of stay is likely to continue dropping.

“Education is usually not your strongest way of making change happen on a massive scale,” said Robert Moore, MD, Partnership’s chief medical officer. “But the evidence is so overwhelming that when doctors heard a single presentation [on Eat, Sleep, Console], we saw this big change.”

Partnership is collaborating with the California Maternal Quality Care Collaborative to continue education around the new protocol, concentrating on four rural Northern California jurisdictions that have been particularly hard-hit by the opioid crisis: Humboldt, Lake, Mendocino, and Shasta Counties. As more providers learn about the treatment, Moore hopes hospitalization times and health care costs will continue to drop as this improved approach to neonatal abstinence syndrome takes hold.

“Keeping the knowledge out there is going to be really important,” Moore said. “Ultimately, learning more on the ground — how are they thinking about these barriers, what are their plans to address the barriers — and keeping that dialog alive is going to be helpful.”

The post Opioid-Dependent Newborns Get New Treatment: Mom Instead of Morphine appeared first on California Health Care Foundation.

For people coping with mental health problems, peer support can be an important part of their treatment. Peer support workers have personally struggled with mental illness, addiction, or both. They help other mental health patients to fully engage in the recovery process. Across the country, innovative peer counseling programs are helping expand access to mental health services, meeting patients where they are with culturally competent care and creating more roles for health care delivery.

Charlie Jones is an Oakland, California, peer support worker. In her 20s and 30s, she was hospitalized several times for mental health issues, Rob Waters writes in California Healthline. Despite the challenges, Jones successfully completed her bachelor’s degree in human development at California State University, East Bay, and today she is the program manager for Reach Out, a peer support program run by the nonprofit Alameda County Network of Mental Health Clients.

Reach Out brings peer support to mental health and adult residential facilities. The program depends on unpaid volunteers to deliver program services. During a recent visit to Great Expectations Residential Care in Oakland, Jones introduced herself to the residents as “Charlie the Angel.” With her that day was peer volunteer Lee Frierson, who connected with the residents by telling them “I’m a peer. I suffer from depression. It helps me to help you guys.”

Research from Emory University shows that peer counseling is a beneficial component of mental health recovery. In a randomized controlled trial (PDF), researchers studied 400 participants with a serious mental illness and one or more chronic illnesses (e.g., diabetes, heart disease). Participants assigned to a six-session health education program led by certified peer specialists (licensed by the state of Georgia) saw greater improvements to their physical and mental health than participants who received usual medical and mental health care. Other researchers have found that peer support for individuals with co-occurring mental health and substance use diagnoses prevented re-hospitalizations and facilitated their ability to live in the community.

California Moves to Recognize Peer Providers

California suffers from a shortage of licensed mental health professionals. Many psychiatrists and psychologists are nearing retirement age, and in general mental health providers are poorly distributed across the state and not reflective of California’s racial and ethnic diversity. Peer providers could play a role in helping the state meet some of its mental health workforce needs. The California Future Health Workforce Commission spent 12 months developing a master plan (PDF) to strengthen California’s health workforce, and one of its priority recommendations is scaling the engagement of frontline workers like peer providers through certification, training, and reimbursement. These workers can draw on “lived experience to support better outcomes for all and to promote recovery and self-sufficiency for people with mental illness and substance use disorder,” the commission wrote in its report. (CHCF is one of five organizations that funded the commission’s work.)

In 2007, the Centers for Medicare & Medicaid Services began allowing states (PDF) to reimburse for services delivered by peer providers. Medicaid funding is available for states that have a formal peer certification process, but California does not have one. That means the state is “leaving money on the table,” Keris Myrick, chief of peer services at the Los Angeles County Department of Mental Health, told Waters.

A bill authored by Sen. Jim Beall (D-San Jose) could change that. SB 10 would create a statewide peer support specialist certification program as part of California’s Medi-Cal program. SB 10 would allow the Department of Health Care Services (DHCS) to use funds from the Mental Health Services Act to develop and administer the certification program. On July 3, the bill moved to the Senate Appropriations Committee.

Last year, former Governor Jerry Brown vetoed an identical bill, citing financial concerns. “A fiscal analysis from the prior bill found a certification program would cost DHCS approximately $2 million in the first year, with an ongoing cost of $3.8 million annually,” reports Sammy Caiola for Capital Public Radio.

While California does not yet have a formal peer certification process, peer training programs are available through organizations such as the Alameda County Network of Mental Health Clients. Frierson, the unpaid volunteer for Reach Out, told Waters he plans to enroll in the training program and hopes to be certified by the state of California.

Restaurant Industry Addresses Mental Health Needs

Beyond certified peer programs like the one being considered in California, innovative programs that enlist social support from friends and colleagues are helping catch people in mental health crises.

Twelve people who worked in Sacramento’s restaurant and hospitality industry died last year from suicide or drug overdoses. Local chef Patrick Mulvaney, who is known for raising awareness and money for issues like homelessness and domestic violence, felt compelled to act. Mulvaney, owner of the farm-to-table restaurant Mulvaney’s B&L, partnered with five organizations to create a peer counseling program called I Got Your Back. The program includes a mental health training curriculum developed by the participating organizations — Kaiser Permanente, VSP Global, WellSpace Health, the Steinberg Institute, and the James Beard Foundation.

Gavin Jenkins reports for the digital media outlet The Outline that “Mulvaney and a handful of staff members were trained on how to talk to someone who is anxious, depressed, or suicidal, as well as what resources to offer them.” Those in-house peer mentors wear a purple pin to signal to their colleagues that they have been taught how to look for warning signs like changes in productivity or social functioning and can provide coping strategies and resources for those in crisis.

Mental health issues are common in the restaurant and hospitality industry. A report by the nonprofit Mental Health America ranked the food and beverage industry (PDF) among the lowest-scoring industries on workplace mental health. According to the US Substance Abuse and Mental Health Services Administration, about 17% of full-time workers in the accommodations and food services industry had substance use disorder in the past.

I Got Your Back pilots are expanding to 22 other Sacramento restaurants by the end of the summer. Candice Wang reports for the Sacramento Bee that data and interviews from those pilots will be collected to make improvements to the program. After that, Mulvaney hopes to roll it out across California and potentially even nationwide.

What types of innovative programs are helping your community meet its mental health care needs? Tweet at me with #EssentialCoverage or email me.

The post Life Experiences Help Peer Counselors Assist Others with Mental Health Issues appeared first on California Health Care Foundation.

SAN LUIS, Colorado — When Francisco and Ramoncita Medina heard about the planned retirement of their longtime doctor Joseph Quintana, MD — the only physician in this rural town — they worried they’d be forced to move. The Medinas, both in their 70s, knew Quintana as their lifeline to care for diabetes, blood clots, glaucoma, asthma, gout, and more. Given Francisco’s hand tremor, his declining vision, and the slick winter roads, driving an hour to the nearest town of Alamosa for their frequent medical needs wasn’t feasible.

For several years, Quintana had been planning to semiretire from Valley-Wide Health System’s San Luis Clinic as soon as a young physician moved to the area to became part of the 27-clinic operation, which serves a vast area of southern Colorado. But a small town without a pharmacy or a coffee shop isn’t very attractive to a young doctor. Like others before her, the young physician lasted only three years in San Luis. “A lot of people don’t like it here because we’re in the middle of nowhere,” said Quintana, who was born and raised in the town. The town of 630 residents is 225 miles south of Denver and surrounded by picturesque, jutting mountains. Much of the local economy is based on ranching, farming, and trade jobs.

But in 2017, access to health care in San Luis grew stronger. Christy Smith, a nurse practitioner (NP) trainee and San Luis Valley native, contacted Quintana. She wanted to fulfill requirements for clinical rotations by working alongside the doctor, and she was eager to stay in the community after graduation because her husband farms potato, barley, and alfalfa there. The limitations that drove away outsiders were the very things she loved about San Luis. Over the next year she observed Quintana and started treating his patients at the Valley-Wide clinic on a team with two full-time medical assistants, a part-time physician assistant, a behavioral therapist, and a case manager. The clinic also offers dental and physical therapy services.

“I had confidence from the beginning that she could do my job well, because I believe nurse practitioners can handle 90% of primary care cases without any input from a physician,” Quintana said. “Many of the people I see come in for respiratory illnesses, urinary tract infections, back pain, and routine monitoring for hypertension or diabetes.” He was impressed by Smith’s patience and willingness to teach disease prevention and management and to explain the benefits of a healthy diet, exercise, and weight loss. By the time Quintana retired, Smith had become a certified family nurse practitioner (FNP-C), and in July 2018 she officially began seeing his patients. Quintana agreed to advise her about more complex cases, such as unidentifiable rashes or uncontrollable hypertension. As she gained experience, her calls to him became less frequent.

Limitations in California

If Smith were in California or 21 other states (PDF), she would not have the legal right to practice independently. Despite research showing that restrictive policies inhibit patients’ access to care and increase hospitalizations and emergency room visits, nurse practitioners in those states aren’t permitted to practice and prescribe without physician oversight. Meanwhile, 28 other states permit NPs to prescribe a wide range of medications and practice without a formal physician oversight agreement, though some states restrict NPs from prescribing scheduled medications or have other policies that could limit their practice authority. States like Alaska, Arizona, Iowa, New Hampshire, Oregon, Rhode Island, and Washington allow NPs to practice autonomously. A 2018 report by Joanne Spetz, PhD, of the Healthforce Center at the University of California, San Francisco, outlines the policy contradictions.

Even though the California physician supply is projected to meet less than half the demand for primary care by 2030, proponents of restrictions on nurse practitioners in California argue for ongoing physician oversight to safeguard quality care. But Jeffrey Bauer, PhD, a medical economist and health futurist, who has analyzed nurse practitioner performance for a half century, said data have not borne out this concern. “I’ve never found a single published article that contradicts the fact that nurse practitioners perform at least as well as physicians, and they do it at half the cost,” said Bauer. He studied more than 300 peer-reviewed citations for his new book, Not What the Doctor Ordered: Liberating Caregivers and Empowering Consumers for Successful Health Reform. “There is no longer an excuse for restricting the full practice authority of nurse practitioners.”

Complementary Practices

In states like Colorado, physicians and patients are reaping benefits from independent nurse practitioners. Tillman Farley, MD, chief medical officer of Colorado’s Salud Family Health Centers, said doctors alone cannot meet the needs of low-income and uninsured patients in his area.

“The 20 nurse practitioners in our system are very helpful with the demand and are more likely to choose a career serving low-income patients,” Farley said. “I’ve observed that nurse practitioners are also more likely to spend extra time with people because they are good at listening and tend to work collaboratively with patients rather than hierarchically.” NPs are ideal providers for well-woman and child exams and for routine care for colds and chronic conditions, and that frees physicians to focus on difficult cases, said Farley.

In 1989 a similar division of labor developed in Durango, a southwestern Colorado town a few miles from the New Mexico border, when nurse practitioner Karen Zink, WHNP-C, MS, established a women’s health practice with a colleague. “It was a win-win situation,” said gynecologist and supporter Lloyd Lifton, MD. “They regularly referred surgical cases that allowed me to use the full extent of my training, and I would send patients with menopausal symptoms to Karen because she has a special interest and expertise in that area.”

During Zink’s clinical training, Lifton mentored her and trusted her as a provider. When she graduated, Colorado law required NPs to form a collaborative agreement with a physician to practice. Lifton agreed, which meant Zink’s prescriptions were sent in Lifton’s name. She had to develop a copious list of protocols for the dozens of conditions she treated and submit them for review by him.

Zink eventually started lobbying Colorado lawmakers for fewer restrictions on nurse practitioners. After many years of trying, the state legislature changed the law in 2010 to allow NPs to practice independently after 3,600 hours of mentored prescribing. Zink had already fulfilled this requirement years earlier, so she was free to practice independently right away, but many new nurse practitioner graduates in Colorado were not as lucky. Many struggled to find physicians willing to invest the time to mentor NPs for two years, and new graduates were leaving the state. In 2015, the regulation was revised to 1,000 hours of mentored prescribing.

Keeping Women Healthy

As an independent practitioner, Zink controls the ambience in her patient rooms and the time allocated to each appointment. She spends an average of 30 minutes per visit. Patients sit in an upholstered, cushioned chair when she confers with them about lab results, anxiety, insomnia, menopause, depression, and sexual matters. She works with an NP partner and employs a registered nurse, a licensed vocational nurse, an office manager, and a receptionist.

Kim Dinallo, 58, of Farmington, New Mexico, started seeing Zink 10 years ago for depression after a hysterectomy. Dinallo’s gynecologist had not recommended any treatment, and Dinallo’s sister suggested Zink. “I could not get out of bed, I cried easily, and I dreaded going to my job as a fifth-grade teacher,” Dinallo said.

Dinallo noticed that Zink was different from physicians. “She is personable, regularly sends me information, and is holistic in her approach,” said Dinallo. After Zink suggested that Dinallo try taking the antidepressant Wellbutrin and hormone replacement therapy, the symptoms vanished. Since then, Zink has helped Dinallo navigate dietary changes to prevent the recurrence of diverticulitis and to reduce the risk of heart disease.

At a recent appointment, the two reviewed blood tests showing elevated triglyceride levels. “Simple carbohydrates can drive up these levels, and triglycerides in women are predictive of heart disease and diabetes,” said Zink. After they methodically reviewed several days of Dinallo’s meals and snacks, Zink encouraged her to snack on celery with peanut butter rather than sugary fruits and to use real cream with coffee instead of a processed, sweet creamer.

A discussion like this takes more time, but Zink sets her own priorities. She prefers scheduling longer visits even if that means earning less money. “I am a nurse and I love women, so I enjoy talking about their mood swings, lack of libido, obesity issues, hot flashes, hypertension, diabetes, and everything else involving primary care” said Zink. “But it has taken years and years to gain full practice authority in this state.”

As political debates persist about whether nurse practitioners should have the right to practice independently, millions of Americans coping with shortages of health care providers sense their health and well-being are hanging in the balance.

“The critical issue at stake is access to care for underserved populations living in remote and rural areas as well as urban centers,” she said. “There is a significant body of evidence showing that the expansion of nurse practitioners’ practice authority will serve these populations well, especially as health workforce shortages loom large.”

The post Independent Nurse Practitioners Bridge Big Gaps in Rural Care appeared first on California Health Care Foundation.

The mass shootings that took place in Gilroy, El Paso, and Dayton can be called many things. Massacres. Acts of terrorism. Hate crimes. An epidemic. One thing you cannot call them is an accident.

These shootings were — and remain — entirely preventable. But only if our government — and specifically, our federal government — has the courage and humanity to act.

A common thread in all of these shootings is that the perpetrator used military-grade guns. In murdering 31 innocent people and seriously injuring dozens more — in a matter of minutes in each case — these guns did exactly what they were designed to do: kill people as efficiently as possible. The guns were easy to obtain. Their central role in these and similar atrocities is impossible to ignore.

Preventing mass shootings from happening again is not about ideology, identity, party, or politics. It’s about saving lives. Emergency room doctors and nurses know this better than anyone. That’s why they are among the most vocal proponents for modernizing our gun laws.

In 1996, Australia had its own wake-up call when a local shooter armed with military-grade guns killed 35 people and seriously injured 23 more in the town of Port Arthur. The government responded by outlawing such weapons and enacting additional gun reforms. In the 18 years prior to the Port Arthur massacre, there were 13 other mass shootings in Australia where 5 or more people were killed. In the 23 years since the government took action, they have had no mass shootings.

I am proud of California’s leaders and voters who have consistently taken steps to prevent gun violence. The state now has the most comprehensive gun safety laws in the country. It enlists researchers to track data on gun violence. It empowers health professionals to do community outreach and patient education to stop shootings before they happen. Not surprisingly, California has one of the nation’s lowest rates of gun deaths.

Unfortunately, California does not have the power to protect its people alone. The Gilroy attacker circumvented California’s requirements by purchasing his gun in Nevada. After Californians passed a ballot measure to ban the sale of high-capacity magazines in 2016, a federal court ruled the law unconstitutional. (An appeal is underway.)

California should keep moving forward to protect its people. It should continue to serve as a model for other states. And it should use whatever leverage it has to compel its federal counterpart to be part of the solution, rather than the cause of harm.

Ultimately, I have faith that our nation will get there, if all who are sickened by the violence continue to make our voices and our values heard. Democracy in action is more powerful than any gun.

The post Democracy in Action Is More Powerful Than Any Gun appeared first on California Health Care Foundation.

When the Affordable Care Act (ACA) passed in 2010, it included a provision to expand Medicaid eligibility to adults in families with incomes under 138% of the federal poverty line. Since the Medicaid expansion went into effect in 2014, research comparing expansion and nonexpansion states has linked expanded Medicaid access to better health outcomes. Additionally, some studies suggest that gaining Medicaid coverage is associated with a decline in medical debt, a reduction in personal bankruptcies, improved credit scores, and less reliance on predatory lending practices. Now the authors of a new working paper, published by the National Bureau of Economic Research (NBER), suggest another benefit: “substantially reduced mortality rates” among older, low-income adults in the expansion states.

For the NBER study, researchers at the University of Michigan; University of California, Los Angeles; National Institutes of Health; and US Census Bureau combined demographic data from the American Community Survey with mortality information from the Social Security Administration for low-income Americans nearing Medicare age. Because the US Supreme Court ruled in 2012 that states could opt out of the Medicaid expansion, the researchers were able to study the differences between residents in expansion states and nonexpansion states. (As of 2019, 14 states have not expanded Medicaid.)

Not surprisingly, the states that expanded Medicaid had higher rates of health coverage. But the researchers also found that mortality rates in those states dropped, “saving 19,200 lives over four years. Had all 50 states expanded the program, 15,600 further deaths would have been averted,” Annie Lowrey reported in The Atlantic.

“The 22 mostly red states that refused to accept expansion starting in 2014 caused 15,600 unnecessary deaths among their residents,” Michael Hiltzik wrote in the Los Angeles Times.

Lead author Sarah Miller, PhD, assistant professor of business economics and public policy at the University of Michigan, told Vox’s Tara Golshan that the results of the preliminary study are actually conservative. “It’s very likely that younger adults were affected too, or people that were high income in our data but could have lost a job,” Miller said.

Progress Still Needs to Be Made

California was among the first states to expand its Medicaid program, Medi-Cal. Public polling shows that residents have very positive views of the program. A statewide poll conducted by CHCF and KFF (Kaiser Family Foundation) found that 70% of Californians have a favorable view of Medi-Cal, and 91% say that Medi-Cal is important for California. Nearly 60% of Californians say Medi-Cal is important to them and their families personally.

Additionally, a KFF Health Tracking Poll conducted at the end of 2018 found that about 75% of the public have a favorable view of the ACA’s Medicaid expansion. Among those living in nonexpansion states, 59% would like to see their state expand Medicaid.

There has been some progress. In the 2018 midterm elections, voters in historically conservative Idaho, Nebraska, and Utah passed ballot measures to expand Medicaid in their states. However, Golshan reported that “despite the mandate from voters, Republican lawmakers in those states have been trying to roll back Medicaid eligibility.”

The remaining 14 states that have not expanded Medicaid are Alabama, Florida, Georgia, Kansas, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming. According to KFF’s State Health Facts, nearly two-thirds of those states are in the top 20 worst states for mortality rates.

The authors of the new NBER study concluded that their results “present consistent evidence of a decrease in all-cause mortality among low socioeconomic status, older adults under the ACA Medicaid expansions.” With the stakes so high, will those 14 states continue to hold out on expanding access to coverage?

Have you read any interesting research about the Medicaid expansion? Tweet at me with #EssentialCoverage or email me.

The post Expanding Medicaid Can Save Lives appeared first on California Health Care Foundation.

Over the last few months, I’ve had the privilege of listening to more than 100 low-income Californians talk about their experiences and aspirations in the health care system. One takeaway from those conversations rises above everything else I heard: They want to be treated as whole people, not as symptoms, visits, or poor people.

The focus groups and interviews we’ve been conducting in recent months were part of a CHCF-funded research project launched last spring to better understand the health care experiences and priorities of Californians with low incomes. (You can read this Q&A from our CHCF blog for more background on the project.) Focus groups are panels with diverse participants led by a professional moderator who facilitates conversations that provide insights into individuals’ experiences and attitudes on a given topic.

CHCF isn’t the first to explore how people experience health care in California, but there are important ways we wanted to dive deeper. Some of the existing data about care experiences and priorities are not available, not segmented by poverty level or insurance status, or are examined using only qualitative or quantitative analysis. This listening project is a powerful complement to existing research because it weaves together qualitative and quantitative work to tell a story about people’s experience of care, with a focus on those who have low incomes.

12 Focus Groups Around the State

In the first phase of this effort, we listened in an open-ended way to people enrolled in Medi-Cal, especially those who use California’s safety net, including community clinics and public hospitals. Medi-Cal is the backbone of the state health care system for low-income residents. We asked about what kind of relationship the residents have with their primary care provider, what their recent health care visits were like, and what factors determine whether the care meets their needs.

Our grantee, NORC at the University of Chicago, conducted 12 focus groups in four California counties — Alameda, Los Angeles, Shasta, and Stanislaus. They included people who identified as Black or Latino or spoke Spanish or Chinese. We also conducted nine individual interviews with people who primarily speak Vietnamese.

Even though most participants were Medi-Cal enrollees, some were uninsured, and over the course of a year many moved back and forth among Medi-Cal, employer-based coverage, and being uninsured. We recruited panelists, including some with chronic conditions, who received care in the recent past from community health centers and/or public hospitals. We tried to ensure that each group represented a mix of people who got their care from more than one provider.

Here are three of the themes that came up across the listening sessions:

“Treat Me as a Person”

In every group and interview, multiple people said that they want to be treated not as a patient but as a person. They want to feel respected and know the provider is listening. They want providers to treat them as individuals and to demonstrate compassion. People were clear about wanting not to feel judged. People with low incomes encounter stigma in so many parts of life. In health care, that stigma can be life-threatening if it discourages people from making or keeping an appointment even when care is urgently needed. It can prevent people from being honest with a provider about their needs and make it less likely they will follow through on plans to improve their health.

The people in the focus groups told us they seek respect from everyone in the facility, not only their primary care provider. Five years ago, a person’s main health care interactions would have been limited to the physician or nurse practitioner. Today, team-based care is becoming the norm, and people spend more time with nurses, social workers, medical assistants, front desk staff, and other health care workers. It turns out that such interpersonal contacts, in addition to those with the primary care provider, also matter and contribute to a person’s entire health care experience.

“Treat All of Me”

Focus group participants expressed frustration with the system being driven by volume rather than quality. Many people told stories about not being able to address more than one health issue in a single visit. Having to schedule multiple appointments on different days was a particular source of significant dissatisfaction. Several participants told us their providers felt rushed and told their patients they could spend only 10 minutes in a visit because of how they were reimbursed. But it’s also worth noting that people also said they loved it when they could see the doctor or nurse practitioner and go to the lab or pharmacy at one facility in a single visit.

For people with low incomes, having to make multiple visits is not merely an inconvenience, it’s a hardship. Most don’t have jobs with paid sick time. Many don’t have access to child care. In many cases, a trip to the doctor requires that they ride multiple buses. For people in rural areas, it means driving long distances. Each of these extra burdens takes dollars from limited paychecks and adds stress, neither of which enhances a person’s health.

“Don’t Just Give Me a Pill”

People consistently said they want their provider to focus more on preventing illness and helping them stay well. Most focus group members said the system is incentivized to concentrate on symptoms instead of root problems. People said their providers offered prescriptions as a shortcut instead of offering more meaningful care. Meanwhile, the management of multiple prescriptions with different refill timelines, different contraindications, and varying cost considerations added more layers of complexity to patients’ lives.

What we’ve been hearing has everything to do with how the health care system is designed. People see a system that they believe prioritizes volume over value, and human social interaction with providers matters far more to patients than system incentives allow.

Much work lies ahead in this fascinating project, but the listening so far has underscored the importance of having a safety-net system — built on a foundation of care, compassion, and respect — that allows and encourages providers to focus on the whole person.

The post “Treat Me Like a Person”: What We’ve Heard So Far from Californians with Low Incomes appeared first on California Health Care Foundation.

The US Department of Homeland Security (DHS) has finalized significant new restrictions to reduce immigration by creating a preference for wealthy, English-speaking, insured, and educated immigrants and putting up new hurdles for impoverished immigrants and their families.

A final rule (PDF) announced on August 12, 2019, directs DHS to apply new criteria to immigrants’ applications to enter the US or to modify their status to become a legal permanent resident (a “green card” holder). The regulation will be used to determine whether they are likely to become a public charge and should therefore be prevented from extending or modifying their immigration status. Our previous article on the CHCF Blog outlines the details of the original proposal.

Research shows the proposed rule has already caused immigrants to avoid public programs. Release of the final rule is expected to exacerbate this situation. “The complexity of the rule, combined with the current negative climate surrounding immigrants and immigration, will likely have a chilling effect on immigrant access to health care and coverage,” according to a report issued on August 14 by California’s Insure the Uninsured Project (ITUP).

As estimated by KFF (Kaiser Family Foundation), more than 13.5 million Medicaid and Children’s Health Insurance Program enrollees nationwide, including 7.6 million children, live in households with at least one noncitizen or are noncitizens themselves and could be at risk of disenrollment because of the new rule.

Expanding the Definition of Public Charge

Previously, only cash benefits, including Temporary Assistance to Needy Families (TANF) and government-funded long-term care, were considered when determining an immigrant’s public charge status. The new rule expands the definition of public charge to include a wider range of core health and safety-net programs:

• Health benefits: Medicaid for people over age 21 who are not pregnant or postpartum, except Medicaid received for emergency medical services
• Food benefits: Supplemental Nutrition Assistance Program (SNAP), the national program, known in California as CalFresh
• Housing assistance: Section 8 Housing Assistance under the Housing Choice Voucher Program, Section 8 Project-Based Rental Assistance, or other subsidized public housing
• Cash assistance: TANF, SSI (federal Supplemental Security Income), and General Assistance, all of which were previously included

The rule redefines “public charge” to mean “an individual who receives one or more designated public benefits for more than 12 months, in the aggregate, within any 36-month period (such that, for instance, receipt of two benefits in one month counts as two months).” This definition means that an immigrant receiving TANF, Medicaid, and SNAP for one year (3 benefits x 12 months = 36 months) would be considered a public charge.

The 217-page rule further outlines a “totality of circumstances” test and creates a system of weighted factors to determine if an immigrant is likely to become a public charge in the future. “Heavily weighted negative factors” include receiving one or more public benefits for more than 12 months in the aggregate within the last 36 months; being unable to demonstrate current, recent, or likely future employment; and having a medical condition that requires treatment that the individual cannot afford or does not have insurance to cover.

A System of Preferences

“Heavily weighted positive factors” include financial wealth, authority to work or employment with a salary of a certain minimum level, and private insurance that is not subsidized by Affordable Care Act (ACA) subsidies. The weighted system creates a preference for wealthy, English-speaking, insured, and educated immigrants and erects new barriers for immigrants who come from disadvantaged backgrounds.

Exactly how use of ACA premium subsidies to purchase insurance through exchanges will influence public charge determinations is unclear. While ACA subsidies are not considered a benefit under the final rule, they are not excluded from consideration either, and having health insurance without ACA subsidies is listed as a heavily weighted positive factor. How this will be interpreted in the totality of circumstances test remains to be seen.

Excluded Benefits

Within the affected communities, there is widespread misunderstanding about which benefits are and are not included in these definitions and who is subject to a public charge determination. Understanding and clearly communicating these exclusions to the public is essential to reducing unnecessary disenrollment.

The final rule excludes certain public benefits from consideration in public charge determinations:

• Health benefits that are excluded:
  • Medicaid benefits for emergency medical services
  • Medicaid for pregnant women and postpartum women up to 60 days after a baby’s birth
  • Medicaid for immigrants under age 21
  • Medicaid for school-based services and services provided under the Individuals with Disabilities Education Act
  • Children’s Health Insurance Program
  • Medicare Part D Low-Income Subsidy (previously considered but not included in final rule)

• Food benefits that are excluded:
  • Special Supplemental Nutrition Program for Women, Infants, and Children Program (this was included in original drafts and then withdrawn after a tremendous nationwide outcry)

• Other benefits that are excluded:
  • Public benefits received by individuals who are in active military duty or in the Ready Reserve component of the US armed forces, and their spouses and children
  • Public benefits received by certain international adoptees and children acquiring US citizenship
  • Public benefits received by individuals who are asylees, refugees, victims of domestic violence, and in other protected classes of immigration

Benefits Only Count If an Immigrant Is Listed as a Beneficiary

Many families with mixed immigration status are unclear about how the rule affects them as a whole or when benefit use by family members could jeopardize an immigrant’s application to extend his or her stay or to become a legal permanent resident.

The rule clarifies that DHS will only consider public benefits received directly by an immigrant for the immigrant’s own benefit. If one or more members of the immigrant’s household, such as an immigrant’s child or spouse, receives benefits, it will not count against the immigrant unless he or she is listed as a beneficiary. States, counties, and other enrollment entities across California and the nation will have to decipher how to clearly communicate this to families to ensure that benefit applications are filled out accurately so as not to jeopardize future immigration decisions.

The final rule also does not apply to public charge deportability. That falls under the purview of the Department of Justice, and a draft rule related to it is anticipated this year.

When Does the Rule Take Effect? What Is Likely to Happen Next?

The rule is scheduled to take effect at midnight Eastern Time, October 15, 2019. It will only apply to petitions and applications postmarked on or after that date. It cannot be applied retroactively.

We believe a protracted court battle over this rule is inevitable. Lawsuits challenging it have already been filed. Just today in California, two lawsuits were filed in US District Court for the Northern District of California.

California Attorney General Xavier Becerra led a multistate coalition challenging the rule as unlawful (PDF). The coalition consists of California, Maine, Oregon, Pennsylvania, and the District of Columbia. In the other lawsuit, nonprofits serving immigrant communities joined with advocates for racial equity, health, children, farmworkers, and working families to argue that the regulation is unconstitutional. The plaintiffs in the case (PDF) are represented by the National Immigration Law Center, Asian Americans Advancing Justice – Los Angeles, the National Health Law Program, and the Western Center on Law and Poverty. It is possible that the rule could be suspended or postponed prior to implementation. If a court determines that it violates underlying statutory law, the rule may be altered or rescinded.

While the implementation date is therefore cast in doubt, the fear generated by it has already led families to withdraw from core safety-net services for which they remain eligible, and that is likely to continue. It is essential that public and private agencies interacting with immigrant communities clearly communicate to these individuals and families which benefits they can and cannot access, and how receiving those benefits may affect their immigration status or that of the people they love.

The post The Final Public Charge Rule Is Out. Here’s How It Affects Immigrants. appeared first on California Health Care Foundation.

The camera pans to the therapist as she finishes scribbling a note and sets down her pen. “You’re a perfect candidate for buprenorphine,” she says to her patient. “Let’s get you to a doctor who can prescribe it.”

As far as we know, this is not a scene in a real TV show or movie, but it’s one that freelance journalist Zachary Siegel would like to see. Siegel, a journalism fellow at Northeastern University’s Health in Justice Action Lab, imagined this scene at a recent panel on addiction and mental health presented by Hollywood, Health & Society. (CHCF is a funder of the group).

To Siegel, who was treated for addiction himself eight years ago, this is an example of health messaging done right.

The messages we are exposed to through shows and movies can profoundly affect our knowledge, attitudes, and even behavior. Recognizing the power of entertainment, Hollywood, Health & Society (HH&S), a program of the USC Annenberg Norman Lear Center, provides writers and producers of films and TV shows with free and accurate resources on health, safety, and national security.

According to the panelists at the HH&S event, there is plenty of room for improvement in the way entertainment media depict behavioral health issues. Gemma Baker, cocreator and executive producer of the CBS show Mom, expressed her disappointment that recovery is often portrayed as dreary, joyless, and hopeless. “Recovery is not the end of the story,” she said. “It’s the beginning.”

That’s why Baker chose to start Mom in the beginning of the lead character’s recovery. “I love that we get to portray people with long-term recovery living full, vibrant lives and who choose to stay sober in the face of heartbreak by rallying around each other,” she told Danielle Turchiano and Amber Dowling of Variety. This, in turn, is likely why fellow panelist Corey Waller, MD, an expert in addiction medicine, said Mom is the only show portraying addiction that he can watch.

In 2016, the Mom team collaborated with former US Surgeon General Dr. Vivek H. Murthy to create a public service advertisement about addiction and drug overdose deaths. The PSA, which aired after an episode of Mom, urged people struggling with addiction to seek treatment, and it reminded viewers that addiction is a chronic illness, not a moral failing.

The latter point is important because, as Siegel writes in Vulture, “The cultural perception of addiction in America remains primarily one in which users are criminalized and accused of moral turpitude. . . . Efforts to destigmatize and humanize addiction run up against the entrenched view that only the weak-willed and reckless lose control of their drug use.”

In the article, he praises the TV show Euphoria, which premiered on HBO in June, for its honest portrayal of addiction infused with harm reduction messaging. For example, when the main character, Rue, played by Zendaya, accepts a drug dealer’s offer of fentanyl, a companion in the room tells his brother, “Go grab the Narcan, just in case.” Narcan is a brand name for naloxone, an emergency drug that saves lives by reversing opioid overdoses.

TV Shows Can Shape Understanding of Health Issues

As the US struggles with an opioid overdose crisis that kills more than 130 people per day, entertainment media provide opportunities to reach the general public with crucial health messages. According to the global marketing research firm Nielsen, US adults spent a daily average of four hours and ten minutes watching live TV in 2018. They devoted an additional 36 minutes a day watching time-shifted TV (recorded programming via DVR or video on demand).

Research suggests that entertainment media can shape viewers’ understanding of health-related issues and even modify their behavior. In the late nineties, researchers at the Kaiser Family Foundation collaborated with a writer and producer of the television medical drama ER to evaluate the effects of health information communicated through the show. They found that “51% of regular viewers said that they talked with family and friends about the health issues that were addressed on the show. A third said that they got information from ER that helped them to make health care choices.”

In Latin America, telenovelas — limited-run TV serial dramas — have been used for decades to deliver social change messages. In Mexico, the government was actively involved in promoting family planning in the 1970s. In 1974 it established the National Population Council (CONAPO) to design, operate, and evaluate public initiatives to regulate population growth. One of its initiatives involved the use of telenovelas to promote family planning. Acompáñame (Accompany Me) was the first telenovela to be broadcast and is largely credited with Mexico’s success with family planning.

The show aired during the 1977–78 season and portrayed three sisters who achieved harmony in their marriages by using family planning. During commercial breaks, viewers were encouraged to call CONAPO to request family planning information. According to the nonprofit Population Media Center, phone calls to CONAPO for such information increased from zero to an average of 500 per month, with many people mentioning Acompáñame as their motivation for calling. The enrollment of women in family planning clinics increased 33% in the year the telenovela aired (compared to a 1% decrease the previous year), and contraceptive sales increased 23% in one year (compared to a 7% increase the previous year).

Changing Depictions of Alcohol and Drug Use

At the HH&S event, moderator John August, a screenwriter known for Big Fish and the recent live-action film Aladdin, asked panelists to name one thing they wished the entertainment industry would stop portraying in shows or movies. August offered the first wish: “Can we please stop with the actual quantity of alcohol that we see characters drinking in movies and TV shows? . . . We all know that it’s tea or something in there, so they’re not actually drinking bourbon, but characters drink so much that they would be dead.”

Waller offered this: “Please stop portraying someone who’s in recovery from addiction as having a weakness inherently. And on the opposite side of that, don’t portray people who decide not to use drugs or drink as lame.”

He makes an important point. These depictions perpetuate dangerous stigmas that make it harder for people suffering from addiction to seek treatment and social support.

HH&S works with its partner organizations, including the US Centers for Disease Control and Prevention, to create tip sheets on health topics for writers and producers. CHCF supported the production of tip sheets about opioid safety and maternity care (PDF).

In Case You Missed It

CHCF President and CEO Sandra R. Hernández penned an op-ed in the San Francisco Chronicle about the Trump administration’s new public charge rule. Read it here.

What do you wish the entertainment industry would portray differently in television shows and movies? Tweet at me with #EssentialCoverage or email me.

The post Can Hollywood Change Attitudes About Addiction and Mental Health? appeared first on California Health Care Foundation.

One of our core beliefs is that improving the health care system in California for the benefit of all Californians requires diverse partnerships. The health care system is complex. So, too, are the experiences and needs of the population. Health care leaders need to be able to engage a diversity of perspectives in healthy and respectful dialogue in order to achieve meaningful progress.

Last week, we made the decision to withdraw funding for the California Birth Equity Collaborative, a project of the California Maternal Quality Care Collaborative, because we had indications that those values were not being upheld. What makes this decision difficult is that the project has been making progress in the content of the work. Keeping in mind the many different organizations and individuals who are involved with this project, CHCF is working carefully on a transition plan to minimize any unnecessary disruption to programs.

The California Birth Equity Collaborative was created to address the fact that Black women in California are three to four times more likely to die because of complications related to pregnancy and childbirth than are their white counterparts. The data show that factors like health status, education, and income cannot account for this disparity. There is a growing body of research to suggest that the central driver of this risk is racial bias in the health care system. This conclusion is consistent with what we heard in the recent Listening to Mothers in California survey (PDF), where 1 in 10 surveyed Black women reported experiencing discrimination in childbirth. This longstanding pattern of racism has led many in the Black community to deeply mistrust the health care system.

Because of that reality, and the fact that the vast majority of births happen in hospitals, the California Birth Equity Collaborative sought to bridge the perspectives and knowledge of the Black community directly with health care system experts and leaders. We recognized from the outset that this would not be easy. We remain convinced that such collaboration will be necessary to reverse a deadly health outcome with roots in racism.

This experience has been a learning process for CHCF. We will apply these lessons as we continue our work and grantmaking to advance birth equity. Our resolve to make a difference in addressing racial inequities in our health care system remains undeterred.

The post Learning Lessons on a Journey Toward Health Equity appeared first on California Health Care Foundation.

In August 1619, a Portuguese ship carrying more than 20 enslaved Africans docked at the British colony of Virginia. In that moment, slavery was established as an American institution. Four hundred years after that pivotal event, with the legacy of human bondage still permeating every aspect of American society, the New York Times Magazine published a special issue titled “The 1619 Project.” This ambitious endeavor aims to place “the consequences of slavery and the contributions of Black Americans at the very center of the story we tell ourselves about who we are,” the Times editors write. (Listen to Times reporter Nikole Hannah-Jones, who led the project, discuss her inspiration for the “massive undertaking” with Reveal podcast host Al Letson.) Naturally, health care has been profoundly influenced by the story of race in America, and the magazine gave that topic its due.

Linda Villarosa, project director of journalism at the City College of New York, examines the country’s dark history of medical experimentation on Black people. In the early 19th century, the physician Thomas Hamilton — a wealthy plantation owner — was “obsessed with proving that physiological differences between Black and white people existed,” Villarosa writes. He subjected John Brown, an enslaved man in Georgia, to painful medical experiments in an effort to determine whether the skin of Black people was physically thicker than that of whites.

Hamilton was far from alone in his racial obsessions and misconceptions, including the belief that Black people have higher tolerance for pain. These myths, “presented as fact and legitimized in medical journals, bolstered society’s view that enslaved people were fit for little outside forced labor and provided support for racist ideology and discriminatory public policies,” Villarosa writes.

Modern-day medical education and practice still reflect the fallacies underlying all forms of racial discrimination. Villarosa refers to a literature review published in the American Medical Association Journal of Ethics in 2013 that found “overwhelming evidence that the management of pain in the United States is inequitable.” African Americans and Hispanics were less likely than white patients to receive adequate pain medication, even though they were less likely to misuse drugs, the journal reported. What’s more, a 2015 survey of 222 medical students and residents found that 58% endorsed the myth that Black people have physically thicker skin than white people, and 12% endorsed the myth that Black people have nerve endings that are less sensitive to pain than white people’s nerve endings.

The Freedmen’s Bureau — Underfunded and Understaffed

In another piece for the 1619 Project, Jeneen Interlandi, a Times editorial board member and magazine contributor, takes a deep dive into the nation’s first federal health care program — the Freedman’s Bureau. During Reconstruction following the Civil War, Congress established the bureau to provide health care, education, and other types of aid to people who had been emancipated. But the bureau’s medical division was understaffed and underfunded — and no match for epidemics like smallpox that devastated makeshift camps for the formerly enslaved.

“As the death toll rose, [white lawmakers] developed a new theory: Blacks were so ill-suited to freedom that the entire race was going extinct,” Interlandi writes. This convenient theory of Black extinction gave political cover to legislators for providing inadequate federal assistance and allowed them to shape laws to preserve racial segregation, Interlandi reports.

The legacy of those discriminatory laws is evident in contemporary racial disparities in health and health status. Interlandi writes that such laws are “as foundational as democracy itself.” The history of exclusionary health policies in the US has repeated itself over the centuries — Interlandi gives the recent example of several states, most of them former slavery states that fought with the Confederacy in the Civil War, refusing to participate in the Affordable Care Act’s Medicaid expansion. Those states are Alabama, Florida, Georgia, Kansas, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming.

As previously described in a CHCF issue brief, the Medicaid expansion has been associated with improvements in coverage rates in California. A recently published issue brief by the Commonwealth Fund documents the reduced gap in uninsured rates among Black adults, Hispanic adults, and white adults since the ACA. However, the gap has shrunk more in states that expanded Medicaid than in those that did not. The Commonwealth Fund researchers conclude, “Our results suggest that expansions of Medicaid in additional states would likely reduce disparities further.”

Emancipation from Structural Racism

The movement within health care to acknowledge and address the role of racism in the poorer health outcomes of people of color is growing. Recently the American Academy of Pediatrics (AAP) released its first policy statement on the impact of racism on child and adolescent health. “Recognizing that racism has significant adverse effects on the individual who receives, commits, and observes racism, substantial investments in dismantling structural racism are required to facilitate the society shifts necessary for optimal development of children in the United States,” the AAP states.

Maria Trent, MD, MPH, professor of pediatrics at Johns Hopkins School of Medicine and coauthor of the statement, tells the Times’ Perri Klass, MD, that racism is a socially transmitted disease affecting those who are targeted as well as those who witness it. “It’s taught, it’s passed down, but the impacts on children and families are significant from a health perspective,” Trent says.

The AAP policy statement called on pediatricians and other child health professionals to examine their own biases, foster diverse and welcoming pediatric practices, and advocate for initiatives that help redress biases and inequities in the health care delivery system.

In a commentary for Scientific American, Erin Daksha-Talati Paquette, MD, JD, M.Bioethics, an assistant professor of pediatrics at Northwestern University, writes, “The education of future medical providers is surely an important step in creating a future health care workforce that is sensitive to the impact of racism on health.”

Training Across the Board

But Paquette goes further, arguing that training is needed not only in medical schools and hospitals but across the educational continuum because “biases are present in young children as early as preschool.” By teaching both children and health professional trainees to appreciate diversity, social change can occur over time, she said.

Training has produced successes by making people aware of their biases and privileges, but education about implicit bias has limitations. “By focusing on individuals as the primary site for solutions, implicit bias depoliticizes gender inequity, shifting focus away from the historical, social, structural, and political contexts in which those inequities are produced and maintained,” writes Cheryl Pritlove and colleagues from Canada’s Li Ka Shing Knowledge Institute in The Lancet.

Although they were writing about gender inequity, the same limitations of implicit bias training hold true for racial inequity. “The implicit bias narrative . . . lets us off the hook,” Olivia Goldhill observed in Quartz. “And if implicit bias is a weak scapegoat, we must confront the troubling reality that society is still, disturbingly, all too consciously racist and sexist.”

Some research suggests that cultural humility training — “a commitment and active engagement in a lifelong process that individuals enter into on an ongoing basis with patients, communities, colleagues, and with themselves” — may be a more appropriate and sustainable form of education for health care providers.

As the health care industry reconciles its historical wrongs with a pressing need to provide equitable care to an increasingly diverse nation, it should heed the spirit of this warning from the Associated Press Stylebook, the copyediting bible for news organizations: “Do not use ‘racially charged’ or similar terms as euphemisms for ‘racist’ or ‘racism’ when the latter terms are truly applicable.”

Have you read the 1619 Project? Tweet at me with #EssentialCoverage or email me.

The post The Real Story of America appeared first on California Health Care Foundation.

For providers in the safety net, tasks as simple as keeping a patient’s home address up to date or sharing a patient’s health record with another entity can be especially difficult. The reasons are many, but the effect is the same: care is delivered more slowly, at lower quality, or less accessibly. The California Health Care Foundation Health Innovation Fund is part of a growing national movement working to harness technology to remove these kinds of barriers for Medicaid plans and providers. The CHCF Health Innovation Fund focuses on technological solutions with the potential to improve access and health outcomes for low-income Californians. The innovation opportunity in California and across the nation is huge — one in five Americans is enrolled in a state Medicaid program.

One technology company CHCF supports is RubiconMD, which is tackling a seemingly simple but frustrating challenge facing Medicaid providers: referring patients to a specialist. Wait times are long within many specialties and geographic areas, especially for Medi-Cal beneficiaries. They are more than twice as likely as privately insured people to report difficulty accessing specialty care. At the same time, studies show that a significant portion of specialist visits are unnecessary. RubiconMD addresses these problems simultaneously by enabling primary care providers to get advice from specialists electronically. This solution, also known as an electronic consult, or eConsult, helps patients avoid the delays and frustrations that follow primary care physicians’ referrals. It also lets health systems make more efficient use of the limited time of overburdened specialists.

Many entrepreneurs are interested in following RubiconMD’s lead, but they frequently express common concerns about leaping into the Medicaid world, where state-level differences are significant and populations diverse. That can make it hard to replicate successes in new markets.

Out of a belief that these concerns may be overblown, CHCF partnered with Village Capital and Speire Healthcare Strategies to launch Primed, a series of four statewide roundtables that brought together payers, providers, state Medicaid officials, investors, and entrepreneurs to share their innovation successes and challenges.

Medicaid Road Trip

The Primed events were held in Colorado, Massachusetts, Tennessee, and Washington, DC. When asked to identify the areas within Medicaid where technology-enabled innovation is needed most, attendees at all four roundtables prioritized the same four essential challenges (see our complete infographic on these challenges at the link below).

This interstate consensus surprised many participants and reaffirmed a basic truth: If you’re offering a real solution to one of these pressing problems, Medicaid is a $550 billion market with immense potential for scale and impact.

Virtual Care on the Rise

RubiconMD executives wanted to validate the effectiveness of electronic consults (eConsults) for improving access to specialty care in the safety net, so they participated in an evaluation in a large public health system. This type of evaluation is a standard requirement of companies supported by CHCF’s Health Innovation Fund. It helps newer companies prove their value to Medicaid programs. Three years after the health system adopted eConsults, wait times for specialists had decreased by an average of 17%, and one in four eConsults was resolved without requiring an in-person specialist visit. An evaluation conducted in a different safety-net system also demonstrated that many primary care providers believe eConsults improved the quality of care they deliver to their patients.

Another technology company poised to serve the Medicaid population is New York–based AbleTo, which provides virtual behavioral health care to people with depression, anxiety, or stress associated with comorbid medical conditions and life events. The program identifies members living with undiagnosed mental health conditions and connects them to licensed providers who deliver therapy and coaching from remote locations. In an evaluation of AbleTo’s program for patients with chronic pain (PDF), participants experienced meaningful reductions in the severity of depression, anxiety, and stress symptoms. These types of virtual care models enable more productivity from the same number of providers while helping patients overcome great distances or limited access to transportation to get care from therapists or coaches.

When CHCF launched the Innovation Fund in 2010, few individuals were starting or investing in technology companies focused on Medicaid. That began to change with the 2014 implementation of the Affordable Care Act as millions signed up for Medicaid services. Entrepreneurs and investors wanted to meet the needs of this growing population. But they quickly learned those needs can be complex — many Medicaid beneficiaries have multiple health conditions and also experience numerous barriers to receiving care.

Looking Ahead

Fortunately, in the last few years more organizations have emerged to help overcome these challenges by harnessing significant capital and in the process attracting national attention. HealthTech4Medicaid formed a coalition of more than 40 CEOs, whose tech companies collectively represent more than $1 billion in venture capital backing, advocating for innovation in Medicaid. The Medicaid Transformation Project, led by AVIA, an innovation network and health care consulting firm, and former Centers for Medicare & Medicaid Services administrator Andy Slavitt, is engaging 28 major health systems to improve outcomes for Medicaid beneficiaries receiving maternity care, behavioral health services, and other categories of care. And venture firms like Town Hall Ventures and accelerator programs like Adaptation Health are helping promising companies attract capital and serve greater numbers of Medicaid plans and providers.

We hope the results of CHCF’s roundtable series offer a road map for how to sustain this growing momentum and translate it into meaningful care improvements for Medicaid beneficiaries.

To learn more about solutions already at work in Medicaid, check out our Primed infographic.

The post Roundtables Highlight Common Tech Challenges Facing Medicaid Programs appeared first on California Health Care Foundation.