On August 7, the Trump administration quietly pulled the plug on a program that protected immigrants from deportation while they or their relatives received lifesaving medical treatment in the US. Since then, it has partially backtracked the change after being widely criticized, but the future of the medical deferred action program remains uncertain.

For immigrants like Maria Isabel Bueso, who came to the US from Guatemala when she was seven years old at the invitation of American physicians, elimination of the program would essentially be a death sentence. Bueso has mucopolysaccharidosis VI, a genetic disease so rare that clinical trials for treatment struggle to find participants. Bueso, now 24, has been treated for the disease at the UCSF Benioff Children’s Hospital in Oakland, California, since 2003.

“The breakthrough that came from the trial has helped people with the disease live longer than 30 years,” report Miriam Jordan and Caitlin Dickerson for the New York Times. “Before the drug, they rarely survived past 20.”

The policy change is the administration’s latest tactic to harm immigrant families. It comes on the heels of a final public charge rule that creates more hurdles for impoverished immigrants, the forced separation of immigrant children from their parents at the US-Mexico border, and the detention of immigrant children in facilities that one pediatrician said “could be compared to torture facilities.”

Immigrants Receiving Lifesaving Care Put at Risk

The United States Citizenship and Immigration Services (USCIS) is part of the Department of Homeland Security (DHS), which processes applications for family immigration and citizenship. Until last month, USCIS allowed immigrants and their relatives undergoing lifesaving treatment to stay in the US for two-year periods until they were fully treated. The agency receives about 1,000 deferred action applications related to medical issues each year, Jordan and Dickerson report.

Without a public announcement or public comment period, USCIS field offices began sending denial letters (PDF) to deferred action program participants like Bueso. “You are not authorized to remain in the United States,” the letter reads. “If you fail to depart the United States within 33 days of the date of this letter, USCIS may issue you a Notice to Appear and commence removal proceedings against you with the immigration court.”

What the policy change “means in practice is that noncitizens — some of them children — may lose access to their health care,” the Boston Globe Editorial Board writes. “Forcing patients to leave the United States and its health system amounts to a virtual death sentence if patients’ home countries can’t handle the complex medical needs that brought them here in the first place.”

Indeed, if Bueso were deported to Guatemala, she would not be able to receive the treatment or medical care that has allowed her to graduate summa cum laude from California State University, East Bay; intern in California Assemblymember Rob Bonta’s office; and advocate nationally for people with rare diseases.

Bueso was receiving her weekly treatment at UCSF when she learned that she could be deported, KQED’s Farida Jhabvala Romero reports. “My mom and I, we started crying together. I started shaking,” said Bueso. “It was just a shock for me, because I depend on that treatment.”

DHS Calls an Audible

As part of the policy change, DHS shifted responsibility for handling medical requests for deferred action from USCIS to a sister agency, US Immigration and Customs Enforcement (ICE), which makes arrests and supervises deportation. But ICE has been blindsided by the lack of transparency around the elimination of the program. “An ICE official said that the department had not been notified in advance about the change and questioned the agency’s ability to assume that role,” Jordan and Dickerson report.

The policy change did not gain traction until the end of August, and the administration was immediately hammered by public outrage. More than 120 members of Congress sent a letter of concern (PDF) to top officials at the Department of Homeland Security, Shannon Dooling of WBUR News reports. “We urge you to immediately reverse this shift in policy, resume consideration of these urgent requests, provide the justification for the policy change, and provide clarification on the agency’s plans for implementation,” the lawmakers wrote on August 30.

“This is a new low,” Senator Ed Markey (D-Massachusetts), one of the letter’s coauthors, told the Associated Press, “Donald Trump is literally deporting kids with cancer.”

Faced with criticism, USCIS partially backtracked its policy change over the Labor Day weekend, announcing that it would reopen all medical deferred action cases that were pending on August 7. However, the agency did not clarify whether it would continue the deferral program after processing the current applications, Miriam Jordan writes in the New York Times.

The USCIS decision buys Bueso some more time in California. “It appears that the administration is revising its new policy, and we are hopeful that it will grant an extension of Isabel and her family’s medical deferred action status,” Bueso’s attorney, Martin Lawler, said in an email to KTVU. But nothing is certain for her or other immigrants in a similar situation.

Bueso is scheduled to testify on September 11 at an emergency hearing on the policy change at the House Committee on Oversight and Reform. You can watch it here.

The post Deadly Policy Change Blindsides Immigrants with Severe Illnesses appeared first on California Health Care Foundation.

The post Number of Uninsured Americans on the Rise While California Holds Steady appeared first on California Health Care Foundation.

This is the first in a series of articles that will explore the different ways safety-net organizations are listening to their consumers and using their feedback to improve the design and delivery of care. CHCF believes that systems are more effective when they incorporate the perspectives of the people they serve. Learn more about CHCF’s own listening research and other related projects.

It’s just after noon on the third Wednesday of the month, and at the Trust Health Center in downtown Oakland, California, patients are sharing pizza around a conference table. Meet the Trust Partners, the clinic’s patient-based board of advisers. The role of the eight-member board is to provide patient feedback to assure that the clinic stays meaningfully connected to the community it serves.

One of the partners, William Terry, tells the group about the years he was homeless, living in a run-down minivan. The unregistered van was such a wreck that whenever he moved it for street cleaning, it left a trail of oil. In eight and a half years, he never got a ticket. “I should be in the Guinness Book of Records,” he said with a laugh.

Terry can reflect with humor on his time living on the streets because now he has an apartment, thanks largely to the Trust Health Center. This Federally Qualified Health Center (FQHC), which is operated by LifeLong Medical Care, opened in November 2015 to serve adult residents of Alameda County who have no home or who are at risk of losing their home. LifeLong provides primary care services, mental health care, and social services support.

Lifelong has a separate governing board overseeing the entire organization that meets the Health Resources & Services Administration’s requirement that the majority of a health center’s board must be its own patients. By law, patients must hold a majority on Lifelong’s governing board. Trust Partners offers an additional way to obtain specialized input from patients who have lived on the streets.

Paida Ndemera, who manages the Trust Health Center, said it provides care for approximately 2,000 patients each year. Due to the unstable circumstances and schedules of those who are homeless, she estimates that fewer than 1,000 of them are actively engaged, meaning they visit the clinic at least three times in a 12-month period.

The nearby nonprofit Homeless Action Center, which offers free legal assistance to people who are homeless, often refers clients to the clinic. “They’re just a block away,” Ndemera said. “You don’t even need to cross the road.” And yet, because of the complex circumstances of their lives, many of its clients never make it there.

The Trust Partners helped the Homeless Action Center staff understand this challenge by explaining that public spaces can be intimidating and unwelcoming for people who are experiencing homelessness. “When I would go to Alta Bates . . . we would go to a small waiting room, and I would be smelling really bad,” Terry recalled. “And the people in the waiting room, they’re not in my situation, so I would stick out like a sore thumb. So that made it hard to go there. . . . You deal with so much disrespect from the public.”

For people who are homeless, many of whom have had negative health care experiences, it can be hard to trust providers or care delivery systems.

The clinic is a welcoming and caring environment, but for people who are homeless, many of whom have had negative health care experiences, it can be hard to trust providers or care delivery systems. To help would-be clinic patients overcome these barriers, the Trust Partners arranged for someone to go to the Homeless Action Center and accompany clients to the clinic. They know that even a two-minute walk can feel much safer when you are with someone who has had a similar experience and helps ensure you won’t be judged or disrespected.

In Clinic We Trust

Since the beginning, the goal of the Trust Health Center is to be “an intentionally created community where people without their own safe space feel welcomed and accepted.” Its founders knew that patients’ perspectives had to be baked into the clinic’s decisionmaking process and the design of its services. They credit the Center for Care Innovations (a CHCF grantee) for helping them launch Trust Partners as a key part of their patient-engagement strategy.

Isobel Harvey, RN, MSN, was the center manager when the clinic opened, and she worked closely with CCI to develop the Trust Partners. “We were serving a group of people who are some of the most marginalized in our society and very frequently don’t have a voice, don’t have control over their own lives,” she said. “What you think people need or want, versus what they say — there’s always something to learn from your patients.”

It’s very enlightening speaking to them and hearing what really is going on in the clinic. —Trust Health Center Manager Paida Ndemera

Ndemera succeeded Harvey in 2017, and she attends Trust Partners meetings to listen to their feedback and opinions on proposed changes to the clinic. The meetings are “a space where they feel comfortable talking about anything and everything,” Ndemera said. “It’s very enlightening speaking to them and hearing what really is going on in the clinic.”

Occasionally patients come into the clinic and act aggressively, threatening other patients or staff. The staff contemplated adding security, but some clinic workers worried that having a security guard would make the clinic feel unwelcoming. According to Harvey, some staff felt that “if the clinic is really called Trust, then we need to trust our patients so that they can trust us.”

But when the Partners discussed it, they surprised Harvey by recommending the clinic hire a security guard to keep the peace in the lobby area. In addition to the guard, they posted ground rules at the entrance — including a reminder to treat other patients with respect. The security presence has decreased the number of fights in the waiting room, making it a calmer and safer space for patients who deal with instability on a daily basis.

The Trust Partners also informed the staff that the public restroom in the lobby area was being used for drug deals and drug use. Applying the principle of harm reduction, the clinic installed a sharps disposal container in the bathroom.

Taking It to the Street

The next project the partners plan to tackle is street outreach. Ndemera said 50% to 60% of the clinic’s new patients come through word-of-mouth referral, and the Trust Partners want to visit nearby encampments to educate residents about the clinic’s services. In effect, the Partners would serve as community health workers (CHWs), frontline workers whose experiences help them connect and build trust with the community they serve.

While people who are homeless might be skeptical of medical professionals, they often trust individuals like Jerry Smith, who first came to the clinic after five years on the streets. The clinic helped him get back on his feet, first tending to a leg wound he endured for three years and then providing him with housing assistance.

Smith is a Trust Partner, and he feels a responsibility to help people who are unsheltered get the physical and mental health care they need. When he was living on the streets, he and his best friend, James, did everything together — recycling cans and bottles, building shelters, looking for a place to wash their faces. After Smith went to the clinic, he tried to convince James to go too. He told James how welcoming Trust staff members were, how other patients wouldn’t stare, how the clinic’s services could help him get off the streets for good. “You have to come with me,” Smith begged.

James never made it off the streets. Smith heard from a friend that James took his own life.

“Things could have changed,” Smith said. “Now it makes me want to go and try harder to get people’s attention.”

The post “Trust Our Patients So They Can Trust Us” appeared first on California Health Care Foundation.

In California, nearly two out of three adults with a mental illness do not receive mental health services (PDF), and only one out of 10 adults with a substance use disorder receives any kind of treatment (PDF). These gaps in care have drawn the attention not only of policymakers, but also health technology investors and entrepreneurs. Last year, health tech start-ups, including Quartet Health, Lyra Health, and Pear Therapeutics, raised nearly $400 million in funding for technology investments related to behavioral health. Investors have included leading venture firms like Venrock and Greylock Partners, as well as national private payers such as Centene and Anthem.

Although research supports the efficacy of some smartphone technology-enabled behavioral health interventions in controlled settings, widespread adoption has been slow, particularly among providers and payers in the safety net. As Thomas Insel — California Governor Gavin Newsom’s designated state “mental health czar” — recently said, “As much as one might hope there’d be an app for that — it’s really complicated.” Insel has dedicated a significant portion of his career to technology-driven behavioral health projects, including a stint at Google life sciences subsidiary Verily, and as co-founder of the start-up Mindstrong, with which he is still involved. Recent pilots have demonstrated evidence of a variety of significant barriers, with neither entrepreneurs nor participating providers and patients seeing much meaningful improvement in access or quality.

The CHCF Health Innovation Fund is optimistic about technology’s potential to improve behavioral health care coordination and integration.

Last year, when mental health providers in Los Angeles County tested a smartphone app to help patients manage emotional distress, they encountered major setbacks, such as concerns about low patient engagement and compliance with patient privacy regulations. In 2015, low participation levels were reported in similar pilots testing computerized cognitive behavioral therapy in California’s safety net. Other behavioral health startups have been stymied in California by a complex behavioral health care system with fragmented funding streams and a daunting array of stakeholders that includes counties, Medi-Cal managed care plans, and public hospitals.

Despite these challenges, the CHCF Health Innovation Fund is optimistic about technology’s potential to improve behavioral health care coordination and integration that goes farther than self-help apps. The fund recently conducted a landscape analysis of companies new to behavioral health tech. The analysis focused on technology-enabled services rather than applications and on those with some traction in the safety net. We identified three main areas where innovators are making meaningful progress:

• Collaborative care
• Telehealth medication-assisted treatment for substance use disorder
• Resource and service referrals

Time will tell whether companies find sustainable revenue sources for these promising services, effectively engage their users, and navigate California’s complex regulatory and reimbursement realities. Still, it’s worth paying close attention to these developments.

Collaborative Care

At least one in five primary care visits involves a mental health issue, but coordination between primary care providers and behavioral health specialists is rare. For patients who require care from a psychiatric specialist, fewer than 3% of psychiatrists and psychiatric nurse practitioners actively develop shared care plans in collaboration with their patients’ primary care providers.

The collaborative care model, which was developed at the University of Washington, pairs trained primary care providers with an embedded behavioral health care manager and psychiatrist to deliver evidence-based medication or treatments. When the primary care physician and behavioral health manager, using validated assessment tools, see that a patient is not improving, a consultant psychiatrist makes recommendations to the primary core provider to adjust the care plan. This model has been around for more than three decades and has been assessed in more than 80 randomized controlled trials. Although it is one of the most road-tested and trusted models for integrating mental and clinical health care, its adoption has been held back partly by providers who cannot afford the additional behavioral health positions or lack the support to integrate new roles into existing workflows.

Those barriers are falling as technology-enabled platforms and tools like telehealth make care newly accessible and scalable — especially in the resource-constrained safety net. Companies like Concert Health and Mindoula are helping medical practices embrace the collaborative care model by providing remote care management and psychiatric services. A key question that remains is how California will reimburse collaborative care in Medicaid. New York state offers one example (PDF) of a possible path forward.

Medication-Assisted Treatment Via Telehealth

Medication-assisted treatment (MAT) is the gold standard for treating substance use disorder, but there are significant shortages of authorized MAT prescribers in many parts of California and the US. Telehealth could save lives by making MAT more available in places facing prescriber shortages.

Early entrants into this field are using a range of approaches, which are outlined in CHCF’s recent brief Innovation Landscape Series: Telehealth MAT (PDF). Some approaches aim to expand the capacity of existing in-person prescribers of MAT by offering the virtual support of a remote psychiatrist. Others, like Groups, which has received a program-related investment from CHCF, offer in-person support programs and use telehealth to help with prescribing. There also are some academic medical centers piloting telehealth MAT initiatives.

All of the companies entering this arena face complex and rapidly-evolving reimbursement and regulatory challenges. A recent paper, Opportunities and Challenges to Utilizing Telehealth Technologies in the Provision of Medication-Assisted Therapies in the Medi-Cal Program (PDF), analyzes the roadblocks facing telehealth MAT providers in Medi-Cal and provides recommendations for removing them.

Resource and Service Referrals

Providers who care for patients with mental illness and substance use disorders have to navigate major challenges in making referrals. In some cases, referrals involve specialty facilities and providers. Others involve community-based organizations providing social services, like housing. All are important to a patient’s stability and well being. Yet the referral process is often hobbled by out-of-date information that can leave providers frustrated and patients without needed support. Even when a referral is made successfully through the conventional approach, there is inconsistent follow-up to let providers know whether the patient used the referred service.

Several startups aim to streamline this referral process. OpenBeds enables emergency department providers to see the real-time availability of inpatient and outpatient psychiatric services within a given geographic area. Currently used in seven states, providers can send a digital referral through OpenBeds and find an available inpatient bed in less than one-third the time it takes to refer via phone and fax. A CHCF publication, Catalyzing Coordination: Technology’s Role in California’s Whole Person Care Pilots (PDF) details how other companies are partnering with counties to centralize and digitize local efforts to coordinate social services for patients with complex needs. Companies like Act.MD offer providers a central, searchable way to find needed services for their patients. They also enable providers to communicate directly with organizations in the network and track outcomes of the referrals they make. Similarly, Quartet’s referral management platform is bridging the gap between primary care physicians and behavioral health specialists to ensure patients receive the care they need and primary care providers are kept informed of their patients’ progress. Quartet also has received a program-related investment from CHCF.

Services like these are only as useful as the information they provide, and to maintain accurate, comprehensive networks, they need buy-in from a broad spectrum of partners, often including health plans, community-based organizations, and health systems.

Keys to Success

Technology alone cannot cure the complex structural problems that plague our behavioral health care systems. However, it does have an important role to play in expanding access and integration, especially on the provider side of the equation. If behavioral health entrepreneurs are going to succeed, they need to be honest about particular challenges to the field and be prepared to address them. And they will need cooperation — both from policymakers who have the power to remove regulatory and reimbursement barriers, and from providers willing to try new ways of solving old problems.

The post Can Behavioral Health Entrepreneurs Finally Break Through? appeared first on California Health Care Foundation.

President Donald Trump has taken a sudden interest in California’s homelessness crisis. Last week, he and several senior White House advisers, including Housing and Urban Development (HUD) Secretary Ben Carson, visited the state to discuss federal intervention to address homelessness. But some state lawmakers registered deep suspicions about the White House’s interest, arguing that the policy options put forth by the White House Council of Economic Advisers (CEA) neglect key drivers of homelessness.

Before Trump’s visit, the CEA released a report titled The State of Homelessness in America (PDF), which documents variation in homelessness across the country and discusses Trump administration proposals to reduce it.

In a conference call with journalists, acting CEA chairman Tom Philipson “repeatedly highlighted homelessness in California, particularly in Los Angeles, and blamed it in part on state and local policies,” the Washington Post’s Jeff Stein reported. Philipson also said that “policing may be an important tool to get [people] off the street.”

Several state lawmakers said, “the president’s positions on homelessness are more about trolling California than attempting to find actual solutions,” according to Liam Dillon and Benjamin Oreskes in the Los Angeles Times. “If the president really cares about solving this crisis, he wouldn’t be talking about criminalization over housing,” said Los Angeles Mayor Eric Garcetti in a statement to the Los Angeles Times. “He’d be making dramatic increases in funding for this country’s housing safety net.”

Research Misstated, Ignored

The CEA report estimated that deregulating the housing market would reduce the homeless population in San Francisco by 54% and in Los Angeles by 40%. But an expert whose work is repeatedly cited in the report, Columbia University Economics Professor Brendan O’Flaherty, PhD, told Dillon and Oreskes the CEA not only vastly overstates the potential impact of deregulation, it ignores research showing public subsidies can help get people off the streets and into housing.

Governor Gavin Newsom, the California State Association of Counties, the California League of Cities, and mayors from the biggest cities in the state agree that ensuring affordable housing is an important factor in combating homelessness. In a letter to the president (PDF), the group called attention to the administration’s proposal of “significant cuts to public housing and programs like the Community Development Block Grant.” They requested 50,000 additional vouchers from the administration through a combination of Housing Choice Vouchers and Veterans Affairs Supportive Housing vouchers. “Mr. President — shelter solves sleep, but only housing solves homelessness,” the group wrote.

On September 18, two days after the letter was sent to the president, HUD Secretary Carson rejected the request for additional housing vouchers. In a letter to the group (PDF), Carson argued that “California cannot spend its way out of [its homelessness] problem using federal funds.” The state must address its “overregulated housing market,” strengthen the ability of police officers to intervene in homelessness, and invest in mental health treatment to “help address this catastrophe,” he wrote.

Housing — an Important Component of Health Care

In addition to the need for more affordable housing, frontline providers say health care must be prioritized for people experiencing homelessness. In a commentary for CalMatters, Coley King, DO, director of homeless services for Venice Family Clinic, wrote, “While housing is a powerful form of health care, seriously ill patients . . . would likely die on the streets without proper medical care.”

In Los Angeles County, where Venice Family Clinic is located, the population of people experiencing homelessness “has grown by 39% over the past five years, but deaths among those experiencing homelessness rose almost twice as fast, 76%, over the same time period,” King wrote.

People experiencing homelessness have higher rates of premature death and greater disease burden than people who have shelter. A 2018 study of homeless adults entering permanent supportive housing found that 90% reported having at least two chronic physical or mental conditions; 68% reported at least two chronic physical health conditions, and 56% reported at least two chronic mental health conditions.

A recent study about hospital visits by New Yorkers experiencing homelessness suggests that closer collaboration between the health care and homeless services sectors would indeed help patients. The study, published in HealthAffairs, found that hospitalization can precipitate homelessness when patients at risk of losing their home enter the hospital. Additionally, hospitals often struggle with a lack of adequate discharge options for patients who already have no home. “Hospital use preceding homelessness presents an opportunity for interventions to prevent homelessness,” the study authors wrote. “Our findings highlight the necessity of collaboration between homeless services and health care systems to best address the needs of their shared client-patient population.”

Los Angeles County Supervisor Mark Ridley-Thomas, a co-chair of Newsom’s Homeless and Supportive Housing Advisory Task Force, has called for better physical and mental health care for people experiencing homelessness. According to the Los Angeles Times’s Steve Lopez, Ridley-Thomas said that the county needs “more psychiatric emergency services, more addiction rehab, and more recuperative care so that homeless patients don’t go from hospitals straight back to the streets.”

Los Angeles County has been involved in several initiatives of Medi-Cal, California’s Medicaid program, to improve health care for people experiencing homelessness. One is the Health Homes Program, in which health plans coordinate physical health, behavioral health, and social services, including housing, for Medi-Cal enrollees with complex health conditions. The county also participates in the Whole Person Care pilot program, which in Los Angeles targets people who are homeless or at risk of homelessness (among other populations) and tests whether coordination across health care and social services can improve health outcomes while reducing medical costs.

CHCF Briefing to Focus on California’s Mental Health System

California’s homelessness crisis is just one of the reasons the state’s public mental health system has drawn attention in recent years. Join CHCF today, September 23, from noon to 1:45 pm for a briefing on California’s public mental health system. Register to to watch via webcast or listen by telephone. A video of the briefing will be available on the event page by Wednesday, September 25.

Two Key Newsom Appointments

Governor Newsom has announced the appointments of two directors of key state health care agencies. Sonia Angell, MD, MPH, was appointed director of the California Department of Public Health. Angell was an assistant clinical professor of medicine and an assistant attending physician at New York Presbyterian/Columbia University Hospital. She also served as deputy commissioner for prevention and primary care at the New York City Department of Health and Mental Hygiene.

Newsom also named David R. Duncan Jr., MD, as director of the Emergency Medical Services Authority. Duncan was the medical director and executive medical officer at Air Medical Group Holdings and REACH Air Medical Services. He also served as medical director at the California Department of Forestry and Fire Protection.

Do you think the Trump administration’s interest in homelessness will help California solve the issue? Tweet at me with #EssentialCoverage or email me.

The post White House Puts National Spotlight on California Homelessness appeared first on California Health Care Foundation.

More than 10 million Californians — mostly children, their parents and caretakers, people with disabilities, and adults typically in low-wage jobs — ­get their health care through a managed care plan in Medi-Cal, the state’s Medicaid program. They rely on their Medi-Cal managed care plan to provide timely access and high-quality care. This includes services such as regular well-child visits and prenatal care, health screenings to catch and treat life-threatening diseases early, and proper treatment of chronic conditions so they don’t lead to disability or premature death.

Unfortunately, data collected by the state have long shown that access to care and the quality of care provided to Medi-Cal managed care enrollees varies widely across regions and even among plans within the same county. In addition, two recent state audits highlight problems both for children statewide and for populations in rural areas.

Two New Studies

Today CHCF released two studies that add to our understanding of the quality of Medi-Cal managed care and offer ideas for improvement. Researchers at the University of California, San Francisco, showed that from 2009 to 2018, the quality of care for Medi-Cal managed care enrollees, on average, stayed the same or declined for over half of the quality measures monitored by state health care officials. Particularly disappointing was the fact that quality declined or stayed the same for six of the nine measures related to care for children, including access to primary care and well-child visits. Simply put, we just haven’t seen the type of quality improvement over the last decade that we would expect from a program as important to our state as Medi-Cal.

The study also shows that Medi-Cal enrollees in nonprofit or public managed care plans received, on average, better quality care than those in for-profit plans. Those living in counties with a County Organized Health System received, on average, better quality care than those in counties with competing managed care plans. (For more background on the types of plans and models in Medi-Cal managed care, see this resource from CHCF’s Medi-Cal Explained series.) In other words, some enrollees are more likely than others to get the care they need when they need it simply because of where they live or the health plan they are enrolled in. To understand trends in quality of care in your area, see these local snapshots.

The good news is that major improvements in quality are possible. A companion study by Chapman Consulting examines a few managed care plans that have increased their scores on several quality measures during the same time frame. The study points to several interconnected strategies that are key to quality improvement, including real-time data exchange, collaboration with providers at the point of service, and targeted financial incentives, among others. This information should inform Medi-Cal’s efforts to expand and accelerate quality improvement in managed care.

Five Ways for California to Improve Quality of Care

State officials should act swiftly to ensure that all enrollees, regardless of where they live or which plan they are enrolled in, have timely access to high-quality care. Some of these actions can be taken immediately. Others could be pursued as part of a bold new vision that guides both the upcoming planning process for the renewal of two federal Medicaid waivers, as well as the contract renewal process for commercial Medi-Cal managed care plans that begins next year. These waivers and this reprocurement are infrequent and important opportunities to reshape the program. Here are five important steps California should take:

1. Establish clear, measurable quality goals for the Medi-Cal managed care program and for individual plans, with a focus on continuous improvement.

   The Department of Health Care Services (DHCS), which administers Medi-Cal, recently signaled that it was raising expectations by increasing plans’ minimum performance level (MPL) on quality measures from the 25th percentile nationally to the 50th percentile. While the intent is laudable, this approach falls short.

   It fails to set the expectation that managed care plans should continue to improve quality even when their scores are at or just above the 50th percentile. It also doesn’t recognize that it is easier for managed care plans in some counties to achieve high-quality care than plans in other counties because of differences in the underlying workforce, capabilities of safety-net providers, or other factors. Kaiser Permanente, for example, currently gets to control who enrolls, an advantage no other Medi-Cal managed care plan has.

   Finally, it rewards some gains more than others. With the MPL set at the 50th percentile, a plan would be better off improving its score on a quality measure from the 49th to the 51st percentile than it would be for improving its score on another measure from the 25th to the 35th percentile. It would be better to establish plan-specific targets for continuous quality improvement. State officials should also “walk the talk” by setting specific, measurable, program-wide improvement targets for Medi-Cal.

2. Pay plans based on quality.

   With his value-based payment initiative, Governor Gavin Newsom has shown he understands how important it is to pay health care providers based on quality and outcomes, not just on the volume of services they provide. It’s time to extend this principle to the way California pays Medi-Cal managed care plans and use financial incentives to drive quality improvement, as I’ve written about previously. Several states have already paved the way. One model would allow plans to share in the savings they produce when higher-quality care leads to savings such as reduced hospital admissions as long as plans meet defined quality benchmarks.

3. Eliminate data blind spots related to disparities and delegation.

   Research, including this DHCS report on disparities in 2015 (PDF), shows that quality of care in Medi-Cal varies widely by race and ethnicity. We can’t improve what we don’t measure, so DHCS should be monitoring and regularly reporting on access and quality in Medi-Cal managed care by race and ethnicity — and making this data easily accessible for others to study. This will enable DHCS to identify challenges, learn from successes, and focus improvement efforts. Similarly, many managed care plans subcontract with other plans or risk-bearing provider groups but do not report quality scores separately for these subcontracted partners. For example, members of Los Angeles County’s L.A. Care plan can get their care directly through L.A. Care or choose one of three plan partners: Anthem Blue Cross, Blue Shield Promise Health Plan, or Kaiser Permanente. These managed care plans and medical groups should be required to report the same access and quality data as plans that contract directly with DHCS, so state officials can assess their performance and enrollees can make informed choices.

4. Consider restructuring the Medi-Cal managed care system.

   Enrollment in Medi-Cal managed care has more than doubled since 2013, yet there have not been significant changes to the underlying structure of the program since it was established over 20 years ago. The new studies suggest it’s time to reconsider the different models of managed care and the role of competition. For example, given their track record on quality compared to public and nonprofit plans, what role should for-profit plans have in Medi-Cal managed care? Similarly, should the state look to encourage existing or new public plans to serve in areas where there are currently only commercial plans?

   Two forthcoming papers from CHCF, which provide deeper analysis of quality and access specifically under the geographic managed care and regional models of managed care, will offer further insights into ways DHCS might want to structure the system differently. The papers will be published in October.

5. Continue to invest in delivery system transformation and in the health care workforce, especially in rural areas.

   Many of the problems documented in these studies didn’t start with managed care and can’t be solved by managed care plans alone. The experiences of County Organized Health Systems that serve enrollees in multiple counties highlight the fact that some areas are more difficult to serve than others, even when a plan has strong leadership and is rooted and investing in its communities. Managed care plans serving rural areas have far fewer health care providers and less robust health care infrastructure available. This limits their ability to provide timely access and to deliver high-quality care.

   Recognizing that this will be a decades-long effort requiring political will and resources, the state must launch long-term investments and partnerships to build the health care workforce, especially in rural areas. The 2019–20 state budget, which provides hundreds of millions of dollars in state funding to ease mental health workforce shortages and low rates of physician participation in Medi-Cal, was a significant first step.

   California should also continue to invest in innovative programs that provide financial incentives and support to transform public hospitals and other safety-net providers and to reorient them to provide greater value. For Federally Qualified Health Centers, which account for a disproportionately large share of primary care for Medi-Cal managed care enrollees, value-based payment should be a priority.

A Healthy California for All

Over the past six years, California has dramatically expanded Medi-Cal and halved the uninsured rate, improving access to care for millions of Californians who otherwise would be uninsured. It’s a remarkable achievement we should all be proud of. Yet there is more work to be done to fulfill the promise of this coverage. Working together, we can heed Governor Newsom’s call to build a “California for All” by creating a system where all Medi-Cal managed care enrollees — no matter where they live or which health plan serves them — get the timely, high-quality care they need to thrive.

The post New Study Shows Lagging Quality Improvement in Medi-Cal Managed Care appeared first on California Health Care Foundation.

In the last decade, the cesarean section (c-section) rate for low-risk, first-time births has risen by 50% nationwide. While c-sections can be lifesaving in limited circumstances, the surgery involves serious risks for mothers and babies. As common as c-sections for low-risk, first-time births are across the country, they are so frequent in Rapides Parish, Louisiana, that US News & World Report reporter Gaby Galvin is calling it “America’s c-section capital.” Her findings have implications for the continuing efforts to reduce the number of medically unnecessary c-sections.

Galvin’s investigation was published in a recent US News & World Report special report on national, state, county, and hospital c-section rates. In 2017, the latest year for which county-level federal data is available, 47% of low-risk, first-time births in Rapides Parish occurred by c-section. For comparison, the federal Healthy People 2020 goal for low-risk, first-time c-section deliveries is 23.9%. Experts agree that decreasing low-risk, first-time c-sections (henceforth referred to as “low-risk c-sections”) is a good way to safely lower overall c-section rates.

Lowering the rate of low-risk c-sections can be challenging. Many factors — including insurance type, the mother’s race, and the hospital where the delivery takes place — contribute to the likelihood that a mother will undergo a c-section. Jill Arnold, executive director of the Maternal Safety Foundation, told Galvin the rate is often driven by a hospital’s culture.

Pooja Mehta, MD, the former chief clinical innovation officer of Louisiana’s Medicaid program and medical director of the Louisiana Perinatal Quality Collaborative, agreed. “When you look at the national data,” she told Galvin, “you can see clearly that the primary source of variation in c-section rates tends to be the hospital.”

In fact, Neel Shah, MD, MPP, assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School and director of the Delivery Decisions Initiative at Harvard’s Ariadne Labs, pointed out that overall c-section rates vary from 7% to 70% among American hospitals. The variation for low-risk c-sections is even greater. “Rather than being driven by personal preferences or medical needs, this appears to suggest that the likelihood of getting a cesarean is largely driven by the choice of hospitals,” Shah wrote in an editorial accompanying the special report.

What Gets Measured Gets Managed

The wide hospital variation suggests that data reporting holds hospitals and health plans accountable for quality improvement in maternity care and helps avert low-risk c-sections. Galvin reported that the Louisiana Perinatal Quality Collaborative, an initiative of the Louisiana Commission on Perinatal Care and Prevention of Infant Mortality, requires participating hospitals to disclose data on low-risk c-sections. Thirty-five hospitals have voluntarily joined the collaborative. Additionally, Louisiana’s Medicaid managed care plans are required to report low-risk c-section data to the state.

California has similar initiatives to increase transparency around maternity measures. Hospital-level metrics are publicly available at the performance reporting website Cal Hospital Compare, which is run by a multistakeholder nonprofit entity. In 2018, Covered California, the state’s health exchange under the Affordable Care Act, gave hospitals until the end of 2019 to meet targets for safety and quality, including the voluntary ceiling of 23.9% for low-risk c-section births. “We’ve told health plans that by the end of 2019 we want networks to only include hospitals that have achieved the target,” Lance Lang, MD, chief medical officer for Covered California, told KQED reporter April Dembosky.

UPDATE — October 1, 2019: Lang told CHCF via Twitter that Covered California has extended the deadline to year-end 2020.

Covered California, the state’s health insurance exchange, gave hospitals until the end of 2019 to meet targets for safety and quality, including a voluntary ceiling of 23.9% for low-risk c-section births.

As Galvin reported in a separate article in the US News & World Report special report, California has taken a multipronged approach to lowering the rate of low-risk c-sections. The California Maternal Quality Care Collaborative (CMQCC), founded in 2006 by Stanford University and state officials, engages stakeholders in its work to support vaginal birth. Elliott Main, MD, medical director of CMQCC, told Galvin that California has embraced “pushing all the buttons at once: working with patients, working directly with physicians, hospitals, health plans, and the state public health department.”

The collaborative’s c-section toolkit addresses hospital culture by educating maternity care providers to support intended vaginal birth and use data to reduce c-sections. Hospitals can opt to report information to the collaborative’s Maternal Data Center, which gives clinicians current perinatal performance metrics and benchmarking data. More than 200 California hospitals voluntarily participate.

New Payment Model May Improve Quality

At the health plan level, some are experimenting with a new payment model that bundles “physician payments for maternity care into a single flat fee that covers all care and procedures,” Carmen Heredia Rodriguez reported for NPR. Proponents of bundled payments hope the model will improve the quality of maternity care and cut health care costs. The Pacific Business Group on Health found that the rate of low-risk c-sections decreased by nearly 20% in less than one year among three Southern California hospitals that tested bundled payments for births in 2014 and also engaged in intense quality improvement work with CMQCC.

However, the payment model has not been successful in all tests. “In Ohio, where the Medicaid program covered complicated pregnancies as well as those that were low-risk, bundling payments into a lump sum for ob-gyns cost the state more than expected,” Heredia Rodriguez wrote.

Some health care experts worry that bundled payments may discourage team-based care or require medical practices to build costly data systems to handle bundled payments. Many existing systems aren’t compatible with the new payment structure. Blair Barrett Dudley, a senior manager at the Pacific Business Group on Health, told Heredia Rodriguez that insurers and health plans need access to real-time data to ensure they are meeting the model’s quality measures.

Raising Awareness of Birth Matters

In the meantime, the health care community can empower expectant parents with data and resources. “For some Americans, particularly those with generous health insurance and those who live in or close to cities, being aware of the wide differences in cesarean rates may be helpful in deciding where to go or not go for care,” Shah wrote. But “many Americans do not have a choice. There may only be one hospital within reasonable driving distance that delivers babies. There may be only one hospital that is affordable. Even in these cases, knowing the hospital cesarean rate is helpful.”

Listening to the childbirth wishes of women is key to improving maternity care in California, according to a survey conducted by the National Partnership for Women & Families.

Californians can use Cal Hospital Compare for information on c-section rates, and the same data are available on Yelp. The My Birth Matters campaign, launched in 2018 by CHCF, Consumer Reports, and CMQCC, provides expectant parents with information about c-sections and encourages meaningful conversations with their care teams about childbirth preferences. The communications toolkit includes resources in English, Arabic, Chinese, Farsi, Spanish, Tagalog, and Vietnamese.

Listening to the childbirth wishes of women is key to improving maternity care in California, according to a survey conducted by the National Partnership for Women & Families with support from CHCF and the Yellow Chair Foundation. Listening to Mothers in California, published last year, found that 74% of Californian mothers agree that providers should not intercede in a childbirth unless medically necessary, yet only 5% gave birth with no medical intervention. One in three California women overall and more than one in four with low-risk pregnancies gave birth by c-section. Racial disparities in c-sections persist: 42% of Black women gave birth by c-section, compared to 31% of Latina and Asian / Pacific Islander women and 29% of white women.

Said Stephanie Teleki, PhD, director of learning and impact at CHCF: “We know what works with childbirth in this country — we just aren’t doing it.”

The post When It Comes to C-Sections, All Hospitals Are Not the Same appeared first on California Health Care Foundation.

California Attorney General Xavier Becerra alleges that Sutter Health used its pre-eminent market power to artificially inflate prices. Photo: Rich Pedroncelli/Associated Press

As a jury trial draws near in a major class-action lawsuit alleging anticompetitive practices by Northern California’s largest health system (PDF), a new CHCF study shows the correlation between the prices consumers pay and the extensive consolidation in the state’s health care markets. Importantly, the researchers estimated the independent effect of several types of industry consolidation in California — such as health insurers buying other insurers and hospitals buying physician practices. The report, prepared by UC Berkeley researchers, also examines potential policy responses.

While other states have initiated antitrust complaints against large hospital systems and medical groups in the past, the case against Sutter Health is unique in both the expansive nature of the alleged conduct and in the scale of the potential monetary damages. The complaint goes beyond claims of explicit anticompetitive contract terms and argues that by virtue of its very size and structure, the Northern California system imposed implicit or “de facto” terms that led to artificially inflated prices. Sutter Health vigorously denies the allegations.

The formation of large health systems like Sutter is neither new (PDF) nor unique to California (PDF). Several factors seem to be encouraging their growth, including payment models that place health care providers at financial risk for the cost of care, increased expectations from policymakers and payers around the continuum of patient needs that must be managed, and economies of scale for investments in information technology and administrative services. Some market participants also point to consolidation in other parts of the health care system, such as health plans and physician groups, as encouragement for their own mergers.

Economic Consolidation in California

In general, economists study two major categories of market consolidation:

• Horizontal consolidation: Entities of the same type merge, such as the merger of two hospitals or insurance companies, or the merger of providers into a physician network.
• Vertical consolidation: Entities of different types merge, such as when a hospital purchases a physician practice or when a pharmacy buys an insurance company.

To measure market consolidation, the CHCF study relied on the Herfindahl-Hirschman Index (HHI), a metric used by the US Department of Justice and the Federal Trade Commission. An HHI of between 1,500 and 2,500 is considered moderately concentrated, and 2,500 or above is considered highly concentrated. According to this measure, horizontal concentration is high in California among hospitals, insurance companies, and specialist providers (and moderately high among primary care physicians), even though the level of concentration in all but primary care has remained relatively flat from 2010 to 2018.

The percentage of physicians in practices owned by a hospital or health system increased dramatically in California between 2010 and 2018 — from 24% in 2010 to 42% in 2018. The percentage of specialists in practices owned by a hospital or health system rose even faster, from 25% in 2010 to 52% in 2018.

Consolidation Is Not Clinical Integration

While this study defined and quantified the extent of consolidation across several industry segments in California, it is important to note that it did not define, quantify, or evaluate clinical integration within the state. Clinical integration has been defined by others in many ways, but generally involves arrangements for coordinating and delivering a wide range of medical services across multiple settings.

As the CHCF study authors point out, other analysis has shown that various types of clinical integration can lead to broader adoption of health information technology and evidence-based care management processes. Data from the Integrated Healthcare Association suggests that certain patient benefit designs and provider risk-sharing arrangements associated with clinical integration can lead to higher quality and lower costs.

Crucially, an emerging body of law (PDF) suggests that clinical integration does not require formal ownership and joint bargaining with payers.

Relationship Between Consolidation and Health Insurance Premiums

Among the six variables analyzed in the CHCF study, three showed a positive and statistically significant association with higher premiums: insurance company mergers, hospital mergers, and the percentage of primary care physicians in practices owned by hospitals and health systems. The remaining three variables studied — specialist provider mergers, primary care provider mergers, and the percentage of specialists in practices owned by a hospital and health system — were statistically insignificant.

The figure below shows the independent relationship between market concentration and premiums for these three variables. As the lines move left to right, concentration increases — that is, fewer individual insurers, hospitals, or providers occupy the market. The vertical axis shows the average premiums associated with each level of market concentration. In short, regardless of the industry structure represented by the other variables, insurer consolidation, hospital consolidation, and hospital-physician mergers each lead to higher premiums.

Unexplained Price Variation and Growth

Health insurance premiums rise when the underlying cost of medical care increases. California ranks as the 16th most expensive state on average in terms of the seven common services the researchers studied, after adjusting for wage differences across states. Among all states, California has the eighth-highest prices for normal childbirth, defined as vaginal delivery without complications. Childbirth is the most common type of hospital admission, and the relatively standardized procedure is comparable across states.

Even within California, prices vary widely and are growing rapidly. For example, the 2016 average wage-adjusted price for a vaginal delivery was twice as high in Rating Area 9 (which has Monterey as its largest county) as it was in Rating Area 19 (San Diego) — $22,751 versus $11,387. (See next figure.) Prices for the service are increasing rapidly across counties — rising anywhere from 29% in San Francisco from 2012 to 2016 to 40% in Orange County over the same period.

The authors of the CHCF report investigated the impact of various types of consolidation on the prices of individual medical services in California. For cesarean births without complications, a 10% rise in hospital HHI is associated with a 1.3% increase in price.

Potential Policy Responses to Consolidation

While the study shows significant associations between various types of market concentration and the prices consumers pay, policymakers should carefully consider implementing steps that restrain the inflationary impact of consolidation while allowing the benefits of clinical integration to proliferate. To that end, the authors of the CHCF report offered a series of recommendations, which include:

Enforce antitrust laws. Federal and state governments should scrutinize proposed mergers and acquisitions to evaluate whether the net result is procompetitive or anticompetitive.

Restrict anticompetitive behaviors. Anticompetitive behaviors, such as all-or-nothing and anti-incentive contract terms, should be addressed through legislation or the courts in markets where providers are highly concentrated.

Revise anticompetitive reimbursement incentives. Reimbursement policies that reduce competition, such as Medicare rules that implicitly reward hospital-owned physician groups, should be adjusted.

Reduce barriers to market entry. Policies that restrict who can participate in the health care market, such as laws prohibiting nurse practitioners from practicing independently from a physician, should be changed when markets are concentrated.

Regulate provider and insurer rates. If antitrust enforcement is not successful and significant barriers to market entry exist — including those in small markets unable to support a competitive number of hospitals and specialists — regulating provider and insurer rates should be considered.

Encouraging meaningful competition in health care markets is an exceedingly difficult task for policymakers. It is no easier to promote the benefits of clinical integration while restraining the inflationary aspects of economic consolidation through public policy. Despite these challenges, the rapid rise in health care premiums and prices in the state require a fresh look at the consequences of widespread horizontal and vertical consolidation in California.

The post Market Consolidation on Trial appeared first on California Health Care Foundation.

California should move swiftly to improve the quality of care in the managed care plans that serve 80% of Medi-Cal’s nearly 14 million enrollees, according to researchers at the University of California, San Francisco (UCSF). Led by Professor of Medicine Andrew Bindman, MD, with support from CHCF, the researchers examined 41 quality measures and found that more than half of the quality measures stayed the same or declined from 2009 to 2018. The metrics included rates of cancer screenings, timely pre- and postnatal care for women, and access to primary care for children.

With so many Medi-Cal enrollees in managed care plans, the lagging quality improvement suggests there is a great opportunity to improve care for California children, their parents and caretakers, persons with disabilities, and adults typically in low-wage jobs. The California Department of Health Care Services (DHCS) administers Medi-Cal. The findings have excited Medicaid experts around the country.

Andy Schneider, a research professor at the Georgetown University McCourt School of Public Policy, said the report represents “an important step forward on the road to full transparency about Medicaid managed care.” In a blog post for the Georgetown University Center for Children and Families, Schneider said it was not clear before the report was released whether the Center for Medicare & Medicaid Services (CMS) knew about the unsatisfactory quality scores across Medi-Cal managed care plans. “Now everyone knows,” he wrote, “and the process of holding the [managed care plans], the state Medicaid agency, and CMS accountable for results can begin.”

Focus on Children’s Care

One of Bindman’s most striking findings is that quality of care in Medi-Cal managed care significantly declined on four measures, including three metrics related to children’s health. For instance, recommended well-child visits for two- to six-year-olds fell from 86% in 2012 to 84% in 2018. The drop of two percentage points might seem small, but “it means tens of thousands of children aren’t getting the well-child visits that they should be getting,” Chris Perrone, director of Improving Access at CHCF, said in an interview with Capital Public Radio’s Steve Milne. “We should be expecting quality to improve over time, not fall flat or in this case decline.”

The study also reveals variation in quality of care based on geography and type of managed care plan. Med-Cal enrollees living in areas served by a County Organized Health System tended to receive better quality care than those in counties with competing managed care plans. Cathie Anderson reported in the Sacramento Bee that “quality measures for for-profit health insurers paled, on average, when compared with those of nonprofit and public carriers.”

“For a program as important as Medi-Cal is, we’re not getting the kind of quality improvement out of it that we should expect,” Perrone told Anderson. “No one expects Medi-Cal to be perfect, but they do expect Medi-Cal to improve, and we think the approaches that [DHCS] has taken to date to try to improve quality over time are not working as they should.”

Use this interactive California map to learn more about the quality of care provided by local Medi-Cal managed care plans by county and region between 2009 and 2018.

Researchers Ask State Officials to Move Quickly

The UCSF researchers called on state lawmakers and DHCS to prioritize quality improvement in Medi-Cal managed care. “State officials must take bold steps to further invest in building California’s health care delivery system to help ensure that all Medi-Cal enrollees, regardless of where they live, receive timely access to high-quality care,” the researchers wrote.

Perrone said DHCS should raise the bar for Medi-Cal managed care plans. The department “should establish specific and measurable goals for improving access and quality for the program as a whole and from each managed care plan,” he told Anderson.

Shifting to value-based payments could encourage managed care plans to meet or exceed quality metrics. Currently the state sets minimum performance levels and penalizes Medi-Cal managed care plans for falling below those levels, Perrone said. If California wants plans to improve, it must adopt financial incentives that reward plans for quality improvement, he said.

DHCS has not yet reviewed the UCSF report, Angela Hart reported (paywall) in POLITICO Pro, but the agency says it is committed to providing high-quality care to all Medi-Cal enrollees. “To hold providers accountable, DHCS is requiring managed care plans to strengthen their onsite reviews of provider officers and ensure that appropriate preventive services are delivered to children,” Anthony Cava, DHCS spokesperson, said in a statement.

Showing What’s Possible

A companion study by Chapman Consulting, also commissioned by CHCF, examined six managed care plans that increased their quality scores between 2009 and 2018 and suggested quality improvement strategies that could be deployed by policymakers, Medi-Cal program officials, and managed care plans. The case studies showed that, among other criteria, leadership commitment, effective data analysis, and financial incentives for members and providers were key to the managed care plans’ quality improvement initiatives.

For example, a case study of the Health Plan of San Mateo showed that its implementation of several strategies helped increase the percentage of women getting appropriate postpartum care by 15 percentage points in a decade (from 60% in 2009 to 75% in 2018), moving it well above the statewide average (64%). The health plan increased data reporting of recent deliveries by members from monthly to weekly. It used the report to identify postpartum members and engage them via phone calls and text messages to schedule follow-up appointments with their providers. It also instituted a specific code to capture postpartum visits so that providers could be rewarded with an incentive payment for each postpartum visit completed.

Richard Figueroa Takes the Reins at DHCS

On September 25, Governor Gavin Newsom announced the appointment of Richard Figueroa Jr. as acting director of DHCS. Figueroa has served as deputy cabinet secretary in the Office of Governor Newsom since January and was director of prevention for the California Endowment from 2010 to 2018. Prior to working at the California Endowment, Figueroa had a long history of state service. He replaces Jennifer Kent, who resigned last month after heading the department since 2015.

How are Medi-Cal managed care plans performing in your county? Tweet at me with #EssentialCoverage or email me.

The post Researchers Call for Quality-Improvement Changes in Medi-Cal Plans appeared first on California Health Care Foundation.

On Friday, October 4, 2019, President Trump issued a proclamation to suspend entry of immigrants into the United States if they cannot prove that they will obtain unsubsidized health insurance coverage within 30 days of entering, or that they have the financial means to pay for any foreseeable health care costs (fact sheet). The proclamation is not yet in effect, and we anticipate legal challenges.

The White House’s stated rationale for the change is to ensure that immigrants do not burden the health care system financially, to protect the availability of health care benefits for American citizens by not crowding emergency departments, to safeguard taxpayer dollars that are otherwise spent on uncompensated care or Medicaid, and to promote self-sufficiency. As stated, this policy is part of the president’s broader immigration plan to “modernize” the “outdated immigration laws and move to a merit-based system.” In effect, this proclamation increases the income level required of immigrants to enter the country, even though Congress has not authorized this change to US immigration policy.

What do the changes mean for those who want to immigrate?

The proclamation would require immigrants seeking to enter the US (such as family members of US citizens or those being sponsored by a US employer) to demonstrate that they will be covered. According to the Migration Policy Institute, a nonpartisan think tank, the policy could exclude two-thirds of future immigrants from coming to the US — primarily family members of US citizens who would have difficulty proving they can get health insurance within 30 days.

The types of insurance that would satisfy the requirement include employer-sponsored plans, unsubsidized health plans purchased through the Affordable Care Act (ACA) marketplaces, short-term health plans that are effective for at least 364 days or the duration of the planned stay, catastrophic plans, a family member’s plan, TRICARE, Medicare, and visitor health insurance that provides “adequate” coverage for at least 364 days or the duration of the planned stay. Among the insurance types that are excluded are subsidized plans offered under the ACA marketplaces or Medicaid for immigrants over the age of 18.

It is important to note that some short-term plans do not provide dependable coverage. By steering immigrants to these weaker, less-regulated plans rather than allowing them to comply by purchasing comprehensive subsidized plans through ACA marketplaces, this new policy would exacerbate the challenge of underinsurance, create confusion for immigrant enrollees, and undermine the ACA’s consumer protection regime.

Who is affected?

The change applies only to immigrants seeking to enter the US. It does not apply to immigrants already in the US who are changing or adjusting their immigration status. However, many groups are exempt from the new policy, including the children of American citizens as well as select groups entering the US for humanitarian reasons. It does not apply to temporary entrants, such as foreign students and visitors.

How will the policy be rolled out?

The rules are scheduled to take effect on November 3, 2019, but the proclamation will almost certainly be challenged in court. Congress has primary authority over American immigration policy, though existing laws delegate part of this power to the president. The White House has advanced this proclamation under the president’s authority to bar entry to classes of immigrants whose presence is deemed to be “detrimental to the interests of the United States.” This is similar to the approach taken when the president placed a ban on entry from immigrants entering the US from predominantly Muslim countries.

In this case, to justify the exclusion of this group of people, the president is asserting that uninsured immigrants erode the capacity of the nation’s health care system to provide care to US citizens. Legal challenges will question the validity of this rationale and whether current law permits this policy. As with the ban on immigrants from Muslim countries, if the courts find that the president’s rationale is merely a pretext for animus toward the affected population, the new rule will be struck down.

The specific procedures to be used to implement the proclamation have not yet been created. Within six months of the policy implementation, the proclamation requires the departments of State, Homeland Security, and Health and Human Services to submit reports outlining whether it is still needed, whether it should be changed, and whether they have recommendations for further protecting the “integrity” of the American health care system.

This proclamation is the administration’s most recent action directed at health care for immigrants. The public charge rule, finalized over the summer and scheduled to take effect October 15, 2019, has already diminished immigrants’ access to Medicaid and other health-related services, including food assistance and housing. National research shows that fear and confusion relating to the public charge policy is causing immigrants to steer clear of safety-net programs for which they are eligible.

Ten lawsuits have been filed across five federal courts seeking to block or delay implementation of the public charge rule, and judges are expected to make rulings soon. Coupled with this new proclamation, these policies will diminish immigrant communities’ access to health care and other essential services.

The post White House Requires Immigrants to Purchase Health Insurance appeared first on California Health Care Foundation.

Under the watchful gaze of state attorneys general and large hospital systems across the country, a landmark antitrust case is playing out in San Francisco Superior Court. People of the State of California v. Sutter Health, brought by California attorney general Xavier Becerra and a group of employers and unions, alleges that Sutter, the Sacramento-based hospital group, has exploited its market dominance in Northern California to squash competition and drive up health care prices. Sutter denies the allegations.

Opening statements in the trial were supposed to begin October 10 but were delayed because not enough jurors were present. As Catherine Ho reported in the San Francisco Chronicle, “the pool of 24 jurors lost several jurors to illness, medical conditions, and other issues. Twelve jurors are needed to decide the case, but because the trial is expected to last three months, many backup jurors were added.” Attorneys for both sides will meet to determine whether it is necessary to select additional jurors.

Sutter “has long been viewed as the classic example of a hospital system that got way too big,” Reed Abelson reported in the New York Times. Over the years, the nonprofit organization has expanded its footprint in Northern California by buying up hospitals and physician practices. Today Sutter has 24 hospitals, 5,500 physicians, and annual operating revenue of $13 billion.

The plaintiffs argue that Sutter leveraged this size to engage in anticompetitive practices, including “using an ‘all-or-none’ approach to contracting with insurance companies,” Kaiser Health News’s Jenny Gold reported. Under all-or-nothing contact terms, an insurer that wants to include any Sutter facilities in its network must include the entire health system. This prevents an insurer from negotiating prices with individual Sutter providers and steering patients to more cost-effective ones — all of which leads to higher costs for employers and individuals.

“There’s a point where you’re starting to show signs of a bully,” Becerra told Abelson. In the complaint (PDF), Becerra cited a 2018 study (PDF) from the Nicholas C. Petris Center at UC Berkeley showing that in Northern California, where the health care market is highly concentrated, procedure prices are often 20% to 30% higher than in the Southern California market, which is not as concentrated.

Prices Vary Across California

A newly published study from the Petris Center, funded by CHCF, confirms that patients in Northern California pay more than Southern Californians for the same services. For example, in 2016, Northern California wage-adjusted prices for a routine childbirth (vaginal delivery without complications) were on average 24% higher than in Southern California. At the extreme was Monterey, where an average uncomplicated childbirth costs $22,751, compared to $11,387 in San Diego.

In general, Californians pay significantly more for common health care services than people in the rest of the country. The average wage-adjusted price for a colonoscopy in 2016 was $876 in California, compared with $710 in the rest of the country.

The researchers, led by Petris Center director Richard Scheffler, PhD, pointed to increased economic consolidation as a driving factor in California’s higher health care prices and insurance premiums. Their findings underscore “concerns over the rapid increase of mergers among hospital groups and medical practices,” Abelson wrote.

The acquisition of physician practices by hospital systems like Sutter is of particular concern because “most of it is under the radar, and it doesn’t get picked up by the regulators,” Scheffler told Abelson. “It’s adding more power to a concentrated market” but is not subject to the same scrutiny that big hospital mergers are, he said.

Implications for the US Health Care System

California v. Sutter Health is a combined case that includes Becerra’s lawsuit, which seeks to halt the anticompetitive practices but does not seek monetary damages, and private litigation brought by employers and unions. The latter group seeks “up to $900 million in damages for overpayments that they attribute to Sutter,” Gold reported. “Under California’s antitrust law, the award can be tripled, leaving Sutter liable for up to $2.7 billion.”

Sutter denies any wrongdoing. “There is robust competition in Northern California, and Sutter Health looks forward to demonstrating in court why its integrated care model promotes competition and, most importantly, benefits patients and communities,” Sutter spokesperson Amy Thoma Tan said in a statement to the Chronicle.

The lawsuit is being watched closely because consolidation is a growing national trend that magnifies the potential for antitrust violations. A victory for the plaintiffs could signal other big systems to police their own behavior more rigorously. “It could have a chilling effect on [anticompetitive] practices nationwide,” Leemore Dafny, a Harvard business professor and former Federal Trade Commission official, told Abelson.

Additional litigation and new regulation are other possible outcomes. State and federal authorities have already brought antitrust lawsuits against health systems in Idaho, North Carolina and Washington State. California policymakers have considered changes to hospital and insurer contracting rules during the current legislative session and the previous one.

Although the outcome of the Sutter lawsuit will be binding only in California, it could send a strong message to the health care market nationwide. Anthony Wright, executive director of Health Access California, told Gold, “You want [hospital systems] to compete . . . by providing better quality service at a lower price, not just by who can get bigger and thus leverage a higher price.”

Have you felt the effects of economic consolidation in your health care market? Tweet at me with #EssentialCoverage or email me.

The post Highly Anticipated Trial to Determine If Consolidation Is Driving Up Costs appeared first on California Health Care Foundation.

Veteran health care journalist Dan Gorenstein wants to demystify controversial health care issues by peeling back the political rhetoric that makes them so confusing. The former senior health care reporter at NPR’s Marketplace is partnering with health policy researchers to produce a new podcast called Tradeoffs. Featuring a mix of data and storytelling, each episode will unpack the potential benefits and drawbacks of policies related to major health care controversies like drug pricing, Medicare for All, high-deductible health plans, and more. Episodes will air on the Acast network, available on the major podcast platforms, every other Wednesday starting October 16. I recently asked Dan to share his motivations for embarking on this journalism adventure and to preview what listeners can gain by tuning in. Our conversation has been condensed and lightly edited for clarity.

Q: Why did you decide to launch the podcast now?

A: The run-up to the 2020 election seemed like the perfect time to produce a new health policy podcast. Memories of Republicans’ efforts to repeal the ACA are still fresh, and the current debate among Democratic candidates is lively. People have a hunger to fix health care, but there are no quick fixes or silver bullets. Tradeoffs exists to “kick the tires” on some of these complicated ideas that frankly are not panaceas. All have an upside and a downside. All have tradeoffs.

Q: What sets Tradeoffs apart from other sources of information about health policies?

A: As a longtime health care reporter, so often my stories focused on people who were consumers or patients. But there are also doctors, nurses, health care executives, lawmakers, employers, and researchers who are characters engaged in this larger $3.8 trillion health care spending system. With Tradeoffs, we hope to expand the group of people who are humanized beyond patients. By helping listeners meet some of those other players and understand their motivations, we hope to paint a more nuanced picture of our health care system that includes both its flaws and its strengths. What also makes our show different is the team we have put together to produce it. We have health policy researchers and economists who understand the literature backwards and forwards working alongside storytellers who specialize in framing, distilling, and creating tension and drama. My cohosts, Harvard physician and economist Bapu Jena and Vanderbilt economist Sayeh Nikpay, understand how to take very complicated ideas and questions and explain them in ways that are accessible to many people.

Q: How will you cover topics like Medicare for All?

A: Sometimes the message we get is that a single-payer system run by the federal government is going to fix all of our health care problems. People won’t have to worry about copays anymore, and it’s a done deal. But as with any sweeping health reform, it’s not that simple. Our show isn’t satisfied with the easy answer — we think it’s important to ask the trickier, messier follow-up questions too. If Medicare for All drives down prices and simplifies the administrative bureaucracy, what economic impact does that have on communities where hospitals are the largest employers? If care is suddenly free and more people want to access it, is our system ready to meet that new demand? Would it become more difficult to get an appointment? We are trying to pair these complex concepts with great storytelling to give people the tools to fairly and clearly evaluate the tradeoffs of various policy proposals.

Q: Why did you choose to do a podcast as opposed to other forms of media?

A: I’ve been a public radio reporter for about 20 years, and I love audio journalism because there’s something powerful about hearing other people’s voices. But it’s hard to tell these complicated health care stories in short amounts of time. Podcasts give you room and space to do a 20- or 30-minute story. Podcasts also create an intimacy with listeners and allow people to get lost in stories in a way that helps them remember what they heard.

In one episode about high-deductible health insurance plans, we follow a man with chest pain who thinks he’s having a heart attack. He’s in a high-deductible plan and is worried about spending the money to go to the hospital. We hear what’s happening to him in real time and discuss what the evidence says about whether people are healthier with these high-deductible plans and how these plans are affecting employers. We’ll also talk about where the evidence stops. If we acknowledge that edge of evidence, then we can highlight the important questions for our country to figure out.

Q: Who is the target audience for the show?

A: I think we will have two groups of listeners. One is the doctors, nurses, other clinicians, industry executives, policymakers, and academic researchers who are intimately involved in health care. They see our system’s failings up close and spend a lot of time and energy trying to individually improve it. The other group of listeners will be what I call “the curious class.” They may listen to public radio and read the Wall Street Journal, New York Times, or Washington Post. They are likely to pay close attention to the 2020 presidential race. They have likely had personal encounters with the frustrations and inequities of our health care system. They want to better understand how our system got so badly broken, and how we might actually fix it.

Q: How has learning about health care policies helped you?

A: When I started at Marketplace, I knew nothing about health policy. Becoming smarter about this topic through my work armed me with a capacity to think about complicated issues, both on a societal level and a personal level. Some of the reporting that I did around end-of-life care helped me, my father, my stepmother, and my family navigate my father’s three-and-a-half-year process of dying from amyotrophic lateral sclerosis (ALS). I did a better job being a son to my father in the last years of his life because of the things that I had learned. And I think that we all deserve the opportunity to have that. I want to be clear that we are a policy show, not a “news you can use” show. But if you can understand the economic motivations of hospitals, the trials and frustrations of doctors who are trying to provide care, how health insurance works and doesn’t work, even at a high-level policy perspective, these little footholds that Tradeoffs provides can help you feel a little less lost as you navigate the health care system.

The post New Podcast Examines Tradeoffs Required to Fix US Health Care System appeared first on California Health Care Foundation.

Before joining CHCF, I spent almost 20 years as executive director of the Women’s Community Clinic in San Francisco. In my time there, we forged some valuable partnerships to serve our clients and community, including our merger with another community health center, HealthRIGHT 360. It was during the merger process that I learned first-hand one of the biggest challenges to forging such partnerships — and it wasn’t what I was expecting.

As the closing date for the merger approached, unanticipated challenges arose. Despite our shared values and the clear financial and operational advantages to combining the health centers, the process revealed that our organizational cultures were different from one another. It became clear that we hadn’t adequately accounted for those differences.

Organizational culture includes your group’s values, beliefs, and behaviors. This can be about how the health center makes decisions, handles conflicts, or their philosophies about patient care. For example, the Women’s Community Clinic had only 40 employees, and staff members at all levels participated in organizational decisions. Everyone had  frequent contact with senior leadership. As a larger statewide organization, HealthRIGHT360 operated differently, which was a big adjustment for the Women’s Community Clinic staff. Another striking difference showed up during one of the first joint staff meetings. HealthRIGHT360’s culture was to dive right into the business of a meeting, a big change for the Women’s Community Clinic staff who expected more up-front relational time before moving through the meeting agenda.

Neither organization’s approach was “right” or “wrong” in the way they did things. But learning to find the balance between these approaches slowed down the process in ways we hadn’t anticipated. The merger closed successfully, but it came with some hard lessons.

Integrating Organizational Cultures

Now I often hear from other community health center (CHC) leaders that they faced similar challenges when merging or forming a partnership with a community-based organization, hospital, or other care provider. “Cultural friction points” show up in a multitude of ways.

In one example, staff members of a primary care clinic partnering with a housing shelter objected to the shelter’s policy of evicting patients who violate alcohol and drug policies. In another, leaders of a CHC provoked concerns when they adopted new business practices in preparation for the significant expected growth from new partnerships. Staffers objected to a new productivity metric — patients per hour — as focusing too much on volume at the expense of client-centric care.

Learning how to navigate these sensitive organizational culture issues becomes more urgent as CHCs increasingly forge partnerships to improve patient care and ensure their own long-term financial viability. Yet, few resources exist to help CHCs with these challenges.

Insights, Exercises, and Examples

Today, CHCF released Building to a Sum Greater than Its Parts: A Hands-On Guide to Cultural Integration in Community Health Partnerships and Alliances. Created by human-centered design experts and based on multiple interviews and workshops with CHC professionals across California, the guide contains actionable insights, hands-on exercises, and real-world examples to help CHCs build more effective, longer-lasting partnerships.

This handbook will guide CHC staff members in these often-overlooked topics:

• How to define an organization’s culture and to talk about it
• The ways culture manifests in an organization and how to identify its cultural strengths
• How future partners can talk about cultural differences and leverage the strengths of each organization
• How to identify and navigate the typical cultural “friction points” found in partnerships

I wish I had this toolkit when I was looking for a merger partner for the Women’s Community Clinic. We hope it helps other CHCs and community-based organizations navigate their partnership journey. Our goal is for you to engineer partnerships that “build to a sum greater than its parts” and that grow and strengthen your organizations and your service to your community.

I’d love to see your feedback on the guide or learn about how you are using it, so please reach out to me here.

The post For Community Health Centers, a Hands-On Guide to Building Partnerships appeared first on California Health Care Foundation.

Are you one of the 62 million Americans who listen to podcasts weekly? Or one of the 16 million Americans who consider themselves “avid podcast fans”?

Audio storytelling has long been a popular medium, but podcasting — a term coined by journalist Ben Hammersley in The Guardian in 2004 — has changed how and where people consume it. According to Edison Research and Triton Digital, 90% of monthly US podcast listeners over age 12 today listen to podcasts at home, 64% listen in a car or truck, and about half listen while on foot. Though people listen to podcasts for many reasons, two rise above the rest: to learn new things (74% of monthly podcast listeners) and to be entertained (71%). A growing share of podcast listeners use the medium to stay up-to-date with the latest news (60%).

Podcasts about health care are gaining steam. Tradeoffs, a new health policy podcast cohosted by longtime health care reporter Dan Gorenstein, Harvard physician and economist Bapu Jena, and Vanderbilt economist Sayeh Nikpay, aims to demystify controversial health care issues and news for listeners.

In the run-up to the 2020 election, health reform is getting plenty of airtime — in candidates’ stump speeches, on the debate floor, and certainly on Capitol Hill. “People have a hunger to fix health care, but there are no quick fixes or silver bullets,” said Gorenstein. There are only tradeoffs. The Tradeoffs podcast aims to explain the confusing, costly, and often counterintuitive American health care system through storytelling and rigorous research. The first episode premiered on October 16, and new episodes will drop every other Wednesday. Episodes of Tradeoffs run 15 to 30 minutes.

To celebrate the launch of Tradeoffs, which is funded by CHCF and the Robert Wood Johnson Foundation, here’s a round-up of informative, entertaining health care podcasts to keep you company wherever you have speakers or headphones.

If You’re Looking for a Full Season (or more)

An Arm and a Leg

Run time: 15 to 26 minutes per episode

“The cost of health care runs our lives,” said veteran reporter Dan Weissmann in the first episode of An Arm and a Leg. Weissmann, whose work has been featured on NPR’s Morning Edition and Planet Money and on 99% Invisible, couldn’t get the idea of a show about the cost of health care out of his mind, so he gave himself a week to talk to some friends about the idea — in other words, to “get it out of my system.” Instead, everyone he talked to wanted to share their health care cost (horror) stories, and An Arm and a Leg was born. In the first two seasons, Weissmann investigated topics like shopping for health insurance, price gouging by hospitals, and the sky-high price of insulin. A third season is in the works. The podcast is coproduced and funded by Kaiser Health News and funded by Public Narrative and the Chicago chapter of the Awesome Foundation.

The Uncertain Hour — Season Three: “Inside America’s Drug War”

Run time: 36 to 50 minutes per episode

The year was 1989, and President George H. W. Bush was addressing the nation in his first televised speech since being elected. Reaching under his desk, he pulled out a clear bag of “crack cocaine — seized a few days ago by drug enforcement agents in a park just across the street from the White House.” In season three of The Uncertain Hour, host Krissy Clark, senior reporter for Marketplace’s Wealth & Poverty Desk, looked back at this pivotal moment and how Bush’s declaration of a war on drugs connects to today’s opioid crisis. She tracked down friends and classmates of Keith Jackson, the young man with no prior criminal record who the Drug Enforcement Administration lured to the park next to the White House to pin with a drug sale. Clark also traveled to Wise County, Virginia, which has been hit hard by the opioid crisis, to learn what the community is doing to prevent overdose deaths. Marketplace is produced and distributed by American Public Media.

The Workaround

Run time: 28 to 32 minutes per episode

Across the country, people are finding creative and shocking ways to circumvent the American health care system and get the help they need. In The Workaround, reporters from Side Effects Public Media talked to patients who have worked around the organ transplant list, the limited number of buprenorphine treatment slots, and the pricey medical food formulations that are necessary for people with a rare metabolic condition. Side Effects Public Media is a public health reporting collaborative led by WFYI Public Media.

If You Only Have Time for One Episode

Armchair Expert — “Nadine Burke Harris” (October 10, 2019)

Run time: 1 hour, 32 minutes (plus a 43-minute fact check)

Comedic actor Dax Shepard — who happens to be married to actress Kristen Bell — hosts an interview podcast that feels like you’re listening in on an intimate conversation between friends. Recently, Shepard invited Nadine Burke Harris, MD, MPH, to the Armchair Expert attic studio for a conversation about her research on adverse childhood experiences (ACEs) and how it led to her “dream job” as California’s first-ever surgeon general. Burke Harris talked about a program in California beginning in January 2020 to reimburse Medi-Cal providers for screening children and adults for ACEs. She also discussed her lifelong love for the X-Men and how it relates to her research — “Our ACEs can be a vulnerability, but I also think they’re the source of our superpowers,” she said.

The Daily — “Death, Profit and Disclosure at a Children’s Hospital” (May 31, 2019)

Run time: 37 minutes

This New York Times podcast, hosted by Michael Barbaro, takes a deep dive into one of the biggest stories of the day every weekday. On May 31, Barbaro brought in Times investigative reporter Ellen Gabler to shed light on turmoil in the pediatric heart surgery program at North Carolina Children’s Hospital. Gabler was sent secret audio recordings from internal meetings made by physicians who felt deeply concerned about the high death rate at the children’s hospital. In one recording, a pediatric cardiologist can be heard saying, “I ask myself, ‘Would I have my children have surgery here? . . . When I look myself in the mirror, and what’s gone on the past month, I can’t say that.” This episode is a somber reminder that lack of medical oversight can literally be deadly.

Fresh Air — “Why an ER Visit Can Cost So Much — Even for Those with Health Insurance” (March 13, 2019)

Run time: 36 minutes

Put expert interviewer Terry Gross and health policy journalist Sarah Kliff in a recording studio, and you get a master class on emergency room (ER) billing. Kliff, who has reported on Washington’s battle over the Affordable Care Act for nearly a decade, read some 1,500 ER bills submitted by Vox readers while she was a senior policy correspondent there (she is now an investigative reporter at the New York Times). In this episode of Fresh Air, Kliff told Gross about some of the crazier ER bills she read, including a $400 pregnancy test, a $629 bandage, and a $27,660 charge for treatment at a city hospital after a college student was knocked unconscious by a city bus. It’s a shocking look at the crushing costs that can come out of “a place where you can’t really shop for health care.”

The next Essential Coverage will be published on November 4. In the meantime, share your favorite health care podcast with me via Twitter or email.

The post Headphones On: What We’re Listening To appeared first on California Health Care Foundation.

This article was originally published on October 18, 2019, in the Health Affairs Blog and is reprinted with permission. 

Shortly before it was set to take effect last Tuesday, five federal districts courts, sitting in Washington (PDF), California, Baltimore, Cook County and New York City issued preliminary injunctions against the Trump Administration’s new public charge rule, halting at least for now a rule that was widely expected to reduce immigrants’ access to health care, place new burdens on safety-net providers, and jeopardize public health, especially in immigrant communities.

Regulatory Background

The rule at issue would have redefined a longstanding provision of the Immigration and Nationalization Act (INA). The provision allows the federal government to deny admission or a green card to non-citizens (excluding refugees, aslyees, and certain other groups granted special humanitarian status) who are “likely at any time to become a public charge.” Previously, that provision had been interpreted to apply only to non-citizens who were likely to be predominantly dependent on cash assistance or publicly funded long-term care. Past or future use of Medicaid or other non-cash benefits did not make someone a public charge.

The Department of Homeland Security (DHS) rule that was set to take effect on October 15 would have dramatically changed that definition, redefining public charge to mean a non-citizen who receives one or more of a specific set of public benefits, including cash assistance, Medicaid, Supplemental Nutrition Assistance Program benefits (food stamps), and housing support for 12 out of 36 months. Receipt of each benefit would count separately, so that receiving Medicaid and food stamps for one month would be treated as obtaining public benefits for two months. The rule also included some important exceptions. Receipt of Medicaid by pregnant women and children under 21 would not be considered. In addition, in accord with the statute, refugees, aslyees and certain other classes of non-citizens were exempt.

The rule also established a complex serious of factors that immigration officials were required to use to decide if an immigrant is likely to become a public charge in the future. Past receipt of Medicaid or other listed public benefits constituted a heavily weighted negative factor, as did having a serious medical condition without having medical insurance, or not being a full-time student or employed. Other negative factors included being under 18 or over 62, lack of English-language proficiency, or a poor credit score. Positive factors included income over 250% of the federal poverty level, or having private (non-subsidized) health insurance.

The Lawsuits

Shortly after the rule was published in the Federal Register on August 14, 2019, 22 states and local governments as well as many advocacy groups filed at least nine separate lawsuits. The challengers claimed that the rule exceeded DHS’ statutory authority, was promulgated in an arbitrary and capricious manner in violation of the Administrative Procedure Act (APA), discriminated against individuals with disabilities in violation of the Rehabilitation Act of 1973, and violated the Equal Protection Clause of the Constitution.

Jurisdiction

In response, the Department of Justice (DOJ) argued that cases were not appropriately before the courts because the harms were speculative and not particularized to the plaintiffs. The five federal courts that have ruled so far each disagreed, pointing in particular to the rule’s impact on uncompensated care and public health, as well as its impact on the mission of the private party plaintiffs. For example, in the case brought by the state of Washington and several other states, Judge Rosanna Malouf Peterson of the Eastern District of Washington noted that the plaintiffs had alleged that the rule would lead to loss of federal Medicaid funds, significant uncompensated costs, burdens to the doctor-patient relationship, reduced access to vaccinations, and increases in childhood poverty and food insecurity. In the Baltimore case, Judge Paul W. Grimm found that Casa de Maryland, an organization that offers social services and legal support to immigrant communities in Maryland, Washington, DC, Virginia, and Pennsylvania, had standing because the rule would frustrate the organization’s mission and force it to shift resources to respond to the rule’s impact on the families it serves.

The Merits: Awarding Preliminary Injunctions

Having found jurisdiction, each of the courts found that the plaintiffs were entitled to a preliminary injunction because they were likely to prove that the rule exceeded DHS’ statutory authority. For example, in cases brought by the City of San Francisco as well as the State of California and private organizations, Judge Phyllis Hamilton of the Northern District of California found that the rule departed from the provision’s “long-standing (sic) focus on the individual’s ability and willingness to work or otherwise support himself, and its longstanding allowance for short-term aid. . . .” Judge Grimm in Maryland likewise found that the rule departed from established precedent: “Congress also has rejected multiple attempts to define ‘public charge’ in the way that DHS now does through administrative rulemaking.”

In New York, Judge George Daniels agreed that the rule departed from the historical precedent, and noted that the defendants had failed to “articulate why they are changing the public charge definition, why this new definition is needed now, or why the definition set forth in the Rule — which has absolutely no support in the history of US immigration law — is reasonable.” Judge Daniels continued, “The Rule is simply a new agency policy of exclusion in search of a justification. It is repugnant to the American Dream of the opportunity for prosperity and success through hard work and upward mobility.” Judge Daniels added that because the US does not have an official language, it is “simply offensive to contend that English proficiency is a valid predictor of self-sufficiency,” and that because DHS had presented no reasonable basis for the rule, the plaintiffs’ Equal Protection claim was very strong.

In Washington, Judge Peterson emphasized that the rule departed from Congress’ intent as evident in not only the INA but other statutes, including the Personal Responsibility and Work Opportunity Reconciliation Act (PDF), which relate to immigrants’ access to public benefits. Judge Peterson added that DHS has no authority over Medicaid and had overstepped its place in assuming a role over public health, which has traditionally been left to the states.

Although the five judges agreed that the plaintiffs had met the standard necessary to obtain a preliminary injunction by showing that the rule exceeded DHS’ authority, they disagreed as to whether the rule likely violated the Rehabilitation Act, which prohibits federal agencies from discriminating against people with disabilities. Both Judges Peterson (Washington) and Daniels (New York) found that the rule likely violated that Act. In contrast, in California, Judge Hamilton concluded that because the rule did not discriminate “solely” based on disability, and the INA permitted health to be considered in the public charge determination, the plaintiffs were unlikely to succeed on their Rehabilitation Act claim. The other judges did not rule on this issue.

The judges also disagreed as to the appropriate scope of the preliminary injunction. Judges Peterson in New York and Daniels in Washington ruled that given the need for uniformity, the injunction should be nationwide. In California, Judge Hamilton held that Ninth Circuit precedent required her to limit the injunction to the states that were before her. Likewise, in Illinois, Judge Gary Feinerman limited the injunction to Illinois. However, because two other judges have now imposed a nationwide injunction, these limitations are, for the moment, of little consequence.

Momentous, But Not Definitive

Taken together, these rulings by five different federal judges strike a momentous blow to the Trump Administration’s efforts to reduce legal immigration and deter lawfully present immigrants from using public benefits. They are not, however, the end of the story. Almost certainly the Administration will appeal each decision, and the matter may well end up before the Supreme Court.

In addition, just before the courts issued their rulings, the State Department issued a new interim final rule (originally scheduled to take effect on October 15) to align the public charge determination undertaken in overseas consular offices with the definitions and criteria set forth in the now-enjoined DHS rule. For the moment, it appears that the State Department has not implemented the rule; whether it will do so shortly remains unclear. Also uncertain is the impact of the Proclamation that President Trump issued last week purporting to require most immigrants seeking visas to enter the US to have health insurance. Although the Proclamation and the Interim Rule echo the public charge rule in treating lack of health insurance as a justification for keeping out noncitizens, these new initiatives were not before the courts that issued injunctions. Moreover, courts have generally given the executive branch more leeway in cases relating to overseas applicants seeking entry than in cases concerning the treatment of immigrants who are residing within the US.

Nevertheless, the courts’ decisions that the public charge rule was likely unlawful in part because of its public health consequences are of critical importance. Courts have now recognized what health care professionals and public health authorities have been stating: that the Administration’s efforts to reduce immigration by penalizing the use of health benefits jeopardizes the health of all Americans. Unfortunately, given the Administration’s continuing efforts to curb immigration through health-focused initiatives, the need to raise the alarm continues.

Disclosure: The author represented parties who submitted an amicus brief supporting the challenge to the public charge rule in the cases in Washington, New York and California. The author has no financial or personal interests affected by the public charge rule or the litigation concerning it.

The post Five Victories for Public Health: Courts Enjoin the Public Charge Rule appeared first on California Health Care Foundation.

California is one of the most diverse places on the planet. One thing we all have in common is a deep desire for ourselves and our loved ones to be healthy, live to their full potential, and have productive, satisfying lives. That shared aspiration explains why the idea that everyone should have access to health care is such a universal value.

Unfortunately, we know some groups face barriers to high-quality care solely on the basis of their skin color or ethnic background. Although health care plays a small but essential role in a person’s overall health, the delivery system has an outsized role to play in addressing health disparities.

With that in mind, CHCF has just released its first California Health Care Almanac devoted to racial and ethnic health disparities across our state. The report tells us where in California people of color disproportionately face barriers to health care and bear a heavier burden of illness. It also reveals a pattern of harm that is especially devastating to the people in our Black communities.

By the Numbers

By 2040, people of color are expected to account for two-thirds of California’s population. That’s why addressing disparities they face today has such huge implications for California’s future.

The findings in the almanac include data on:

• Life expectancy. The average life expectancy at birth in California was 80.8 years. It was lowest for Blacks at 75.1 years and highest for Asians at 86.3 years, an 11-year gap.
• Health and insurance status. Latinos were most likely to report being in fair/poor health and have higher rates of uninsurance.
• Access. About 1 in 5 Latinos lacks a usual source of care and is less likely to have a checkup. One in 6 Latinos also reported difficulty finding a specialist.
• Quality. Black children and adolescents are much more likely to end up in the emergency room because of complications from asthma. Rates of preventable hospitalizations for Black adults were much higher than rates for other races/ethnicities.
• Mental health. About 1 in 5 multiracial and Black adults reported depression compared to about 1 in 10 Asian adults.
• Prevention. Latinos have the lowest rates of colorectal cancer screening. Black and Latina women were less likely than white and Asian women to have breast cancer diagnosed at an early stage.
• Maternal health. Blacks fare worse on maternal/child health measures. They have higher rates of preterm births, low-birthweight babies, infant mortality, maternal mortality, and low-risk, first-birth cesareans.

With these data comes responsibility. Knowing these disparities exist should compel policymakers, health system leaders, providers, and consumer groups to act. We must keep working on broad improvements to make care more affordable, accessible, and effective. Addressing disparities around coverage, access, and quality is mainly the job of the health care system. Disparities in health outcomes require the health care system to be part of the solution and work in tandem with other sectors. In every case, all of us need to ask ourselves what unique challenges racial and ethnic groups face in getting the care and help they need, and then target improvement efforts to address those structural realities. Ultimately, eliminating disparities for communities of color will benefit all Californians.

Significant Progress

I am optimistic that California can solve these problems. Here are just a few examples of noteworthy progress.

• In 2013, before the Affordable Care Act was implemented, there were major differences in the uninsured rate of white and Black Californians. Now, the uninsured rates for both groups are at historic lows, and there is no statistically significant difference between them. We know that coverage is a prerequisite to people having access to the care they need.
• A decade ago, Kaiser Permanente launched the Equitable Care Health Outcomes Program, which uses a team-based, population health approach to reduce racial health disparities among its members. For Black members, the program’s goal was to improve hypertension control, which prevents heart attacks, strokes, and kidney disease. For Latino members, Kaiser focused on increasing screening for colorectal cancer, which is highly treatable if diagnosed early. After seven years, hypertension control levels for Black members had improved by 22%, and disparities between Black and white members were reduced by 71%. Colorectal cancer screening rates increased for Latino members by 20%, and disparities between Latino and white members decreased by 44%.
• Health Net wanted to do something about disparities in maternal health — including high maternal mortality rates — for Black women in Los Angeles County. Health Net Medical Director Dr. Pooja Mittal devoted her recent CHCF Leadership Fellowship project to developing a pilot program (PDF) to provide doula services to pregnant Black women. (Continuously supporting women in labor improves outcomes during childbirth, research shows.) Dr. Mittal aims to have 150 women in the pilot. So far, 50 women have enrolled, and all 18 of the deliveries to date were healthy births. Health Net will begin to share preliminary results later this year.
• Two years ago, California’s public hospitals launched a range of projects (PDF) to reduce racial and ethnic health disparities in five key areas: blood pressure control, colorectal cancer screening, diabetes care, heart disease, and tobacco screening and cessation. The effort was part of a five-year initiative within the Public Hospital Redesign and Incentives in Medi-Cal (PRIME) program. After one year, 12 of 17 public hospitals saw meaningful improvement in erasing disparities. For example, after identifying care gaps and conducting telephone outreach to patients in Spanish, the Central Valley’s Kern Medical persuaded more Latino patients to take aspirin to reduce their risk of heart attack and stroke. Arrowhead Regional Medical Center in San Bernardino County increased colorectal cancer screening for Latino males through a tailored educational campaign. Contra Costa Regional Medical Center in Martinez helped Black patients lower their blood pressure through a multifaceted program that the patients helped to design.

Leverage from Data

Progress is possible, but improvement efforts cannot succeed without data transparency. On that score, the state Department of Health Care Services has a large role to play. The department recently began publicly reporting on access and quality in Medi-Cal managed care by race and ethnicity. They should also use state data to focus targeted improvement efforts on specific populations and to work with health plans to do the same with their medical groups and community clinic partners.

Disparities won’t disappear overnight and change won’t happen on its own. Progress requires the entire health care system to demonstrate leadership, rigorousness, humility, and persistence. Count on CHCF to be an active partner in this vital effort.

The post It’s Time for California to Solve the Double Standard of Care appeared first on California Health Care Foundation.

As policymakers confront significant social and economic inequality throughout our country, the role of racial and ethnic disparities in health care must be acknowledged and addressed. The success of these efforts depends on our ability to track relevant health care data about different population groups. How sick are patients when they show up at the doctor’s office? What types of experiences do they have there? What kind of treatment outcomes can they expect? We need to understand whether improvements in morbidity and mortality are shared by the most vulnerable, or if they mostly benefit a select few. Only then can we begin to move to a society where all of us have an equal opportunity to live a long, healthy, and productive life.

Why Measure Disparities in California?

Nowhere is the need to measure disparities greater than in California, one of the few states where people of color compose the majority of the population.

CHCF has released a Health Disparities by Race and Ethnicity: The California Landscape, which looks at racial and ethnic disparities in California. Based on data from multiple sources, this compilation facilitates comparisons across measures to inform potential equity-guided improvement strategies (EGIS). An EGIS identifies specific populations at risk of suboptimal outcomes and delivers customized clinical interventions for them.

What Drives Disparities?

According to the US Centers for Disease Control and Prevention, health is largely determined by the environment in which a person lives and works. These “social determinants of health” include income, education, and social support, and account for more than half of the factors affecting health status. Medical care makes a smaller but significant contribution — around 20%. And another 20% is the result of health behaviors like substance use and a sedentary lifestyle, which can be affected by medical care and the environment.

Assessments and interventions to reduce disparities in health can include social determinants. However, in practice, many interventions focus on medical care and health behaviors, because modifying the environment in which a person lives and works requires activities beyond the traditional scope of health care and population health services. It is simply easier for providers to manage and improve the care they deliver, and this is where most reductions in disparities have been achieved.

What drives disparities within the acute care medical system? An emerging consensus focuses on structural racism, or the effects of persistent discriminatory beliefs and historical decisions around the allocation of resources that negatively affect certain groups today. The role of implicit bias — a set of automatic and unconscious stereotypes and prejudices that affect everyone, including health care providers — must also be acknowledged. The net effect is forgone or substandard care due to a patient’s race, language, immigration status, or sexual orientation.

How Are Disparities Reduced?

While policymakers sometimes assume that they can reduce disparities by improving overall health care performance, improvements in quality do not necessarily produce reductions in disparities. Often, as overall performance improves, the performance of individual groups improve by similar amounts; disparities are still present even though both groups have experienced gains. For example, as colorectal cancer screening rates have improved nationally, differences among groups related to race, ethnicity, and family income have changed little.

But we know that disparities can be reduced. And for any effective disparity-reduction strategy, the first step is measurement. Multiple reports — including this new CHCF report, the California Pan-Ethnic Health Network Landscape Report, the National Healthcare Quality and Disparities Reports, the Commonwealth Fund Scorecards on State Health System Performance, and the National Veteran Health Equity Report — show that disparities are common, and not rare phenomena attributable to a few poor performers. More importantly, these efforts provide crucial population-level benchmarks for policymakers, providers, and purchasers tracking the effectiveness of interventions targeting access barriers and quality failures.

For example, the US Veterans Health Administration (VHA) has long tracked disparities in care delivered in its facilities. By reducing known barriers to care, such as copayments and transportation difficulties, and putting in place strong continuous quality improvement efforts, VHA has largely eliminated many disparities for its clients. Veterans with high blood pressure or diabetes are more likely than patients outside of the VHA to receive all needed services in VHA facilities, and differences among groups of veterans are small.

Another key component of effective disparities reduction is aiming quality-improvement efforts at the care of particular groups. Traditional quality improvement focuses on raising average performance and assumes that different groups of patients are distributed evenly around this average. But through our measurement efforts, we know this is not the case. By applying quality-improvement efforts for groups receiving poor care, the EGIS approach allows concentrated and cost-effective interventions.

An example involving both of these strategies — measurement and targeted improvement — can be found in Covered California, the state’s health insurance marketplace. Beginning this year, plans are required to collect self-reported patient identity data (PDF) from at least 80% of enrollees. Plans are then required to use these data to show year-over-year reductions in race, ethnic, and gender disparities in the care of diabetes, hypertension, asthma, and behavioral health. Further disparities-reduction efforts are expected for other vulnerable populations including speakers with limited English and LGBTQ+ patients.

Toward a Plan to Reduce Disparities in California

In compiling and summarizing so many different types of data on health disparities in California, the CHCF Almanac provides a critical snapshot of current successes and opportunities for improvement. Disparities data will allow equity-guided improvement strategies and disparities-focused policymaking — essential steps on the path toward a society that is stronger by being equitable and efficient.

What else might policymakers seeking to reduce health care disparities in California consider? Additional data are always useful. While we have some information on various groups and their experience in California’s health care system, there are many things we don’t know. Capturing patient race and ethnicity data in California’s new all-payer claims database is one strategy for expanding our knowledge about how care is being delivered. Ensuring that health plans meet and exceed the Covered California patient data targets is another important undertaking.

Prioritizing measurement and reporting on disparities within the Medi-Cal program is also crucial. Medi-Cal is a critical source of coverage for millions of low-income Californians. Diversity among Medi-Cal enrollees is striking: more than 70% are members of racial and ethnic minority groups. Almost 40% identify their primary language as other than English. Fortunately, the state recently began publicly reporting on access and quality in Medi-Cal managed care by race and ethnicity. Additional reporting on the experience and outcomes of managed care and fee-for-service enrollees is worth serious consideration.

While what gets measured usually improves, what gets measured and prioritized often improves faster. Policymakers in California should identify specific measures that are amenable to change. What makes a good target? At the VHA, we’ve prioritized diabetes, hypertension, and mental illness for these reasons:

• The root cause of disparities in those conditions can be addressed within the acute care system.
• There are proven interventions.
• We can identify specific places and providers that can improve.

Finally, several interventions within the acute care delivery system hold promise for reducing disparities across a range of conditions and could be considered for widespread adoption. These include increasing access to culturally and linguistically competent care through the use of interpreter services, community health workers, and implicit bias training; supporting patient-centered medical homes; supporting facilities that allow patients enhanced access to primary care services on evenings and weekends; and promoting care coordination initiatives that utilize community-based navigators and integrate physical health with behavioral health services.

Whatever California may choose to prioritize, efforts to reduce racial and ethnic disparities in health care are essential endeavors that will pay dividends to the state and nation. We can begin to realize the American ideal of equal social and economic opportunity for all only with a system that delivers high-quality care to everyone, regardless of who they are or where they live. Let’s continue building that system together.

The post New California Data Resource Highlights Need for Bold Action on Health Disparities appeared first on California Health Care Foundation.

Across California there are far more patients seeking specialty care than there are specialists available to help them. This is especially true for people with low incomes and those living in vast rural areas. Electronic consults, also known as eConsults, offer one tonic for our overtaxed system.

With this type of telehealth, primary care providers are able to electronically submit clinical questions to a network of specialists and, within hours, receive medical guidance. Studies have shown the clear impact eConsults can have on access, including reducing patient wait times for specialists and lowering unnecessary referrals for in-person specialist visits.

Much less research has been done on the impact that eConsults have on primary care providers, especially in the safety net. Within that limited literature, primary care clinicians report largely positive experiences, but some have surfaced concerns about the added burdens that eConsults place on them. CHCF recently funded JSI Inc., a public health research and consulting firm, to survey primary care providers within the Community Health Center Network (CHCN), a nonprofit Medi-Cal managed care organization, about their use of eConsults.

The findings were mostly positive, especially relating to the effects of eConsults on providers’ job satisfaction and their perceptions of quality of care. Among the challenges noted were the extra time and technological savvy that eConsults can require, as compared to traditional referrals. More detailed results can be found in this infographic and in the full report (PDF).

I spoke to one of the survey respondents, Kim Nguyen, MD, an internal medicine physician and associate medical director at CHCN’s LifeLong Ashby Health Center, about her experiences with RubiconMD, the eConsult platform used by CHCN. RubiconMD is one of a handful of third-party eConsult platforms and has received a program-related investment from the CHCF Health Innovation Fund. This interview has been lightly edited for length and clarity.

Q: In your experience, how does the eConsult process compare to the traditional referral process for specialty care?

A: To request an eConsult, I open the platform, enter relevant information from the patient’s record, such as lab results or history, type in my clinical question, and then send it off to the specialist network. With a traditional referral, I just tell the nurse a referral is needed, and they handle all the paperwork from there. That’s easier for me as the provider, but I know it puts a greater burden on my patients.

Every referral starts with a letter being mailed to the patient’s home. That can take days and of course get lost. The patient then needs to find a specialist who has availability, but that can be difficult for many reasons — there can be insurance issues and specialists can be booked for months in advance. Conflicts can arise in a patient’s life that may prevent them from ever scheduling the appointment. Or some may just not show up for it. With an eConsult, I can get a much faster answer for my patients and even have a care plan for them within a day or even the same day. That leaves far fewer cracks for my patient’s care to fall through.

Q: In which kinds of clinical situations do eConsults prove most valuable?

A: I have found eConsults to be especially helpful for patients with oncology concerns. When a possible cancer diagnosis is on the line, it is critical to move quickly to get an answer for the patient and then start the patient on any needed treatment. Primary care doctors typically cannot get a patient an appointment with an oncologist before a cancer diagnosis is confirmed.

My goal as the primary care provider is to try to get that diagnosis as quickly as possible. By engaging an oncologist via an eConsult, I get quick guidance on which tests to order to produce the most precise and rapid diagnosis possible. It can take weeks to get them all done and evaluated, so forgetting a test or ordering the wrong one could ultimately delay a patient’s vital cancer treatment by days or weeks. It’s so important to get it right at the start, and eConsults help me do that. I also frequently use eConsults for patients with dermatology concerns.

Q: How do you decide whether requesting an eConsult is the right next step?

A: You need to think about access. Some specialists may not be available for months. If the patient does not have insurance, they likely cannot see a specialist, making an eConsult their only means of accessing specialty expertise. If the problem requires a specialist to do a detailed in-person visit, like a neurological exam or a biopsy, those cannot be accomplished with an eConsult and should be referred immediately. The same is true of problems that are both chronic and complex and likely require ongoing management by a specialist.

Q: Have eConsults affected your views about the care you have provided?

A: It can be really discouraging to know all the barriers that await a patient you have just sent out for a referral. Specialty care access is a real challenge for our patient population. Giving patients timely access to expertise that they otherwise might never get — for me, that’s encouraging. It’s a chance to avoid some of the systemic failures that patients like ours often encounter.

Q: Has your use of eConsult changed over time?

A: Reflecting on your use of eConsults can be a good way to help you assess your own weak spots and identify how you can improve as a clinician. I started paying closer attention to the types of questions I was submitting on RubiconMD and realized I was relying heavily on eConsults for dermatology cases. A lot of dermatology expertise comes from volume and repetition, and I had not done much dermatology during my internal medicine residency. So, I started working to improve my own knowledge in that area. Ultimately, if you can become your own expert in problems you see often, you can reduce the need to rely on outside specialists, whether electronically or not, and that saves everyone time.

The post Examining the Effects of Electronic Consults on Primary Care Providers appeared first on California Health Care Foundation.

When I first met Chris in my palliative care clinic, he wasn’t sure why he needed to see me.

Bald, with deep-set brown eyes and a tattoo of his mother’s face wrapped around his forearm, Chris was midway through his fourth line of chemotherapy for stage IV colon cancer. Three other combinations of medications hadn’t stopped the growth of his cancer, but they had set his fingers and feet ablaze with nerve pain and stripped him of his ability to taste.

During our first appointment, we talked around, rather than about, his disease. His wry sense of humor stitched together the otherwise disparate parts of our conversation — his obsession with March Madness, his critique of a new crime novel, and his career in accounting, which ended when he was diagnosed at age 45. Sweat dotted his forehead as he read aloud the lists of medications he took and the movies he wanted to see, both detailed in his journal. He clenched his fists and grimaced during bouts of abdominal pain, shifting his slight body in his wheelchair. Eventually he admitted that he wasn’t sure what palliative care is or why he needed it.

Chris qualified for palliative care simply because he was living with — and visibly suffering from — a serious illness. Although a growing number of studies demonstrate that patients like Chris enjoy an improved quality of life (and in some cases live longer) when they receive palliative care along with standard cancer treatments, Chris was among the 71% of American adults who haven’t heard of palliative care. Chris’s brother, who accompanied him to our appointment, told me he had insisted that his oncologist refer Chris to my clinic. “I looked at my brother and thought he had zero quality of life, and when I read about palliative care I wondered why Chris hadn’t already been getting this service,” he said, tapping his pen on a notepad filled with questions he and Chris had written in preparation for our appointment. I nodded, recalling that despite his brother’s advocacy and research, Chris’s oncologist had emailed me to say that he wasn’t sure why Chris needed palliative care since “hospice is a long way off still.” Like many physicians and patients, Chris’s oncologist did not understand palliative care or how and when it can help people with serious illness.

Why Palliative Care?

Helping my patients and colleagues understand what palliative care is — and what it isn’t — is a common and necessary part of my job. While Chris’s brother and his oncologist had heard of palliative care, each had a different understanding of its general purpose and its specific role in Chris’s care. Some, like Chris’s oncologist, mistakenly equate palliative care with hospice, or with care in the final hours of life, which leads to patients getting palliative care far too late. Others incorrectly assume that patients must choose between palliative care and life-sustaining, disease-focused treatments. Contrary to these commonly held beliefs, patients should receive palliative care services at any stage of illness, and in conjunction with chemotherapy, dialysis, and other forms of life-prolonging treatment.

I believe that palliative care is about empowering patients caught in circumstances that can feel defeating. It is about both articulation and action. Life with a serious illness is a foreign landscape, one fraught with new physical, social, and existential realities and choices — many of which remain unacknowledged because of the fear and anxiety that society and the medical establishment have yoked to the concepts of mortality and suffering.

Despite this very human fear and anxiety, most people do want to talk with their doctors about serious illness. A recent CHCF survey of California adults found that about 9 in 10 respondents reported that if they had a serious illness they would want as much information as possible about what they should expect now and in the future. Eighty-two percent said that if they develop a serious illness, they want to discuss with their doctor their wishes for medical treatment toward the end of life. And yet 78% of survey respondents living with a serious illness have not been asked by a physician about these treatment wishes.

Helping my patients and colleagues understand what palliative care is — and what it isn’t — is a common and necessary part of my job. —Sunita Puri, MD

It might seem intuitive that we should be talking with our patients about how to live well with a devastating illness. Yet although we physicians learn a dizzying amount of standardized information in medical school and residency, exposure to palliative care remains uneven. We learn to seek the help of cardiologists when a patient’s heart condition merits their expertise or procedural skill. We learn to call kidney specialists when patients meet criteria for dialysis. Yet the threshold to refer patients to palliative care specialists is often based on subjective, faulty perceptions about which patients would benefit from our services. Indeed, physician attitudes toward palliative care — rather than patients’ need for this subspecialty care — can profoundly affect whether people receive it early enough to benefit them. These misconceptions are reinforced by late and poorly explained referrals.

The Sooner, the Better

Several medical organizations have developed guidelines to help physicians recognize when they should consult palliative care specialists. The American Society for Clinical Oncology recommends that all patients with advanced cancer receive dedicated palliative care services in conjunction with active treatment. The American Heart Association issued a policy statement highlighting the importance of referring patients with advanced heart failure or debilitating stroke to palliative care specialists as soon as possible. But adherence to these guidelines remains elusive.

Only when I worked directly with a palliative care physician at the tail end of medical school did I finally understand how to treat the physical suffering of very sick patients and to ask about their hopes and wishes. —Sunita Puri, MD

In order to empower physicians to understand what palliative care is and how it can assist the seriously ill, we must standardize exposure to palliative care in medical school and residency training. Lectures won’t suffice, just as conversations about cardiology are no substitute for the educational value of caring for a patient with heart disease.

Only when I worked directly with a palliative care physician at the tail end of medical school did I finally understand how to treat the physical suffering of very sick patients and to ask about their hopes and wishes. During that clinical rotation, a patient with metastatic breast cancer asked me to share my thoughts on her prognosis. I squirmed, searching for words I hadn’t been taught. I needed to experience the discomfort of my lack of expertise to fully appreciate the expertise of the palliative care team. Had palliative care been modeled for me throughout my training as an essential part of treatment for patients living with a serious illness, I might have been able to meet the needs of the many seriously ill patients I cared for during my residency.

Waiting Until “Next Time”

Sometimes the transformative power of palliative care can best be understood in its absence.

I saw Chris twice more before he died. He told me that the pain medications I’d prescribed helped him sleep through the night for the first time in many months. We talked about the list of books he hoped to read, now that he could lie in bed more comfortably. He told me he wanted to talk to me about what he might expect and plan for in the coming months. We agreed to discuss them next time, in about two weeks.

There wouldn’t be a next time. I saw him again the following week in the intensive care unit, after he suffered an overwhelming infection following another round of chemotherapy. Bound to a ventilator and a dialysis machine, he lay in a hospital bed adorned with a blue balloon emblazoned with the words “Get well soon!” I stood next to his brother as he cried and told me that Chris had written a list of questions about whether to continue with chemotherapy and what his other options might be. “He told me he thought the end might be near, and he just wanted to try and be at home for that, but he didn’t know how to make that happen, and neither did I,” his brother said, his head in his hands. Chris died the next day in the hospital, his body consumed by cancer and complications of chemotherapy.

Even though Chris had been sick for 18 months, I only knew him for a few weeks before he died. That evening, I imagined how Chris’s life might have been different if we’d met earlier. What questions might he have written in his journal? Might he have moved through the world with more ease if we’d managed his pain and fatigue sooner? Might he have forgone this last round of chemotherapy and enjoyed some quality time with his family if we had the opportunity to discuss hospice? Would his brother have found more peace had Chris died at home?

I returned home and added Chris’s first name to a list I keep in my own journal — patients who might have written the endings of their stories differently if only they had been empowered to do so. I regretted the choices Chris didn’t realize he could make, the list of questions I would never answer. I sat on my couch for a while, looking back at the names of other patients, hoping the time will come when I never have to add another.

The post Missed Opportunities in Serious Illness Care appeared first on California Health Care Foundation.

More than 80,000 acres of California have burned since the Kincade, Tick, Getty, and other wildfires erupted last month. Millions of Californians are dealing with unpredictable, dangerous, and smoky conditions complicated by the massive power shutdowns aimed at preventing faulty power company equipment from sparking more blazes. As first responders, state agencies, and local nonprofits work around the clock to fight fires and help displaced people, California health care organizations are grappling with how to operate in what former governor Jerry Brown called “the new normal” in an interview with POLITICO.

Hospitals and clinics in the US are wholly dependent on the aging electrical grid to provide services. They need “power to run everything from ventilators to electronic health records, to ferry patients via elevator through hospitals, refrigerate medications, and countless other tasks,” Nicole Wetsman wrote in The Verge. A planned blackout might confront health care facilities administrators with a wrenching choice: “Do you keep your refrigerator full of vaccines running,” Wetsman asked, “or do you keep the community’s electronic health care records online? Your backup generator can’t do both.”

State and federal law requires health facilities in California to have 72 hours of backup power available, but generators can be vulnerable during disasters and may be able to provide only limited power. Those laws don’t apply to community health centers, and a recent survey of California community health centers by Direct Relief, a Santa Barbara–based nonprofit group focused on disaster preparedness, revealed that only 44% have a backup energy source available.

In Northern California, the first round of Pacific Gas & Electric (PG&E) public safety power shutoffs was implemented on October 9, with power restored to 100% of affected customers by October 12. But only a week and a half later, PG&E ordered a second round of power shutoffs in anticipation of strong wind gusts that could increase the potential for rapid fire spread. As Brown warned, these blackouts may be par for the course in today’s California. Are health care organizations prepared?

Considering the Trade-Offs

Some facilities have figured out workarounds during the power shutdowns. When PG&E informed Winters Healthcare, which has a medical and dental clinic 30 miles west of Sacramento, that its clinics were within the blackout zones, executive staff members had to make quick decisions. PG&E “said we could be down 24 to 48 hours, and it might be five days,” Winters Healthcare Executive Director Christopher Kelsch told Wetsman. “It’s hard to know what to do.”

Ultimately, they decided to close the dental clinic, use their backup generator to power the electronic health record system, and send temperature-sensitive vaccines to a nearby health facility unaffected by the outage, Direct Relief reported.

When some of LifeLong Medical Care’s Oakland clinics lost power, staff moved vaccines and medications to a nearby hospital, and a clinician kept each office open in the dark. “Service would be limited, and there’s no light . . . [but] our patients rely on us to be open when we are needed,” Kate Lewis, LifeLong’s director of operations, told Direct Relief.

Other facilities have had to suspend operations due to the wildfires or power shutoffs. Tara Bannow reported in Modern Healthcare that Kaiser Permanente’s Sylmar and Porter Ranch medical office buildings had to temporarily close in early October because of wildfire smoke. In Northern California during the first round of PG&E shutdowns, elective surgeries were rescheduled at Kaiser’s Santa Rosa hospital.

For the Most Vulnerable, the Added Threat of Fire

California’s wildfires have also been disruptive — and in some cases, deadly — for residents, especially those with medical conditions requiring electrical equipment. As Gabrielle Paluch, Michele Chandler, and Gabrielle Canon reported in the Palm Springs Desert Sun, “one man dependent on electrically powered oxygen equipment died 12 minutes after PG&E shut down power to the rural Sierra Nevada foothills hamlet of Pollock Pines east of Sacramento.” And patients with chronic kidney disease, who rely on as many as three dialysis treatments per week to stay alive, have had to scramble to relocate their care when their regular dialysis center has no power.

Patients with chronic kidney disease, who rely on as many as three dialysis treatments per week to stay alive, have had to scramble to relocate their care when their regular dialysis center has no power.

Older adults may need more time or support to prepare for power outages or to evacuate. On The RAND Blog, senior behavioral scientists Joie Acosta and Regina Shih (no relation to this author) wondered if planned power outages may be doing more harm than good. “With the large and growing population of older adults [in California], an expected increase in the frequency and intensity of hot days due to climate change, and the possibility that power outages can last for up to five days,” they wrote, “planned power outages to prevent wildfires could have grave public health implications for older adults.” A toolkit from the RAND Corporation aims to build older adults’ resilience during natural and human-caused disasters by bridging public health and aging-in-place efforts.

In agriculture-rich California, farmworkers are also vulnerable during wildfires. “October marks not only fire season in California, but also the peak of the grape harvest,” Anna Maria Barry-Jester wrote in California Healthline. “In areas [of Sonoma County] not imminently threatened, some workers labored through the heat and dangerous smoke to retrieve some of the hundreds and thousands of dollars worth of grapes that had yet to be harvested. As the fire continues to spread, many now are finding that their work — and paychecks — have been suspended.”

How to Breathe Easier

The long-term health impacts of smoke exposure on affected populations are unknown because insufficient data have been collected. But as the frequency of California wildfires increases, epidemiologists are doing long-term studies on sporadic events. Researchers at UC Davis are studying Bay Area women who were pregnant at the time of the 2017 Atlas Fire to understand the impact of wildfire smoke on mothers and babies, Catherine Ho reported in the San Francisco Chronicle. In another UC Davis study, researchers are focusing on the general population to learn whether wildfire smoke correlates with respiratory problems, mental health issues, or sleep problems.

With so little known about the impacts of smoke exposure, health experts recommend that people living in areas with poor air quality stay indoors with doors and windows closed. You can check current conditions at AirNow.gov, which was developed by the US Environmental Protection Agency, National Oceanic and Atmospheric Administration, National Park Service, and tribal, state, and local agencies.

If you must venture outside in unhealthy conditions, consider wearing a certified “N-95” or “P-100” mask, which can filter out particulates. However, note that these masks must fit and seal properly to be effective — this means they are not suitable for people with facial hair or for children. “There are lots of sites . . . that will sell you masks for children, but in general, we don’t recommend people get the over-the-counter masks, because they don’t tend to work very well,” Nelson Branco, a pediatrician in Marin County, told Jenny Jarvie of the Los Angeles Times.

How You Can Help People Dislocated by Wildfire

There are many ways to help those who have been affected by California wildfires. Northern California Grantmakers (NCG) has a compilation of vetted wildfire relief and recovery funds that accept donations, and Southern California Grantmakers maintains a list of fire relief funds. You can also view a recording of NCG’s recent webinar on what is needed from philanthropy during and after the Northern California wildfires, and a recording of the webinar on supporting immigrant communities after a disaster, produced by the Center for Disaster Philanthropy and Grantmakers Concerned with Immigrants.

How is your community responding to the recent wildfires? Tweet at me with #EssentialCoverage or email me.

The post Wildfires Create “New Normal” for California Health Care Facilities appeared first on California Health Care Foundation.