Safety Net Health Plans Tackle Social Issues
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1 Safety Net Health Plans Tackle Social Issues Meg Murray, CEO, ACAP Deborah Kilstein, VP QM and Operational Support October 20,
2 Agenda ACAP Overview Safety Net Health Plans Address Social Determinants Prescription Drug Abuse Questions 2
3 About ACAP 3
4 ACAP s Mission To represent and strengthen not-for-profit safety net health plans as they work with providers and caregivers in their communities to improve the health and well-being of vulnerable populations in a cost-effective manner. 4
5 ACAP Represents 58 Safety Net Health Plans Arizona University of Arizona Health Plans California Alameda Alliance for Health CalOptima CenCal Health Central California Alliance for Health Community Health Group Contra Costa Health Plan Gold Coast Health Plan Health Plan of San Mateo Health Plan of San Joaquin Inland Empire Health Plan Kern Family Health Care L.A. Care Health Plan Partnership HealthPlan of California Santa Clara Family Health Plan San Francisco Health Plan Colorado Colorado Access Denver Health Connecticut Community Health Network of Connecticut District of Columbia Health Services for Children With Special Needs Florida Prestige Health Choice Hawaii AlohaCare Illinois Family Health Network Indiana MDwise Kentucky Passport Health Plan Maryland Maryland Community Health System Priority Partners Massachusetts Boston Medical Center HealthNet Plan Commonwealth Care Alliance Neighborhood Health Plan Network Health 5
6 ACAP Represents 58 Safety Net Health Plans Minnesota Metropolitan Health Plan New Hampshire Well Sense Health Plan New Jersey Horizon NJ Health New York Affinity Health Plan Amida Care Elderplan & Homefirst GuildNet Hudson Health Plan Monroe Plan for Medical Care, Inc. Univera Community Health VillageCare MAX VNSNY CHOICE Ohio CareSource Oregon CareOregon Pennsylvania AmeriHealth Caritas Pennsylvania UPMC for You Rhode Island Neighborhood Health Plan of Rhode Island Texas Children s Medical Center Health Plan* Community Health Choice Cook Children s Health Plan Driscoll Health Plan El Paso First Health Plans Sendero Health Plan Texas Children s Health Plan Virginia Virginia Premier Washington Community Health Plan of Washington Wisconsin Children s Community Health Plan *Incubator plan. 6
7 Addressing social determinants of health Health Services for Children with Special Needs therapeutic soccer camp 7
8 Leading Determinants of Health Health Care 10% Genetic 30% Behavior 40% Environment 5% Social 15% McGinnis, JM et al Health Affairs, April 2002; Kaiser Permanente 2010 Community Benefit Annual Report 8
9 Impact of Social Needs on Health Recent Commonwealth Fund Report, found social needs were a direct cause of death for a number of Americans 133,000 deaths due to individual poverty 240,000 deaths due to low educational attainment 162,000 deaths due to weak social support Comparable to deaths for acute myocardial infarction and cerebrovascular disease (2 leading causes of death in US) ADDRESSING PATIENTS SOCIAL NEEDS An Emerging Business Care for Provider Investment, Bachrach, Pfister, Wallis and Lipson, Manatt Health Solutions, Prepared for the Commonwealth Fund, May 2014, Page 10 9
10 Conflicting Choices: The Kitten Paradox 10
11 Why are Safety Net Health Plans Interested in Social Determinants? Since their inception, Safety Net Health Plan case management staff have addressed social issues Increasing use of social workers as part of case management staff Believe that targeted investment in social determinants is required to meet goals of triple aim (better care, lower costs, higher member satisfaction) 11
12 Major Social Determinants Housing Food Education Employment Community Live Learn Work Play 12
13 Housing and Homelessness 13
14 Housing Initiatives Housing support for frequently hospitalized UPMC for You Working with HUD, developed shelter plus care pilot program that provides housing & local care coordination for high-utilizers who are experiencing homelessness Community-Based Housing Health Plan of San Mateo Provides supportive housing for individuals transitioning from long-term-care facilities Project Connect Central California Alliance for Health Working with multiple agencies to provide housing, case management and recuperative care for homeless individuals 14
15 Food Security 15
16 Healthy Food Improving Access to Healthy Food Health Plan of San Joaquin Provided grant funding to support county-wide mobile farmer s market, urban community farm, and nutritional education. Diabetic Food Pack Program CareSource Partnered with food bank to create portable, diabetic friendly food packs to use as jumping off point to expand member s understanding Food Rx Program CareOregon Provide food vouchers via Food Prescriptions that can be used at the mobile organic food market parked outside the clinic 16
17 Education and Schools 17
18 Focus on Education Internship Program Community Health Choice Hires high school interns, educates them about health care and provides work experience within the daily operations of the health plan Book Club Family Health Network Established book club that provides free books & rewards students for completing academic work and improving their reading skills Scholarship Program AlohaCare Provides scholarships for plan members or other students majoring in a health-related field Individualized Family Service Plan Involvement HSCSN - See attached slides 18
19 HSCSN Interaction with Schools Support Functions IEP Family/ Parent Teacher Provider Transport HSCSN Care Managers Mentor Youth HSCSN Outreach HSCSN Customer Care Life Skills Center HSC Inpatient/Outpt. HSC Home Care Transitions Center Youth T. Collaborative 19
20 This image cannot currently be displayed. Partnering with Your Child s School: A Guide for Parents Developed from a collaboration with The HSC Foundation and the George Washington University Graduate School of Education and Human Development Available online in English and Spanish hscfoundation.org/aboutus/publications 20
21 Employment and Job Training and Job Training 21
22 Job Training Initiatives Employment of Enrollees as Outreach Staff (Peer Specialists, CHOWs, Health Navigators, Member Advisory Members) Amida Care Hired, trained and employed enrollees to serve in community-support roles 22
23 Health Equity 23
24 Social and Community Context Reducing Disparities Neighborhood Health Plan Based on data analysis, targeted initiatives to increase breast-cancer screening for African-American women over age 40 and reduce BP for African-Americans with diabetes Male Caregivers Support Group Health Services for Children with Special Needs Developed support group specifically tailored to male caregivers so they could discuss the needs of their children with others in similar situations Health Education for Teenagers Passport Health Plan Focused multi-prong educational activities in an effort to decrease the incidence of risky behaviors and preventable conditions in adolescents 24
25 Health Plan Operations Family Resource Center Project L.A. Care Health Plan Opened Family Resource Centers in two underserved areas of Los Angeles County to serve as a resource for members, health care providers and the broader community Poverty Simulation Employee Training CareSource As part of their investment in employee training and education, added poverty simulation module to employee training process to help them relate to and engage more effectively with the health plan enrollees 25
26 Some Policy Implications Need for More Formal Evaluation (establish evidence base) Cost Effectiveness Reimbursement and Rate-Setting Innovation 26
27 Risk Adjustment for SES Would take into account how providers would be scored if the provided care to comparable groups NQF s current policy does not include SES risk adjustment (only adjusts for clinical factors) NQF created expert panel to look at the issue Draft recommendations (3/14) supported adjustments for SES for measures where there is evidence to support an influence of SES on the performance rate ACAP supports but NCQA, CMS and some advocates expressed significant concerns about potential negative consequences (inadequate information on impact of SES on quality scores, lock in lower expectations, mask disparities in performance) 27
28 Addressing Rx Drug Abuse 28
29 People Abusing Analgesics DIRECTLY &INDIRECTLY Obtain Them by Prescription: Most Recent Pill Source Source Where Respondent Age 12+ Obtained Analgesics: More than One Doctor One Doctor (2.1%) (17.3%) Other 1 (4.6%) Bought on Internet (0.4%) Drug Dealer/ Stranger (4.4%) Bought/Took from Friend/Relative (16.2%) Free from Friend/ Relative (55.0%) Source Where Friend/Relative Obtained One Doctor (79.4%) More than One Doctor (3.6%) Free from Friend/Relative (6.3%) Bought/Took from Friend/Relative (6.5%) Drug Dealer/ Stranger (2.3%) Bought on Internet (0.2%) 1 Other category includes Wrote Fake Prescription," "Stole from Doctor s Other 1 (1.7%) Office/Clinic/Hospital/Pharmacy," and "Some Other Way." Source: SAMHSA, 2009 and 2010 National Survey on Drug Use and Health
30 Drug Overdose Death Rates in USA More Than Tripled Since Nearly 17,000 Died of Rx Opioid Overdose in Motor Vehicle Traffic Poisoning Drug Poisoning (Overdose) Deaths per 100,000 population Year More OD Deaths than Motor Vehicle Deaths Since 2009 NCHS Data Brief, December, 2011, Updated with 2009 and 2010 mortality data Motor vehicle traffic, poisoning, and drug poisoning (overdose) death rates: United States,
31 Drug overdose deaths by major drug type: USA, ,000 Opioids Heroin Cocaine Benzodiazepines 16,000 14,000 Number of Deaths 12,000 10,000 8,000 6,000 4,000 2, Year CDC/NCHS National Vital Statistics System, CDC Wonder. Updated with 2010 mortality.
32
33 Doctors Need to Know How to Treat Pain: Education on Pain in Medical Schools Number of Schools USA (median: 7 hours) Canada (median: 14 hours) Veterinarian schools: 75 hours on pain >30 Number of Hours of Pain Education Mezei, L and Murinson, BB., J Pain, 12, , 2011.
34 Doublingof Treatment for Pain Reliever Use : Most Recent Treatment in the Past Year for the Use of Pain Relievers among USA Persons Aged 12 or Older, Numbers in Thousands Difference between this estimate and the 2011 estimate is statistically significant at the.05 level. 34
35 Data in Several States Show That Hepatitis C Virus Among Adolescents and Young Adults Has Increased in Recent Years Of cases with available risk data, injection drug use was most common risk factor for HCV transmission CDC, MMWR, October 28, 2011/60(42): CDC, MMWR, May 6, 2011/60(17); ; From a small number of cases who responded to further investigation.. 92% reported opioid analgesic abuse 89% reported heroin use 95% used opioid analgesics before switching to heroin
36 1. Affinity Health Plan 2. AmeriHealth Caritas Health Plan 3. CalOptima 4. CareSource 5. Children's Community Health Plan 6. Colorado Access 7. Commonwealth Care Alliance 8. Denver Health Medical Plan Inc. 9. Gold Coast Health Plan 10. Horizon NJ Health 11. LA Care 12. Neighborhood Health Plan 13. Passport Health Plan 14. Priority Partners 15. Texas Children s Health Plan SUD Collaborative ACAP Participating Plans
37 Why a Substance Abuse Disorder Collaborative? Impact of Prescription Drug Abuse Triple Aim Improving care and reducing cost Expansion Population (Medicaid and the Exchange) ACA requirements for Essential Benefit Package Performance measurement (HEDIS, STARS) 37
38 What Plans Are Doing Members Population focus Consumer engagement Education Screening/Assessment Post treatment support F/U calls, peer support, self help group Family counseling and support Naloxone availability Providers Training Contract requirements PCMH Pay for Performance SBIRT training Medication Assisted Treatment Pain Management referrals and guidelines Patient contracts Integration & co-location (PCP, counselors, BHO)
39 Plan What Plans Are Doing Care coordination and specialized case management Pain management treatment benefits Formulary Changes Refining poly-pharmacy monitoring Revamp Lock in Evaluation of referral policies Network development centers of excellence & telehealth Data Analytics Data Sharing with providers HEDIS/STARs Systems Needs Assessment ER Usage Better integration physical and behavioral health Aligning reimbursement models Chronic care model Transition to aftercare Health Homes Benchmarking Supportive Housing Community Engagement
40 Issue Effective Lock-in Programs Lock-in should be only one step in process Interdisciplinary team meetings Includes referral for substance abuse treatment and behavioral health assessment, as appropriate Specialized care management Includes member education and counseling Use of health advocates and community outreach Pain management Referral, assessment, and patient contracts Data analytics and data sharing (plan, PCP, prescriber, pharmacy) 40
41 Pain Management 18 of 23 plans (79%) provide access to nonpharmacy pain management services Some of these services included physical therapy, chiropractic care, swim therapy, wellness groups, and acupuncture If required, referrals generally come from PCPs or case managers (not all plans require referral) 41
42 Pain Management Issues Network Adequacy: Lack of pain management providers in geographic area Limited alternative therapies/providers available Telemedicine may hold promise Plans report needing more effective pain management services/well-trained providers who can target their population and needs Need for better and widely-accepted treatment guidelines 42
43 Other Prescribing Issues Lack of coordination among PCPs, Pain Management providers PCPs need more training Need physician-developed prescribing standards and opiate oversight committees 43
44 Medication Assisted Treatment Plans support use of MAT Limitation on suboxone prescribers Limit on number of providers due to the certification requirements and 100 patient panel limit Many refuse to participate in health plan network Unlike other services, often operate on a cash basis Plans responsible for pharmacy benefit, but have no contractual relationship with prescriber 44
45 Measurement Issues HEDIS measures limited to initiation and engagement do not work in carve-out situations Other than Part D, no measures on opioid prescribing High dosage use Extended use Use in combination with other drugs Need the collaborative development of appropriate measures Measure alignment and prioritization is critical 45
46 Questions? Meg Murray CEO, ACAP Debbie Kilstein Vice-President, ACAP ACAP is currently hiring a VP for Medicare and Long-term Care! See for more information 46
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