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April 10, 2017

Headlines in Health Policy b8acd3ab-e1ab-4fbc-8287-edc0d2b6aac4

Newsletter Article

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Can Building Relationships Help Engage High-Need Patients? Part II

Part II
Laren and Kim

By Brian Schilling

For a certain subset of patients, the thing that often gets in the way of receiving high-quality health care is simply being sick. This subset of very sick patients gets a lot of attention in medical circles for the simple reason that the care they receive is extremely expensive. They are among the 5 percent of patients who account for about 50 percent of health care spending, much of it on ineffective or inefficient care. It’s an article of faith among many in the health care world that if we could just improve care for this group, we could save an enormous amount of money.

“With better access to care and a better relationship with their provider, high-need patients are less likely to delay care and less likely to go to the ER.”

But how, exactly? Efforts to improve the lot of the high-need patient are still being tested and evaluated. A handful of new programs focused on these patients are emphasizing relationship-building and focusing more intently on meeting patients’ nonmedical needs outside the doctor’s office. In this second part of our three-part series on high-need patients, we meet a patient and her care coordinator from the Medical Home Network in Chicago.

Laren, 62, Chicago

Through Blurred Vision, a Glimpse of Hope

In some ways, Laren may be the luckiest member of her very large family. With seven sisters and two brothers, she was the last member of the troop to be diagnosed with diabetes, in 2006. This shared family curse has left one brother on dialysis and a double amputee; several have vision problems and trouble walking; all are struggling. And while she may have been lucky to be last, Laren’s diagnosis didn’t feel lucky at all.

Laren Addison, photographed by Alyssa Shchukar

“It depressed me,” Laren said softly. “I really felt like, ‘Oh, well, that’s that.’”

Since that initial diagnosis, the disease has progressed, leading to problems with her legs and feet, increasing levels of neuropathy, low energy, and so on. She also has high blood pressure and struggles with depression.

For almost 10 years, with no health insurance and little social support, Laren managed her illnesses in a highly unproductive manner: she ignored them. There were occasional trips to the doctor or the ER, and on-again off-again attempts at insulin, but no routine of care and no real attempt to address underlying causes.

Then came the cataracts. “My vision got so bad I couldn’t see,” said Laren. “I couldn’t read my mail. How could I take medicine? I couldn’t even read the bottle. I couldn’t see faces.”

Laren’s despair deepened until she began to entertain thoughts of just ending things. At that point, about two years ago, she found herself in the psychiatric unit of Mt. Sinai Hospital on the south side of Chicago. Sinai treats a stream of patients facing similar challenges and is part of Chicago’s Medical Home Network (MHN), a broad alliance of clinics, hospitals, and other organizations that collaborate to improve care for the area’s underserved populations (see sidebar at bottom for details). Laren was assigned a case worker, Kim Reams-Parham-Parham, to help her get the care and support she needed.

Laren Addison and Kim Reams-Parham, photographed by Alyssa Shchukar

Reams-Parham has been a case worker for two years, although she’s been employed by Sinai as a registered nurse for nearly 10 years. Reams-Parham, and other professionals like her throughout Chicago, participate in MHN both because it gives them an opportunity to build rewarding relationships with patients and because the organizations they work for have committed to working together wherever possible to control costs. In Reams-Parham’s role as a case worker, she’s responsible for about 70 patients. Some of these she sees almost daily, others far less frequently.

“I’m there when they need me,” said Reams-Parham. “But the goal is for them to not need me so I actually feel good when I can help people enough so that they don’t need to call—it means they’re on the right path.”

Kim Reams-Parham, photographed by Alyssa Shchukar

Laren says that some of the most invaluable support Reams-Parham provided wasn’t of a medical sort at all. Reams-Parham sat with Lauren and helped her fill out her Medicaid paperwork, something she’d been trying but unable to do for almost five years. As a result, she now has health coverage for the first time in recent memory. Reams-Parham also arranged transportation for Laren to and from various appointments, without which, Laren says, she simply wouldn’t have gone. And finally, she helped Lauren adjust to and follow her new insulin regimen, which involved self-administered injections four times a day.

But most importantly, Reams-Parham helped Laren get her sight back, scheduling cataract surgery in June on her right eye, and then in September on her left. Both surgeries were successful and Laren is taking advantage of her newfound freedom to move about on her own, regularly attending services and other functions at the New Covenant Baptist Church near her home.

“It’s nice to be able to go to church again,” she says. “You don’t really know what it means just to be able to see someone’s face.”

Laren describes her diabetes today as being “under control,” and she’s looking forward to a bright future.

Reams-Parham says she speaks to Laren only about once a month. “When I started working with the MHN effort, I was focused on meeting a set of performance targets. That’s still important, but now the satisfaction I get out of helping people is really what makes a difference to me.”

Next week’s issue will include the final part in our series on high-need patients, and will share the story of Somali immigrant and his care coordinate in Minneapolis.

Medical Home Network—Chicago

The Medical Home Network (MHN) was established in 2011 in Chicago with the backing of area hospitals, clinics, the Illinois Medicaid program, and dozens of other entities, to increase communication and data-sharing within the metropolitan area’s highly fractured delivery system. The effort has led to marked improvements in the quality of care available to many of Chicago’s most underserved and vulnerable residents. Today, 22 hospitals and more than 200 medical home sites can share patient data and information through MHN’s online platform, leading to efficiencies that have helped slash readmission rates (15%), increase timely follow-up care (more than 100%), boost engagement among the target population, and nearly triple the rate of area patients who have a health risk assessment on file (79%). The backbone of the MHN program is a battery of care coordinators who take a hands-on approach to ensuring that patient care is coordinated and that no one falls through the cracks. These care coordinators, who are employed at participating clinics, receive extensive training on changing patient health habits, linking patients to available community resources, leveraging technology to improve health, and ensuring that all participating entities have access to up-to-date information about patients in the system.

Staff: 34

Notable: Launched its own accountable care network in 2013

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Repeal and Replace

  • GOP Health Bill in Shambles, House Commences Two-Week Break AP by Alan Fram and Ricardo Alonso-Zaldivar—The Republican health care bill remained in shambles Thursday as House leaders threw up their hands and sent lawmakers home for a two-week recess. GOP chiefs announced a modest amendment to curb premium increases, but internal divisions still blocked their promised repeal of former President Barack Obama's law. Ominously, lawmakers from both ends of the party who've opposed the GOP legislation said Thursday's revision wasn't enough to turn them around. 

  • Frustration Mounts, Careers Jeopardized Over Obamacare Failure Politico by Rachael Bade and Jennifer Haberkorn—House Republicans are no closer to passing legislation to repeal the Democratic health care law. Tempers are flaring at the White House over House Republicans’ failure to repeal Obamacare. But that hasn’t changed the reality on the ground: As Congress skips town for a two-week recess, Speaker Paul Ryan and his team are no closer to approving legislation. In fact, some Ryan allies worry that the White House involvement has only set GOP leaders back further.

  • To Revive Health Bill, GOP Adds an Obamacare-Like Subsidy Bloomberg by Billy House, Zachary Tracer, and Anna Edney—At the prodding of the White House, House Republicans made a last-minute addition to their Obamacare replacement bill Thursday aimed at protecting high-cost patients as lawmakers leave Washington for their two-week spring break. The amendment to the bill adopted Thursday would create a subsidy for insurers that cover sick, expensive patients, and could help revive Republican lawmaking efforts to repeal and replace large parts of the Affordable Care Act. They also echo a key program under Obamacare, which like the GOP proposal uses subsidies to lower premiums.

  • As Latest Health Plan Dies, Republicans Can’t Agree on a Culprit New York Times by Jennifer Steinhauer and Robert Pear—The new bill to repeal the Affordable Care Act is dead, killed off by House Republicans who never actually read the legislation—because in fact, it never actually existed. Conservative groups moved quickly on Wednesday to shift the blame for the failure of a seven-year promise to repeal the law onto some not-as-conservative Republicans, after a small but powerful group of hard-line House conservatives failed again to come to a meeting of the minds with the Trump administration over how best to repeal and replace President Barack Obama’s signature achievement.

  • Speaker Paul Ryan Says Republicans' Obamacare Repeal May Take Months USA Today by Craig Gilbert—A new push to pass a GOP health care bill will take months, not days, House Speaker Paul Ryan indicated Wednesday, as the latest talks among Republicans produced no apparent breakthrough. “We’ve got a couple months at least,” Ryan said in an interview with the Milwaukee Journal Sentinel.

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What's Next?

  • Centers for Medicare and Medicaid Services (CMS) Readies Insurance Market Stabilization Rule Modern Healthcare by Virgil Dickson—CMS has sent a rule designed to stabilize the individual health insurance market to the Office of Management and Budget for final review. The Trump administration hopes to finalize the rule very soon.The administration is rushing to publish the final rule to calm insurers, who are nervously trying to decide within the next two months whether to offer plans for 2018 and what to charge for premiums.The rule sent to OMB, which includes the CMS' responses to more than 4,000 public comments, takes steps to limit consumers' ability to enroll in plans outside the Affordable Care Act's annual open enrollment period.

  • White House Divided on Obamacare Payments Politico by Josh Dawsey, Joanne Kenen and Jennifer Haberkorn—The disintegration of the latest Obamacare repeal bid in the House has thrown the health law’s fate back to a divided circle of White House advisers wrestling with whether to pay out key subsidies—or cut them off and blow up the health law. The aides have limited time to figure things out; health plans must decide in June whether to stay in Obamacare insurance markets next year or pull out. If billions of dollars of cost-sharing subsidies dry up, the plans are more likely to leave, possibly quite rapidly.

 

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Polling

  • Obamacare Has Majority Support for First Time The Hill by Max Greenwood—More than half of Americans approve of the Affordable Care Act (ACA), according to a Gallup poll out Tuesday, marking the first time the law has gained majority support since Gallup began tracking public opinion on it in 2012. Fifty-five percent of Americans say that former President Barack Obama's signature healthcare reform law should remain in place, though 40 percent say it needs significant changes. 

  • For Better or Worse, Trump and GOP Now Own Health Care Kaiser Health News by Julie Rovner—Ownership of the ACA has officially been transferred from President Barack Obama and Democrats in Congress to President Donald Trump and congressional Republicans, according to a new poll. In the monthly tracking poll from the Kaiser Family Foundation, 61 percent of respondents said any problems with the law moving forward are the responsibility of Trump and Republicans in Congress, while only 31 percent said future problems are the fault of the Democrats who passed it.

  • Poll: Most Young People Say Government Should Pay For Health Care AP by Laurie Kellman and Emily Swanson—Most young Americans want any health care overhaul under President Donald Trump to look a lot like the Affordable Care Act signed into law by his predecessor, President Barack Obama. A GenForward poll says a majority of people ages 18 to 30 think the federal government should be responsible for making sure Americans have health insurance. But there's one big exception: A majority of young Americans dislike "Obamacare's" requirement that all Americans buy insurance or pay a fine.

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Medicaid Expansion

  • Kansas Activists Vow to Keep Fighting to Expand Medicaid Stat by David Steen Martin—Kansas came close this week—achingly close—to expanding Medicaid to extend health insurance to low-income adults like her. The Republican-dominated Legislature had passed the bill and supporters vowed to override the governor’s veto. But on Monday, the House fell three votes short. The failed veto override also crushed hospital executives and community clinic directors who had hoped against hope for a Medicaid expansion, which would have brought in a flood of federal dollars to help pay for the care they now often deliver for free.

  • Virginia Republicans Reject Medicaid Expansion AP by Alan Suderman & Sarah Rankin—Republican lawmakers in Virginia rejected another bid to expand Medicaid, saying the cost of providing new health coverage to thousands of poor adults would cripple the state. The House of Delegates voted against Medicaid expansion Wednesday as lawmakers reconvened for a one-day session to consider Democratic Gov. Terry McAuliffe’s amendments and vetoes.

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Medicaid Expansion

  • Inspecting the Role of the Physician in Accountable Care Organizations (ACOs) Modern Healthcare by Elizabeth Whitman— As delivery system reform experts puzzle over what makes accountable care organizations successful, they might want to pay more attention to the physicians in those organizations, suggests a study published Monday in Health Affairs. The study found significant physician churn from year to year, as well as an uneven distribution of patients among physicians in one Medicare Pioneer ACO.

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Editor

Editor: Peter Van Vranken

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http://www.commonwealthfund.org/publications/newsletters/headlines-in-health-policy/2017/apr/april-10-2017