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Julie Darnell University of Illinois at Chicago Collaborators: Christina Andrews, University of South Carolina Teri Browne, University of South Carolina Sarah Gehlert, Washington University in St. Louis Robyn Golden, RUSH November 19, 2013 University of Chicago Slide 2 Outline I. Strengths of social work that align with the goals of the ACA II. Social workers role in assuring access to health insurance coverage III. Heightened focus on integration and care coordination: Implications for social workers IV. Expanded coverage for behavioral health services: Implications for social workers V. Resources in Illinois Slide 3 Slide 4 Five Health Social Work Strengths that Align with the ACA 1. Individuals are situated within social contexts. 2. The systems perspective considers & connects multiple intersecting spheres: health, education, employment, and child welfare. 3. Physical & mental/behavioral health are integrated. 4. All efforts and actions are guided by a base of evidence that is informed by research within communities. 5. Social Work historically has targeted services to disenfranchised groups. Slide 5 Slide 6 Why is Help in Enrolling in Insurance Programs Needed? Huge numbers of uninsured: ~50 million in 2011 1 Historically modest rates of participation in Medicaid among eligible populations 2 32%-81% in studies Many individuals dont know about insurance coverage 3-4 Unaware or skeptical they would qualify or would find affordable coverage 48% have heard nothing and 28% only a little about exchange 78% have not heard enough to say whether state will expand Medicaid Sources: 1 U.S. Census. (2012). Income, Poverty, and Health Insurance Coverage in the United States: 2011.; 2 Sommers, B. et al. (2012). Understanding Participation Rates in Medicaid: Implications for the Affordable Care Act. U.S. Department of Health and Human Services; 3 Perry, M. et al. (2012). Faces of the Medicaid Expansion: Experiences of Uninsured Adults Who Could Gain Coverage. Kaiser Commission on Medicaid and the Uninsured; 4 Kaiser Family Foundation. Kaiser Health Tracking Poll: March 2013. Slide 7 Types of Consumer Assistance Consumer assistance programs Navigators In-Person Assisters Certified Application Counselors Exchange/Marketplace Medicaid Champion for Coverage Slide 8 Status of State Exchanges Declared state-based exchange Planning for partnership exchange Default to federal exchange Slide 9 Consumer Assistance Program State-Based Exchange Partnership Exchange Federally- Facilitated Exchange Statewide Consumer Assistance Programs (CAPs) OPTIONAL NavigatorREQUIRED In-Person Assister (IPAs)OPTIONALREQUIREDNONE Certified Application Counselor (CAC)-Medicaid OPTIONAL Certified Application Counselor (CAC)-Exchange REQUIRED Sources: Enroll America. (March 2013). How can Consumers Get Help Enrolling in Health Coverage; Kaiser Family Foundation. (April 2013). Consumer Assistance in Health Reform. Darnell, J.S. (2013). Navigators and Assisters: Two Case Management Roles for Social Workers in the Affordable Care Act. Health and Social Work; Robert Wood Johnson Foundation. (March 2013). Navigators and In-Person Assistors: State Policy and Program Design Considerations; Brooks, T. In-Person Assistors May Look a Lot Like Navigators. Retrieved from http://ccf.georgetown.edu/all/in-person-assistors-may-look-a-lot-like-navigators/.http://ccf.georgetown.edu/all/in-person-assistors-may-look-a-lot-like-navigators/ Slide 10 Duties of Navigators & Assisters Duty Consumer Assistance ProgramsNavigator In-Person Counselor/ Assister Certified Application Counselors MedicaidExchange Education/Outreach State option Enrollment in QHPs State option Enrollment in Medicaid State option or Refer State option Mid-year changes State option Culturally/linguistic- ally appropriate Grievances and complaints State option or Refer Data collection and reporting State option To be determined = Yes; = No Sources: Kaiser Family Foundation. (April 2013). Consumer Assistance in Health Reform; Robert Wood Johnson Foundation. (March 2013). Navigators and In-Person Assistors: State Policy and Program Design Considerations. Slide 11 IL: In-Person Counselor $27 million distributed to 44 organizations in Illinois http://www2.illinois.gov/gov/healthcarereform/Documents/Health%20Benefits%20Exc hange/FINAL%20IPC%20Grant%20list%20071713.pdf Slide 12 Navigators http://www.cms.gov/CCIIO/Programs-and-Initiatives/Health- Insurance-Marketplaces/Downloads/navigator-list-8-15-2013.pdf Slide 13 Challenges and Opportunities Opportunity: Consumer assistance roles align closely with social work case management functions Consumer assistance programs (CAPs) Navigators In-person assisters (IPAs) Certified application counselors (CACs) Challenge: Social work is swimming against the tide as other health professionals (nurses) and non- professionals (lay individuals) have assumed these roles Slide 14 Additional Challenges Slide 15 Additional Challenges: 30 million uninsured in 2019 Slide 16 The Uninsured Who are they?How many? Unauthorized/Undocumented11 million Medicaid eligible but not enrolledNext largest Unaffordable coverage*3 million (net): Not eligible for Medicaid -Supreme Court *Some of the 18-19 million+ who are exempt from penalty *6 million not exempt from penalty, of whom: .6 million < 100% FPL 2.4 million 100-300% FPL In between coverage? Source: Congressional Budget Office. (2012). Payments of Penalties for Being Uninsured under the Affordable Care Act. Slide 17 Free Clinic Patient Slide 18 Slide 19 How to Get More Involved: Eligibility & Enrollment Advocate for Medicaid For coverage expansion Against cuts in benefits Advocate for immigration reform, coverage of unauthorized and newly-arrived immigrants Advocate for continuous coverage Join (or form) oversight bodies (e.g., boards, advisory groups) that oversee exchanges Become certified/trained as: Navigators, Ombudsman, Assisters, Application counselors Slide 20 Slide 21 How to Get More Involved: Eligibility & Enrollment Advocate for Medicaid For coverage expansion Against cuts in benefits Advocate for immigration reform, coverage of unauthorized and newly-arrived immigrants Advocate for continuous coverage Join (or form) oversight bodies (e.g., boards, advisory groups) that oversee exchanges Become certified/trained as: Navigators, Ombudsman, Assisters, Application counselors Slide 22 Slide 23 ACA, Social Work, and Care Coordination ACA creates opportunity for new social work roles Avenues to sustainable care coordination by social workers increasingly available Provisions include Changing incentives Changing payment structures Move away from fee-for-service ACA provisions of note: Penalties for hospital readmissions Value-based purchasing Bundled payments Patient-centered medical homes Accountable care organizations Slide 24 Second Curve Adapted from Ian Morrison First CurveSecond Curve Option on the Health Exchange Direct Contracts with Employers Medicare Advantage Plan Accountable Care Organizations Bundled Payment Pilots Readmission Rate Penalties Traditional Fee-for-Service Payment System Population Health Per Capita Payment System Slide 25 Patient Protection and Affordable Care Act of 2010 Reform componentWhat it means What we need to work on ReadmissionsFinancial penalties for excess readmissions Quality and patient safety Care coordination Evidence-based care maps Clinical documentation Value Based Purchasing Payment based on performance on core measures Hospital Acquired Conditions 1% reduction in payment if in top quartile Slide 26 Patient Protection and Affordable Care Act of 2010 Reform componentWhat it means What we need to work on Coverage expansionMore patients with insurance Manage access Alignment and partnerships Manage quality and cost Manage populations Care coordination Informatics Bundled paymentsLump sum payments to multiple providers for designated conditions Accountable Care Organizations Manage care of specified beneficiaries; quality/cost; share of cost savings Patient-centered medical home Services, structures and access for continuous & comprehensive care Slide 27 Avoidable Readmissions Penalty Incentive to improve care transitions and reduce avoidable readmissions Lost reimbursement to drive performance improvement Penalty for each hospital based on risk adjusted actual 30-day readmission rate compared to expected readmission rate Reduced Medicare DRG payments by 1%, rising to 3% in 2015 3 target conditions starting in FY 2012, expanding to 7 in FY 2015 Hospital-specific readmission rates posted on Hospital Compare website for public viewing Expand to skilled nursing homes and HH agencies Slide 28 Community Based Care Transitions Program (3026) Provides funding to hospitals and community-based entities that furnish evidence-based transition services to Medicare beneficiaries at high risk for readmission Preference for medically underserved areas, small communities, rural areas and AoA programs Services must include at least one of 5 interventions Arranging post-discharge services Providing self-management support (or caregivers support) Conducting medication management review Funding up to $500 million over 5 years started in 2011 Slide 29 Bundled Payments Bundled payment pilot began January 31, 2013 Single Medicare payment to cover all services for an episode of care to be distributed among care providers: Acute hospital services Physicians services Care coordination and transitional care services Post-acute services Home health care Skilled nursing facility services Inpatient rehabilitation services Pilot testing four variations on bundling model over 3 years to assess efficacy Slide 30 Medical Homes Change in outpatient care delivery toward coordinated, chronic care, including the following supportive services: Care coordination Case management Health promotion Transitional care Patient and family support Referral to community services Additional funding available for coordination through greater reimbursement Slide 31 Accountable Care Organizations Medicare Shared Savings Program (3022) creates incentive for the establishment of Accountable Care Organizations (ACOs) Networks of physicians and other providers Integrated, cooperative services designed to foster collective accountability Share savings resulting from the ACOs coordinated care Reduced Medicare expenditures Improved beneficiary health outcomes No consensus on vital components of an ACO Will have to address social issues to see true cost savings Opportunity for social work to achieve savings and quality improvement Slide 32 The CMS Innovation Center Test innovative payment and service delivery models To reduce program expenditures To preserve or enhance the quality of care furnished to Medicare and Medicaid beneficiaries Preference given to models that improve health care coordination, quality, and efficiency Authority to expand any model Funding of $1 billion per year for 10 years Released through ongoing Funding Opportunity Announcements Targeted distribution within priority areas Budget neutrality requirement waived during testing Slide 33 PCORI Patient-Centered Outcomes Research Institute governed by 21-member Board of Governors Patient-Centered Outcomes Research (PCOR) helps people and their caregivers communicate and make informed healthcare decisions, allowing their voices to be heard in assessing the value of healthcare options. Research priorities: Assessment of prevention, diagnosis and treatment options Improving healthcare systems Communication and dissemination research Addressing disparities Accelerating PCOR and methodological research Slide 34 Thrive Under Reform Key elements to making the ACA successful Engaging patients Prevention and wellness Not transactions but a journey Transparency of performance Focus on burden of treatment, not illness Cost and quality in the same breath Where does social work fit? Slide 35 Getting to the Table What can social workers do to get to the table? Find cross-institutional ways to collaborate Learn to communicate and market social work Frame social work from other perspectives Speak the language of other professions Vary the message to fit the mission of the team Find ways to partner with other disciplines Example: Delegating tasks to community health workers so social worker can focus on skilled activities Share evidence about effective social work interventions Slide 36 Focus on Social Needs of Patients: A Look at the Evidence Shier et al. March 2013. Health Aff vol. 32 no. 3 Slide 37 Enhanced Discharge Planning Intervention for Older Adults OutcomeOdds ratio95% CI lower95% CI upper Patient stress 0.850.611.19 Caregiver stress 1.020.731.42 Physician appointment made * 2.701.644.45 Physician appointment kept * 2.091.512.89 General health rating (excellent/very good vs good/fair/poor) 1.270.851.88 30-day mortality (N = 906) 1.540.763.10 Readmission within 30 days 1.110.761.62 Altfeld, Susan J., et al. "Effects of an Enhanced Discharge Planning Intervention for Hospitalized Older Adults: A Randomized Trial." The Gerontologist 53.3 (2013): 430-440. Slide 38 Older Patients with Advanced Illness Challenge: Hospital social work departments, which traditionally had the primary responsibility for addressing problems affecting a patients life in the community after discharge, have been deprofessionalized, shrunk, or eliminated altogether in the last generation. Opportunity: Hospitals and health plans wishing to practice dignity-driven decision making have invested additional resources in social workers to manage the task of working effectively with the home and community-based service network. Bruce Vladeck Erin Westphal Dignity-Driven Decision Making: A Compelling Strategy For Improving Care For People With Advanced Illness, Health Affairs. June 2012 Slide 39 Percentage Of Discharges With Long Length-Of-Stay Among Adult Patients At Denver Health Medical Center, January 2007August 2011. MacKenzie T D et al. Health Aff 2012;31:1786-1795 2012 by Project HOPE - The People-to-People Health Foundation, Inc. Complex Discharge Panel May Heave Influenced Decline in LOS Slide 40 Slide 41 Impact on Behavioral Health Insurance coverage for behavioral health will expand significantly under the ACA through two key provisions: Medicaid expansion Creation of the marketplace Slide 42 Impact on Behavioral Health The ACA requires that behavioral health be included in essential benefits offered by all private insurers All state Medicaid programs will also be required to provide behavioral health coverage However, public and private insurers will have some discretion in the types and volume of behavioral health services covered Slide 43 Impact on Behavioral Health The ACA also aims to enhance the quality of coverage by extending the reach of the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 Medicaid and newly-established HIEs will be required to offer behavioral health benefits that are no more restrictive than benefits for medical services Slide 44 Behavioral Health Workforce Increase in coverage for behavioral health services is expected to lead to increased demand for behavioral health services Demand for Medicaid-covered behavioral health services is expected to increase most, as a higher proportion of low-income individuals have untreated behavioral health disorders Slide 45 Behavioral Health Workforce ACA also emphasizes integration of physical and behavioral health through ACOs and PCMHs Great overlap among behavioral health disorders and chronic and acute medical conditions Many ACOs and PCMHs are emphasizing identification and treatment of these high risk populations Slide 46 Behavioral Health Workforce Bureau of Labor Statistics estimates significant increase in demand for behavioral health services providers Increase in demand of 34% for healthcare social workers and 31% increase for behavioral health social workers between 2010 and 2020 (16% for other SWs) Slide 47 Implementation Challenges Service systems may not be ready to address rapid growth in demand for behavioral health services At present, only 50% of substance abuse treatment providers accept Medicaid Immediate access to truly integrated services may be limited to health care innovators engaged in early ACO/PCMH efforts Slide 48 Implementation Challenges Case of Massachusetts: Enrollment difficulties; co-pays as deterrents to help seeking; loss of presumptive eligibility clause (Capoccia et al., 2012) Some left out of ACA coverage expansions, including undocumented residents Among those with coverage, great variation across states in the generosity and scope of coverage for behavioral health services Slide 49 Opportunities for Social Workers Assume leadership roles in systems expansions of behavioral health services Demonstrate capacity to contribute to integrated care models by assisting patients with co-occurring behavioral health conditions Slide 50 Patient Navigation: A Lit Review StudyYearPatientsDesignDiseaseSocial Worker RoleResults Peacher, Palomino, Lo & Woodruff 2013100 mostly Latino- rural CA ObservationalCancerConvert uninsured or inadequately insured to adequate insurance --Improved insurance status for all but 2 patients Tejeda, Darnell, et al. 2013250 mostly AA, Latina uninsured, public ins.-Chicago Quasi- experimental with controls Cancer- breast/cervical Supervisor & navigator Identified and resolved barriers --Intrapersonal barriers are the most frequently identified barrier --System barriers persist beyond first encounter with navigator Markossian, Darnell, and Calhoun 2012897 mostly AA, Latina uninsured, public ins.-Chicago Quasi- experimental with controls Cancer- breast/cervical Supervisor & navigator Identified and resolved barriers --Intervention subjects had shorter time to resolution than controls Ell, Lee & Xie20103 pooled analyses Depression, Cancer, Diabetes Communication/system navigation, referral to community resources --Patients perceived navigation services as helpful --Physicians viewed navigation tasks as new Ferrante, Cohen and Crosson 201075 mostly female, elderly, white, insured QualitativeUnknownChoosing, understanding and using health coverage, providers, and services Making decisions about treatment Managing conditions & care received by multiple providers --Navigators helped patients obtain ancillary & social services --Navigators arranged appointments --Navigators provided emotional support Dwight- Johnson, Ell and Lee 200555 LatioRandomized to collaborative, usual care Cancer- breast/cervical Problem solving therapy Rx adherence System navigation --Improvements in depression and emotional well-being Tingen, Weirich, Heydt et al. 19981,522 mostly AACorrelationalCancer-prostateNavigate health system--Perceived benefits predicted participation in screening --Demographic factors predict screening Slide 51 Slide 52 Illinois Health Matters Slide 53 Illinois.gov Slide 54 Getcoveredillinois.gov Slide 55 Consumer Assistance Slide 56 A Cautionary Tale? Slide 57 Slide 58