Welcome to the April 2019 monthly newsletter. You can find past newsletters in my LinkedIn articles and on my website with some additional background materials, different stories and initiatives that might be of interest. Join me in improving and coordinating initiatives that advance health, health equity and community and healthcare redesign.
This month you can read about: a young man with a cello as a life line from poverty; Humana’s Bold Goal progress; Medicare Advantage increased flexibility to invest in improved living conditions; Medicare expanded coverage for telehealth; suggested changes in hospital community benefits; Texas Health Resources’ investments, and Medicaid trends in investments, designed to address living condition improvements; Proposed ICD-10 Z codes to improve payment and tracking of Social Determinants of Health (SDOH); addressing drivers of community-wide problems verses addressing the needs of sicker individuals; almost 50% of cancer deaths tied to modifiable behavior that are impacted by living conditions; and the challenges facing the “middle market” i.e., older adults with middle level income. Also checkout Equality Health’s Webinar about culturally-based innovations in Arizona.
The start of second quarter has shown continued health industry focus and investments in addressing the living conditions that drive health outcomes. I am all for expanded investment, but what is the right goal?
The proposed new ICD-10 Z codes are designed to enable coverage for non-medical services for the chronically ill and to presumably track the extent of the problems. A recent article mentioned mission creep as a concern that resonates with my fears on healthcare literally consuming socials services and supports with the image of PAC man in my head.
This fear was reinforced at the Aging in American annual conference where a significant portion of the Social determinants of health (SDOH) related discussions were about how community-based organizations CBOs) partner with healthcare or healthcare begins paying for the community supports with the caveat that it is closely aligned with the Health system goals. It also appeared to have the unintended consequence of shifting the CBOs focus. Should all interventions be driven by avoiding hospitalization and ER visits or should we be focused on more programs and resources that improve lives and sustain health. Are we perpetuating the sick care system by using the narrow lens?
Most of these interventions are important regardless of whether someone is chronically ill, and particularly if they are at risk for social isolation and loneliness. The personal story of Eddie Adams should be a cautionary tale. No children or young adults, including his brother who was killed by a roommate, should have to struggle just for basic subsistence in the country with the greatest total wealth.
The Castrucci Auerbach article emphasizes we need to address the community drivers that cause these inequalities in addition to connecting the highest risk individuals from a clinical vantage point. As a country we are barely scratching the surface of this more systemic and community based goal.
We need strategies and tactics at the community level that are available to everyone. If we cannot shift the current path, then at a minimum the programs should always have an expansion plan/option in which local communities can determine what needs to be more broadly available and how the combined stakeholders implement the plan through additional funding mechanisms. Transportation, food and housing should not be an uncertainty nor should social connection.
If, as anticipated, healthcare costs are substantially reduced, then some portion of those savings should go back to the communities for the benefit of the broader population – no strings attached. At the Federal level a portion of this funding should shift from Medicare and Medicaid to the Administration for Community Living and the Administration for Children and Families, and perhaps a new or expanded state block grant for community development to address the underlying causes of inadequate services and resources regardless of the current severity of health risks.
The challenges that will face our aging population and currently undermine the opportunities for children in low-income families should be more than enough incentive to invest in these improvements now.
Share your personal or community stories by connecting via LinkedIn or email email@example.com I welcome suggestions in all topic areas, particularly community driven models.
A Personal Story
Music and a cello will hopefully be Eddie Adams’ ticket out of poverty, but not without sustained challenges even after he received a scholarship, grant and financial aid from George Mason University. The article about Eddie is uplifting. It also highlights how much he had to overcome to get to a college program, including homelessness and family alienation, and how much more he needs to accomplish to stay on his path out of poverty and into classical music.
Humana’s progress report on its Bold Goal initiative for its Medicare Advantage plans reduced unhealthy days for older adults in 5 out of seven communities. Humana vows to increase patients who are screened and referred for services from 500,000 to 1 million in 2019. The program concentrates on food insecurity and loneliness. Baton Rouge and San Antonio seemed to improve the most with 5% and close to 10% reduction in unhealthy days respectively.
Government Initiatives Federal and State
The Centers for Medicare and Medicaid’s (CMS) final Medicare Advantage rate announcement for 2020 supports coverage of certain living condition services for the chronically ill.
“MA plans will have greater flexibility to offer chronically ill patients a broader range of supplemental benefits that are tailored to their specific needs, such as providing meals beyond a limited basis, transportation for non-medical needs, and home environment services if these benefits have a reasonable expectation of improving or maintaining the health or overall function of the patient as it relates to their chronic condition or illness.”
Medicare also published final rules expanding Medicare Advantage coverage for telehealth to more rural and urban areas and giving beneficiaries the option to choose in-person or remote appointments. Although at first glance this may not feel related to living conditions it actually increases flexibility for individuals in accessing care that previously was inaccessible due to living conditions relating to transportation, isolation and income.
Should the hospital Community benefit be redesigned? A recent editorial suggests that non-profit hospital investments in communities should be focused locally and less on uncompensated care. At a time when we know improvements are needed at the local level, mergers and acquisitions are pushing in the other direction. An AMA Journal article contemplates a similar shift through levers at all government and system levels.
Health System and Community-based Services
The Article Meeting Individual Social Needs Falls Shot of Addressing Social Determinants of Health, by Brian Castrucci and John Auerbach describes the limitations of most health system initiatives addressing living conditions as not looking to the drivers of the underlying problems in communities and instead focusing on connecting the sickest individuals to needed services. It shouldn’t be an either/or decision.
Texas Health Resources (THR) awards $5.2 million in social impact grants to help address social isolation of seniors.
“The initiative is called Texas Health Community Impact and focuses on specific ZIP codes where chronic disease and premature death are more common, and partners with agencies in education, healthcare, and government.”
City Block closes $65M series B. This relatively fast investment in a merged model of primary care and linked services for improved living conditions shows market receptivity for alternative models and an increased focus on disparities.
Research, Metrics & Technology
Forbes reports AMA and United Healthcare created a collaborative supporting use of new ICD-10 Z codes that include both claims data and self-reported information about living conditions for SDOH to standardize data collection and be able to track referral activities and payment. An example provided was transportation for a dialysis patient. This goes somewhat hand in hand with the new flexibility for MA plans finalized by CMS.
CDC seeks public comment on the proposed new Z codes that fall into the following categories: education and literacy; Employment and unemployment; low income; housing and social environment. The full list of proposed codes can be found on pp.45-46 and public comment is due by May 10, 2019.
Addressing social factors that affect Health, Manatt’s Issue Brief on Medicaid Emerging Trends and Leading Edge Practices is based on in depth reviews of 17 states’ managed care contracts and 6 states 1115 waiver provisions.
The Brief discusses the following 6 leading Medicaid practice topics:
- Moving beyond screenings to systematic efforts to connect enrollees to social supports
- Expanding the scope of SDOH interventions to more populations and social issues
- Building a stronger network of community-based organizations and collaboration with providers
- Creating opportunities for affordable housing
- Aligning financial incentives to support SDOH interventions
- Systematic evaluation and greater use of SDOH data
Nearly half of cancer deaths attributed to modifiable risk factors such a smoking, obesity and cancer screening. The risk factors were greater for African American and Hispanic populations and individuals with less education.
Health Affairs released a series of reports on housing and health needs of US older adults in the middle market (middle income, i.e. annual income and assets of $60,000 or less, but not eligible for Medicaid). The series includes a study about the demographics of people 75 and older and explores the characteristics of an anticipated 14.4 million by 2029 who will not be able to afford assisted living and anticipated medical out-of-pocket costs.
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CURRENT & UPCOMING EVENTS
Listen to the Equality Health Assessing and Addressing Social Determinants of Health Through the Lens of Culture Webinar It provides distinct perspectives on how and why to develop interventions, highlighting the needs and innovations in Arizona.
2019 Health Summit: What Determines Health? May 30th hosted by Central Penn Business Group on Health and LiveWell health
Social Determinants of Health Symposium June 6 Cleveland Ohio
Background and Definition
I have chosen the phrase “Living Conditions” rather than social determinants of health (SDOH) to make the concept more accessible. This focus tracks with the Centers for Disease Control and Prevention’s SDOH definition “as conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”
Go here for more information from CDC on its organizing SDOH framework in Healthy People 2020