Category Archives: Primary-care

Three Strategies for Improving Social Determinants of Health

A shoutout to Irving Stackpole for bringing this to our attention today on LinkedIn. This is an important topic that can address the serious issue of poverty in our inner cities.

The topic of food deserts first gained national attention thanks to the efforts of former First Lady, Michelle Obama, who not only created a vegetable garden on the White House grounds, but championed the creation of other gardens in inner city elementary schools.

One in particular was created at a Washington, DC school, and Mrs. Obama invited Chef Robert Irvine of Restaurant: Impossible to cook for inner city school children at Horton’s Kids, a local community center that provides after-school meals for kids.

So an article last week in Managed Care magazine, discussed the three strategies health care systems and payer organizations are trying to address patients’ social needs.

The first strategy, Tackle a neighborhood, focuses on the work ProMedica, a 13-hospital not-for-profit system in Toledo, Ohio is undertaking.

In the UpTown neighborhood of Toledo, the average median household income is less than $21,000 a year, and more than a quarter of all adults have not completed high school. Few residents have homes or vehicles, and healthy food options are hard to come by.

One way they are dealing with the food deficit in the neighborhood is by opening a grocery store called Market on the Green, and is a joint project of ProMedica and the Ebeid Institute.

They also initiated a job-training program, a financial opportunity center, and personal-finance advice and programs.

Last year, ProMedica doubled down and announced a 10-year plan to invest $50 million to create a national model for neighborhood revitalization. In March, they announced a partnership with a New York City-based nonprofit to invest additional capital to spur further economic growth.

Lastly, they expanded their screened 4,000 Medicaid patients who use the food clinic, and found that emergency department utilization decreased by 3%, and 30-day readmission by 53%, with a modest increase in utilization of primary care.

They also expanded screening  to include housing, transportation, and other social needs.

The second strategy is Tackle the top problems.

Here, Humana has been working on its Bold Goal, a population health strategy to improve the health of the communities it serves by 20%.

Humana wants to increase the number of “healthy days” in seven markets: Louisville, KY; Knoxville, TN; San Antonio, TX; Broward County, Fl; Baton Rouge, La; New Orleans; and Tampa Bay.

In the first year, the San Antonio market showed a 9% increase in healthy days, which was attributed to several initiatives, namely a telepsychiatry pilot to increase access to behavioral health services, food insecurity screening at primary are offices, and a collaboration with other organizations to improve diabetes management,

Finally, the third strategy is Develop a social determinants workforce.

Trinity Heatlh, a 93-hospital health care system in Michigan, and one of the largest Catholic systems in the country, has been addressing their patients’ social needs through a series of small experiments.

Trinity’s strategy is to develop a cadre of community health workers who will use pathways, regimented, evidence-based multistep protocols to help individuals address their specific needs.

Trinity found that by focusing on patients covered by Medicare, Medicaid, or both, and assisted by community health workers, they reduced their emergency department and hospital utilization considerably.

Trinity also hired AmeriCorps workers to serve as community health workers in nine markets. They focused on the social determinants of health of a narrow group of patients: high-utilizing eligibles in an ACO or other at-risk contract.

The strategies these organizations are undertaking are bold initiatives that show some promise of success, but time will tell just how successful they will be.

Yet, in an era of huge tax cuts going to the wealthy, and budget cuts  eliminating many government programs or severely limiting them, these companies are taking decisive action to reverse decades of neglect and despair in our inner cities.

But they won’t be effective unless there is greater cooperation from the communities they wish to serve, and from the rest of the health care community, and those in other institutions.

There is an accompanying story here: Social Determinants of Health: Stretching Health Care’s Job Description.

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Americans Are Skipping Health Insurance

Bloomberg on Monday published an article by John Tozzi that reported that some Americans are taking a risk and skipping health insurance because of the cost.

In the article, “Why Some Americans Are Risking It and Skipping Health Insurance”, Bloomberg interviews three families; the Buchanans of Marion, North Carolina, the Owenses of Harahan, Louisiana, and the Bobbies in a suburb of Phoenix, Arizona.

The Buchanans decided that paying $1,800 a month was too much for health insurance and decided to go without it for the first time in their lives.

Doubling insurance premiums convinced the Owenses to do so as well, and Mimi Owens said that, “We’re not poor people but we can’t afford health insurance.”

Saving money to pay for their nine-year-old daughter Sophia, who was born with five heart defects, forced the Bobbies to go uninsured for themselves and their son Joey.

These three families are but a small part of the dozen other families Bloomberg is following to understand the trade-offs when a dollar spent on health insurance cannot be spent on something else. Some are comfortable financially, others are just scrapping by.

According to Tozzi, the share of Americans without insurance is near historic lows, the current administration is rolling back parts of the ACA. At the same time, Tozzi reports, the cost for many people to buy a plan is higher than ever.

In the case of the Buchanans, wife Dianna, 51, survived a bout with cancer 15 years ago, her husband, Keith has high blood pressure and takes testosterone. Both make more than $127,000 a year from an IT business and her job as a physical therapy assistant. They have additional income from properties they own.

However, their premium last year was $1,691, triple their mortgage payment, and was going up to $1,813 this year. A deductible of $5,000 per-person meant that having and using coverage would cost more than $30,000.

What made the Buchanans take this step was when Blue Cross and Blue Shield of North Carolina and the major hospital system in Asheville, could not reach an agreement, putting the hospital out of network. Keith Buchanan said, “It was just two greed monsters fighting over money.” He also said, “They’re both doing well, and the patients are the ones that come up short.”

The Buchanans are now members of a local doctors’ practice, for which they pay $198 a month. They also signed up for a Christian group that pools members’ money to help pay for medical costs. For this membership, it costs the Buchanans $450 a month, and includes a $150 surcharge based on their blood pressure and weight.

After dropping their coverage with Blue Cross and Blue Shield, Keith injured his knee, went to an urgent care center and was charged $511 for the visit and an X-ray. “If we can control our health-care costs for a couple of years, the difference that makes on our household income is phenomenal,” Keith said.

There is evidence, Tozzi writes, that having insurance is a good thing. People with insurance spend less out of pocket, are less likely to go bankrupt, see the doctor more often, get more preventive care, are less depressed and have told researchers they feel healthier.

Yet, some 27.5 million Americans under age 65 were uninsured in 2016 (myself included), about 10 percent of the population, according to the Kaiser Family Foundation.

The most common reason cited by KFF was that the cost was too high. A Gallup poll suggested that despite declining for years, the percentage of adults without coverage has increased slightly since the end of 2016.

However, other data, Tozzi writes, showed no significant change.

The following chart outlines the household income and health insurance status of people under 65 who qualify for government help with having insurance.

For the Bobbie family, the current administration’s proposal to make it easier for Americans to buy cheaper health plans could open options for the rest of the Bobbie family, but with over $1 million in medical costs for Sophia, these less-expensive choices would lack some of the protection created by the ACA that allowed her to get coverage.

The tax scam that became law in December will lift the ACA’s requirement that every American have coverage or pay a fine.

Some states are trying out the new rules, offering plans that don’t adhere to ACA requirements. This is the case in Idaho where the state’s Blue Cross insurer attempted to offer a so-called “Freedom Plan” that had annual limits on care and questionnaires that would allow them to charge higher premiums to sick people or those likely to become sick.

The current administration judged reluctantly that this plan violated ACA rules.

The Owenses decided to do something like what the Buchanans did. They tried a Christian health-sharing ministry for a few months, but joined a direct-primary care group, which Mimi Owens called, “the best care we’ve ever had.”

The three American families are by no means not alone in having to decide whether to have insurance or to take the risk and forgo paying huge premiums to save money or to use it for another family member with more pressing medical issues.

Two of these families are not low-income, as they both earn over $100,000 a year and could afford to buy health coverage if it was affordable. But the reality is that premiums have risen and will continue to rise and will price them out of the market.

Except for the Bobbies, no one in the other two families have serious medical issues that are exceedingly expensive, and they have found lower cost alternatives, but for many other families in the U.S., that may not be an option.

The only real solution is universal health care. Then the Buchanans, Owenses, and Bobbies of America will not have to worry about how they are going to pay for medical bills if some serious medical condition arises. We can and should be better than this.

Challenges Facing Work Comp

In three weeks, members of the medical tourism industry will gather in Puerto Vallarta, Mexico to attend the 6th Mexico Medical Tourism Congress.

You may recall that I was invited and attended the Congress last year, and was invited again this year. However, due to personal and financial reasons, I am not attending this year.

I am however, posting my PowerPoint presentation below for your viewing, with narration by yours truly. I hope you find it interesting and informative.

Challenges Facing Workers’ Comp (PowerPoint)

Challenges Facing Workers’ Comp (video)

 

Influx of Newly Insured Not Impacting Primary-Care Physicians

Readers of this blog will recognize the following three previous posts, “Will Medical Tourism Relieve the Doctor Shortage Due to Obamacare?” from 2013, “Affordable Care Act to Lead to Physician Shortages ― What it Could Mean for Medical Tourism in Work Comp” from 2014, and “New Report on Doctor Shortage: What it could mean for Workers’ Comp and Medical Tourism” earlier this year, in which I discussed the potential impact of the Affordable Care Act (ACA), more commonly referred to as “Obamacare” on the predicted shortage of primary-care physicians.

Today, Drew Altman, president and CEO of the Kaiser Family Foundation, and David Blumenthal, president of the Commonwealth Fund, wrote an article in the Wall Street Journal titled, “ How Primary-Care Physicians Are Handling the Influx of Newly Insured.

According to Altman and Blumenthal, most physicians in primary-care said that their ability to provide high-quality care had not changed since January 2014.

Altman and Blumenthal included a graph showing the percentages of physicians who were polled by Kaiser and the Commonwealth fund on their ability to provide high-quality care.

BN-KJ094_ACApri_G_20150917182430

The survey found that, so far, the fears of problems have largely not come to pass. However, physicians did report increased demand for services under the ACA; four in ten (44%) said that the total number of patients they see had increased since January 2041.

Six in ten, or (59%), reported an increase in the number of patients who were newly insured or covered by Medicaid, but this was not swamping their practice.

The chart shows that 59% said their ability to provide care had stayed the same, 20% said that it had improved and gotten worse.

Altman and Blumenthal concluded their article by saying that not yet two years into the coverage expansion of the ACA, it is still too early to know what effect will be, long-term, on the demand for services.

It could also be, they said, that the net increase of 16 million newly insured is less of a burden than expected; however, they concluded by saying that primary-care providers have been able to keep up demand without any negative impact.

Whether this remains so, is yet to be determined, but so far, it appears that there is no nationwide crisis.