Care Transitions & Health Reform: What's the Big Deal?

You may have heard the buzz about care transitions as an aging professional, or health care professional, or even if you are simply keeping up on current events. Transitions in care are a form of care coordination during a transitional event. Care transitions are broadly defined. Here are a few examples: transitioning within a hospital from the emergency room to an in-patient floor; transitioning from a nursing home back home; transitioning from private payer health insurance to Medicare. Right now the focus is on the transition from the hospital—and there’s good reason for this. Here’s a few key numbers to explain why:

19.6% According to a study published in the New England Journal of Medicine in April 2009, 19.6% of Medicare beneficiaries discharged from a hospital stay were readmitted to a hospital within 30 days. That means almost 1 out of every 5 Medicare beneficiaries to leave the hospital returns in 30 days or less! If you open the window of time after discharge to 90 days, this number jumps to 34%–this is more than 1 out of 3 Medicare beneficiaries. In Illinois, the study showed our 30-day readmissions to be slightly higher than the national average at 21.7%.

$17.4 Billion According to the same article referenced above, the cost of the readmissions for Medicare beneficiaries totaled $17.4 Billion for one year! This is almost 17% of the $102.6 billion that Medicare reimbursed hospitals for the year of the study. With health care costs in the United States continuing to increase, care transitions are understandably an identified area for health care systems improvement.

$500 Million In accordance with section 3026 of the Affordable Care Act, CMS made $500 Million available for the new Community Care Transitions Program (CCTP). CCTP is a unique funding opportunity for community-based organizations (CBOs) to lower readmissions to the hospital. CBOs are able to apply for reimbursement of care transition service provision through a Medicare fee-for-service mechanism. CCTP requires CBO partnership along the continuum of care including: hospitals, skilled nursing facilities, home health agencies and more.

2014 The Illinois Hospital Association is partnered with Blue Cross Blue Shield of Illinois to address high hospital readmission rates through the “PREP” Program. PREP stands for Preventing Readmissions through Effective Partnerships, and 201 hospitals in Illinois have pledged to lower hospital readmissions in the state by 2014. One of the five initiatives of the PREP Program is improving transitions of care.

3025 Section 3025 of the Affordable Care Act introduces penalties to hospitals for preventable readmissions. Starting in 2013, Section 3025 allows CMS to withhold up to 1% of Medicare payment reimbursement to hospitals. By 2015, up to 3% of Medicare reimbursement to hospitals may be withheld due to preventable readmissions. This means that hospitals that do not improve their readmission rates will receive an overall reduced Medicare reimbursement from CMS. For medium to large hospitals, a 1% reduction in reimbursement is estimated to cost from $500,000 to $1,000,000 in lost revenue. If hospitals don’t figure out how to lower readmissions, it is going to cost them a lot of money.

12 Let’s take a look at what’s happening in Illinois with care transitions from the hospital. The Illinois Transitional Care Consortium (ITCC) was formed to more effectively address needs of older adults transitioning from the hospital to the community by linking hospital based services with the aging network through intensive care coordination. ITCC consists of 12 partners: community-based organizations, hospitals, a university research facility, and a policy and advocacy research organization. ITCC developed the Bridge Model: a unique social work led model of transitional care that builds upon the Care Coordination Unit (CCU) system and Aging Network in Illinois. ITCC is currently developing a proposal for funding through the Community Care Transitions Program (CCTP), described above.

For more information on care transitions, please feel free to contact me, Kristen Pavle, Associate Director of the Center for Long-Term Care Reform at Health & Medicine Policy Research Group.

This post was originally posted on the Chicago Bridge's blog site. For more information on older adults, visit the Chicago Bridge website.

CLASS Act, Voluntary Long-Term Care Insurance Program of Affordable Care Act, is Called-Off

On October 14, 2011, the Obama Administration announced that the voluntary long-term care insurance program of the Affordable Care Act, the “CLASS Act,” is not viable for implementation. The announcement came from Kathleen Sebelius, Secretary of the United States Department of Health and Human Services, in the form of a letter to the Speaker of the House of Representatives. In this letter, Ms. Sebelius describes the thorough research done on the financial and structural solvency of the CLASS Act if implemented. The bottom line: the CLASS voluntary long-term care insurance program will not work because the cost will be too high for individuals who need care.

What is Long-Term Care?

Let’s take a look at what long-term care is before getting into why we need long-term care insurance. Long-term care (LTC) covers a broad range of services and supports for individuals requiring medical and/or social care over an extended period of time. 

• This includes activities of daily living (ADLs) like feeding and bathing; and instrumental activities of daily living (IADLs) like grocery shopping and doing laundry. 
• Long-term supports and services (LTSS) can be delivered in two main areas: institutions (like nursing facilities) or the home and community based setting (Assisted Living, Supportive Living, private apartment or home).

To learn more about how Illinois LTC measures compared to other states, read my blog post about a recently published study on LTC across the country.

What does this announcement mean to people with long-term care needs?

The CLASS Act offered a way for the United States to start addressing the long-term care needs of millions of Americans.  Persons with disabilities and older persons are the largest populations with LTC needs.  For more information on what the CLASS proposed to do, read Illinois’ Health Matters Blog Post by Lisa Ekman on the CLASS Act.

According to the National Clearinghouse for Long-Term Care Information, over 20 million people had LTC needs in 2008, with more than half of these people being over age 65. According to Politico Pro, only 7 million of these individuals have the private insurance to cover their LTC needs.

With the advance of medical technology and the aging of our population, people are living longer and with chronic conditions that require LTC. Here are some statistics:

• The number of adults 65 years and older will more than double from 40 million today to over 85 million by 2050. See Census Bureau data here and here.   
• An estimated 130 million Americans live with at least one chronic disease, and at least 65 million older adults experience multiple chronic conditions[1]. 
• 25% of older adult Medicare beneficiaries have more than four chronic conditions and are responsible for at least 80% of Medicare spending[1].

Now that the CLASS Act has been called off, the American public should be asking: “What is our country going to do for people who need long-term care?” Right now, we simply do not have a LTC system that can handle the number of people who need LTC. Medicare only pays a small portion of long-term services and supports; Medicaid requires people to spend down their savings in order to access LTC. And both Medicare and Medicaid are constantly under attack at a federal level for budget cuts. Meanwhile, the millions who require LTC will continue to have LTC needs, many of which will go unmet.

What Can You Do?

If:

• You are a person with a disability or an older adult who requires long-term care, OR 
• You know someone who requires LTC, OR  
• You support the program for those who have LTC needs

Then:

Share your story, and call your Senators and other elected officials! Simply call their offices and tell them that you support, and would like the Senator to also support, Medicare and Medicaid because these programs help you address America’s (perhaps your) LTC needs. More specifically, you can tell them that you do not want any cuts to benefits or changes to eligibility for these programs.

For your reference:

• Senator Dick Durbin’s Illinois office phone number is: (217) 492-5089 
• Senator Mark Kirk’s Illinois’ office phone number is: (217) 492-4062

Your voice and your stories are important and are a way to tell our elected Congressmen WHY we need LTC programs, and WHY we need to protect Medicare and Medicaid.  
 
Questions? Comments? Please let me know, I look forward to hearing from you and continuing the conversation.

For additional resources on how the Affordable Care Act addressing LTC, please download the Health Care Reform Impact in Illinois, Long-Term Care Reform Provisions Brief.

Kristen Pavle
Associate Director
Center for Long-Term Care Reform
Health & Medicine Policy Research Group
312.372.4292 x 27

[1] Boult, C., Karm, L., & Groves, C. (2008) Improving chronic care: The “Guided Care” model. The Permanente Journal. 12 (1), 50-54.

Latest Developments in the implementation of an Illinois Health Benefits Exchange: Senate Bill 1313

Back in the spring, the Illinois General Assembly passed a bill enacting the intent to create a health benefits exchange, a state-wide marketplace called for by the federal Affordable Care Act that will act as a tool to aid consumers to shop for insurance. The exchange has the potential to create a competitive and regulated environment that will keep health insurance costs at reasonable levels, and thus more available to individuals and small businesses, while also making the process of shopping for insurance more straightforward and manageable. In order for the health benefits exchange to operate this way, it is important that the exchange is created with the needs and protection of consumers and small businesses in mind. Earlier this fall, the study committee on the exchange released a report on their findings.  This past week, during the Illinois General Assembly Fall veto session, steps were taken to establish the exchange. State Representative Mautino introduced his amendment (House Amendment 2) to SB 1313, a bill which dictates the makeup of the health benefits exchange governing board.

Decisions that have been made in SB1313, House Amendment 2:

The composition of the health exchange governing board has been outlined in the amendment to SB 1313 in a way that supports a board that is likely to take interest in consumers and small businesses. The board, as outlined in the amendment, will be made of 9 members:

·         2 from the Attorney General’s office

·         1 small business owner

·         1 employee of a small business

·         1 consumer representative

·         1 community-based health care provider who primarily serves individuals under 200% of poverty

·         1 health actuary or economist

·         1 member of organized labor

·         1 individual who qualifies for Medicaid

None of the seats on the board will go to legislators, brokers, or insurers. There are also pieces in the amendment that support the creation of a racially and geographically diverse board, as well as clauses that protect against board members who have conflicts of interest in the governing of an exchange board.

Decisions not made in SB 1313:

The amendment puts the board in charge of deciding how the exchange will be financed.  There are many options outlined in the amendment, some that support the interest of the consumer, such as a fee levied on insurance companies, and some that are less supportive, such as a fee to users of the exchange.

What will happen next:

Now that the bill has been filed, it needs to be approved. On November 8^th, the House Insurance Committee will be holding a hearing to discuss SB 1313.   The Committee has 11 Democrats and 9 GOP members.  In order for the bill to pass the House, it will need to get support from 71 votes, opposed to the normal 60, due to rules of the veto session. If you want to see a health benefits exchange that supports the interests of individuals and small businesses, call your state representative and tell them to vote Yes on SB1313.

Making the Grade: A Scorecard for State Health Insurance Exchanges

According to the Illinois Department of Insurance, health insurance premiums have risen on average 181 percent since 2005. This could be the week action is taken in Illinois to fix our health insurance marketplace for Illinois families and small businesses.

Lawmakers are expected to consider legislation that would create an Illinois health insurance exchange that, if designed right, would help increase choices and lower costs for Illinoisans purchasing health insurance.

There’s no need to start from scratch though. Many states have already taken action to create health exchanges to deliver better value for consumers, and Illinois should follow their lead.

In fact, a report recently released by Illinois PIRG, "Making the Grade: A Scorecard for State Health Insurance Exchanges," closely examines the 12 states that have already created exchanges and rates them according to how accountable they will be to consumers and the public, how much they can do to lower premiums and improve the quality of care, how friendly they will be to consumers, and how stable they will be.

Not all exchanges are created equal.  That’s why it’s important to evaluate the policies that will matter most to consumers, including whether the exchange will be protected from insurance industry influence, and if it will negotiate with insurers for better rates.

Among the important policies to consider to make an Illinois exchange consumer-friendly include:

• Giving it the power to leverage enrollee’s buying power to negotiate with insurers for higher-value, more affordable coverage. 
• Barring insurers and other industry representatives from serving on the exchange board, so it will be more accountable to the public and to consumers.
• Making sure consumers will have an easier time shopping for coverage through easy-to-use tools and comparisons between plans.

For the sake of our pocketbooks, let’s hope Illinois lawmakers do their homework and ensure that our exchange makes the grade.

Brian Imus, Director
Illinois PIRG

Guest Post: Why Health Reform Holds No Fear For One Pediatrician

Reprinted with permission from CommonHealth WBUR.org

I remember the bad old days. By which I mean, I remember the 1990s era of “capitation” and all its ills — the rigid HMO spending limits that made money come between patients and their physicians.

But I’m not scared that they’re coming back.

Some worry that the coming “global payment” phase of Massachusetts health reform — in which health care providers are put on annual “global” budgets for each patient’s total care rather than paid for each procedure — will mean a return to capitation.

That would be terrible. As a pediatrician of 25 years, I remember the problems with capitation. It discriminated against special-needs children. It drove a wedge into the doctor-patient relationship, creating conflicts of interest by making doctors responsible for controlling costs. Access was restricted. Chronic disease management was not a priority.

But I welcome the impending era of global fees. If the concept of the Medical Home is incorporated — with its family-centered care incentives and rewards for innovations that save families money and time as well as improving quality — it could work.

Some see global payments as “capitation in sheep’s clothing.” However, if negotiated properly, there can be enormous opportunity for physicians to unleash their creative skills as never before in collaboration with families. It could be an opportunity to empower and educate families to manage more of their own minor health-care issues if they so choose — and as their deductibles increase, they will so choose.

Also, in our current system, insurance rate increase are coming more and more out of families’ pockets, not employers. Will there be a day when they just simply can’t afford going to the doctor? We need to act!

My practice, Westwood-Mansfield Pediatric Associates, is preparing for global fees. In our office, the most common reason for an illness visit is a sore throat. We responded to this by giving patients (at certain routine check-ups) a free home strep test to be used if certain criteria are met, with the proviso that patients must be seen in the office if the home test is positive or if the individual is not feeling better within 48 hours.
Since 65%-75% of rapid strep tests are negative in our office, we have been able to reduce office visits for sore throats by 20% and replace them with healthy lifestyle visits for overweight children.

We also give a prescription for a course of oral steroids, along with a written “Nighttime Asthma Attack Plan,” to parents whose children have asthma and instruct them on how to manage an asthma attack in order to prevent an ER visit. In addition, we have produced and posted, ourselves, videos of many common problems and how to avoid the emergency room.

The old fee-for-service system has stifled our capacity to be creative. The existing categories of services that can be billed for has also contributed to these barriers. Our own fear of change also plays a role.

The late Steve Jobs and Apple have been successful because they have been able to give people what they want before they realize they need it. This is what we strive to do. By empowering families to manage minor illnesses themselves (through patient handouts, websites, YouTube videos, and even “Apps”) we can shift the focus to the top health care problems of children – obesity, asthma, ADHD/learning style issues, mood disorders and allergies. In this model pediatricians can have a very rewarding job and make a good living.

Ultimately, the fact is that pediatrics has changed, and we have to change with it. Immunizations have eradicated most serious infectious diseases. Pediatrics must redefine itself as a specialty focused on wellness, seriously ill children, and chronic disease management and less on volume.

We can work on the concept of the Medical Home to improve care for our families in a team-based manner. In market terms, we need to give parents more value for either their co-pay dollars or their deductibles. Empowering our families is where our value will be coming from in the future, and global payments can help us get there.

Dr. Lester Hartman
Guest blogger
Dr. Hartman is a senior associate at Westwood-Mansfield Pediatrics, a Masters in Public Health candidate at Harvard and vice president of the Haitian Organization Program for Education and Health. 

Neighborhood Stories: The Importance of Community-Based Health Organizations

Today, Illinois Health Matters launched the third release in their ongoing multimedia series, Neighborhood Stories. This installment reveals through video and investigative journalism the importance of community based organizations, such as neighborhood health centers and grassroots health coalitions. Such organizations provide a variety of comprehensive services to people in underserved communities, such as the South and West Sides of Chicago, who often do not have health insurance or access to quality, affordable care.
 

In “Community-Based Organizations Play a Critical Role in Reform,” author Jeffrey Steele finds community organizations act as a vital link between the federal level ACA, the state-level policies that result from the act, and the people who will benefit from the health care reform. Steele describes various ways that community organizations in Chicago are helping to implement the ACA. For example, there is an individual in every community-based organization that Celine Woznica, program director for the Asian Health Coalition in Chicago, calls a “mother hen.” They are usually trusted and respected members of community that people come to and ask questions. Inquiries may range from where to go for a flu shot to how to get heating assistance to when to go for citizenship classes. “These staff are the very people who have to be well versed on the Affordable Care Act, and how to help people take advantage of it -- from preventive care to the health exchange,” Woznica says.

Community organizations are integral to distributing accurate information about the health reform process. At Erie Neighborhood House, a west side social service organization and community service agency, they are focusing on more “in person” workshops while other groups may utilize ethnic media and webinars. As Jim Duffett, Executive Director of Campaign for Better Health Care, sums up, “The more people who take ownership at the local level, the stronger we’ll all be in winning comprehensive reform.”

The video, “Wellness on the West Side,” profiles the story of Eliazar Mejia, a woman diagnosed and treated for diabetes at Lawndale Christian Health Center (LCHC). LCHC is a shining example of “coordinated care” – where they provide a multitude of different types of care and programs all in one place. Many people who do not have insurance, such as the 38% of LCHC’s patients, end up letting a health problem develop and worsen until it sends them to the emergency room. LCHC fills the gap between no care and the emergency room for its 60,000 patients. Bruce Miller, the CEO of LCHC, sums up the organization’s overall commitment to its patients: “Our goal as a community-based organization is to provide care for everybody who needs care. Whether they have insurance, whether they don’t have insurance, we’ve never cared. So, as we think about the future, what the impact could be of health care reform, it’s our hope certainly, that many of our uninsured patients will have…better access to care, and will use that care more frequently.”

“Wellness on the West Side” is just one in the Neighborhood Stories series, presented by Illinois Heath Matters. Previous videos profile individuals and families, small businesses, and the importance of a consumer-focused health policy in Illinois. All videos and articles are featured in the “Neighborhood Stories" section of the Illinois Health Matters website, along with articles that share how community organizations, including Health & Disability Advocates, local Chambers of Commerce and others are educating and informing underserved groups about their health care coverage options under the new law. The multimedia series is part of the Local Reporting Initiative, supported in part by The Chicago Community Trust.

Making Progress Toward a Health Insurance Exchange in Illinois

Last week was an important one for Illinois consumers and small businesses as lawmakers inched closer to establishing a state-run Health Insurance Exchange.  

Why is this important? As Timothy Jost, exchange expert writes in a Commonwealth Fund blog: “The health insurance exchange is the centerpiece of the private insurance reforms in the Affordable Care Act (ACA). If the exchanges function as planned, they will expand coverage to more Americans, reduce insurance costs, and improve the quality of coverage and perhaps of health care itself.”  However, if designed poorly, “experts warn, healthy people could avoid the exchanges, leaving them to sicker people with rising premiums."

First, some background:

On July 14, 2011, Senate bill 1555 was passed and signed by Governor Quinn, which created the Illinois Legislative Health Insurance Exchange Study Committee to aid in going forward with the establishment of a health insurance exchange (also known as the competitive insurance marketplace) in Illinois. The legislative study committee held five meetings, and commissioned two reports, one from Deloitte Consulting on the current state of healthcare in Illinois, and the second from HMA/Wakely Consulting Group, on the possible options and directions the exchange could take. On September 27, 2011, the Committee released a draft report of their findings from the five meetings and the two consultant reports. Although no definite decisions were made in the report, it is still the most substantive picture of the Illinois exchange to date.

Response to the Report:

Most of the report focused on the possibilities that Illinois must consider and decisions that must be made regarding the type of governance and the financing of the exchange. Many organizations weighed in with written comments in response to the report. Below are some of the issues and concerns that have been raised over the policy options outlined in the report:

·         The HMA/Wakely report listed two options for the operating model of the exchange: either as a “market organizer” or “market developer.” The market organizer approach means that the exchange would simply certify any health insurance plan that met the requirements for the exchange, relying on the competition of the marketplace to keep the cost of insurance down. The market developer style would have the exchange taking a more active approach to use their leveraging power in order to get the best possible value of plans from insurance agencies. Much support has been shown for the market developer option, aligning the exchange model with the interests of consumers for quality, affordable insurance.

·         Out of the three options presented for the governmental structure of the exchange, the overwhelming majority of opinions expressed have been in favor of a “quasi-governmental” model, as opposed to the “state-run” and “non-profit” models. The quasi-governmental model would keep the exchange in connection with other state-run agencies that it may need to coordinate with and promote a high level of transparency and accountability, while remaining a higher level of political neutrality.

·         The membership of the exchange governing board is one of the hot button topics in the report. The report underscores that members of the board should be well versed in the domain of health care, but should not have conflicts of interest, specifically noting that insurers, agents/brokers, HMOs, Prepaid Service Providers and other individuals with an interest in the Exchange should not be voting members of the board, though they could be members of an advisory committee. Some groups are advocating for a list of constituencies that must be represented on the board (for example, more representative of minority populations who are over-represented among the uninsured), while others think that a list of that nature would cause more problems for the board than it would solve.  Another major concern is whether or not legislators should be allowed on the board. Many groups have expressed their disapproval of legislators holding seats on the board – so that the exchange could be truly independent, non-partisan, and non-political — although some see their presence as non-voting members as a possibility. 

·         To finance the exchange, there are many options on the table, including charging consumers a fee to access the exchange, assessments on health plans offered in the new marketplace, assessments on all Illinois health insurance companies, the use of state general revenue, levying a fee on all health care stakeholders in the state (a list that could include prescription drug and medical supply companies, providers, hospitals, etc.), or assessing a progressive surtax on the revenues of all insurance providers. Many advocacy groups are against the idea of a fee to consumers, as the exchange targets those who are currently uninsured, who typically tend to have lower incomes, and could be put off or prevented from using the exchange if there is a fee. However, there are doubts that a funding option like the insurance revenue surtax would be approved. Some groups have stated that the best option might be for the enacting legislation to leave open the description of funding, so as to allow for multiple sources. 

Stay tuned! The final report will be issued this week and we’ll let you know if there are any changes.