On Monday, the Department of Health and Human Services (HHS) released Navigator grant recipients for the 2014 open enrollment period. In total, $60 million dollars were awarded to 90 organizations in the 27 states with Federally-facilitated Marketplaces and the seven states with Partnership Marketplaces. While the majority of awards went to the same grant recipients as 2013, there are also many new grantees for 2014. In particular, HHS selected new recipients based on their requirement that all Marketplaces must have at least one Navigator entity that is a community and consumer-focused nonprofit. Additionally, HHS chose new grantees who demonstrated a strong capacity to reach specific, hard-to-reach populations.

We welcome the 2014 grant recipient decisions because of their ability to help enrich the enrollment experience for consumers in several ways. First, awarding 2014 grants to many of the 2013 recipients will provide consumers with consistency and familiarity in Navigator programs. Newly-enrolled consumers can now turn to the same Navigators they worked with last year for assistance with renewing or switching their coverage. In addition, selecting new Navigator recipients who are uniquely-positioned to reach populations with high numbers of uninsured consumers will help ensure the remaining uninsured are aware of their coverage options and financial assistance opportunities.

We would also like to acknowledge the organizations who served as Navigators last year but will not participate in this year’s efforts. We know they worked tirelessly to bring the ACA to their communities, many of them in unique and creative ways. We hope they will continue to bring their dedication and new ideas to the table by participating in the broader outreach and education efforts in their states. To learn about the many innovative outreach, education and enrollment strategies employed by state-based consumer health advocates during the first open enrollment period, see our report: Connecting Consumers to Coverage: Mobilizing for Enrollment.

Overall, we feel the combination of new and old grant recipients will provide for a robust and effective enrollment assistance system during the next open enrollment period. By allowing both the newly-enrolled and remaining uninsured to learn about their options from community members they know and trust, they will be better able to enroll in or renew meaningful, affordable coverage.

The expanded non-profit hospital community benefit requirement under the Affordable Care Act creates an important opportunity for community-based organizations and advocates working with their local non-profit hospital to address unmet community health needs. As we previously wrote about  here, the IRS’ proposed rules for non-profit hospitals encourage them to address disparities in health and financial barriers to care. Addressing these barriers and challenges can be accomplished through hospital community benefit spending, and it all starts with the Community Health Needs Assessment (CHNA).

Through funding from the Kresge Foundation and the Surdna Foundation, our Hospital Accountability Project (HAP) has worked closely with three communities (Bronx, NY; Minneapolis, MN; and Portland, OR) over the past several months. The HAP team provided technical assistance to a lead organization in each community and designed and co-facilitated a pilot curriculum for building grassroots capacity and fostering engagement in local non-profit hospital community benefit activities, including the CHNA.

What did we learn from these pilot sites? We learned that most community groups do not have enough background and context about the importance of non-profit hospital community benefits. They were shocked to learn that in 2002, the Congress Joint Committee on Taxation estimated the value of community benefit to be more than $12 billion. That figure is likely much higher today. Furthermore, as community members considered hospitals in the role of anchor institutions, meaning that they are usually one of the biggest employers in their communities and they are unlikely to relocate, they gained new perspective on the reasons for and benefits of close collaboration. A community group partnering with hospitals not only makes sense for the issues they are tackling, but also because the ACA requires hospitals to engage with vulnerable communities, which are often already served by coalitions and organizations in the community.

The groups we worked with also wanted to understand the financial information related to hospital community benefit spending reported annually on the IRS Form 990 Schedule H. We are working with The Milken Institute School of Public Health at The George Washington University, through funding from the Robert Wood Johnson Foundation, to develop and test a Community Benefit Web Tool prototype. This prototype will provide easy access to community benefit investment information from the Schedule H form, and, when finalized, will enable users to compare hospital investments on the basis of factors such as geographic location, community economic status, and hospital characteristics, such as number of beds and teaching status.

Our experiences with these three pilot sites taught us a great deal about how to prepare communities to engage with their local hospital community benefits activities. For example, many non-profit hospitals have been conducting their first CHNAs, and grassroots groups want to “get in on the ground floor.” Grassroots groups can partner with and help hospitals compile data about their community’s unmet health needs, prioritize those needs, identify and implement strategies to address community needs, and evaluate the impact, as we discussed in our recent CHNA Health Equity blog.

As a result of this work, we developed and tested a pilot curriculum, collectively titled: Putting People First: Working with Hospitals to Address Community Health. As part of Putting People First, we have made some exciting new resources available to help advocates and community-based organizations understand what community benefit is, how they can engage in the CHNA process, and how to partner with local non-profit hospitals to address some community needs that might not ordinarily be thought of as leading to good health outcomes. This includes workforce development, housing and economic development activities. We discussed these opportunities more in depth in our December 2013 webinar with the Democracy Collaborative and in our presentation What it Takes to be Healthy.

We look forward to sharing additional resources and tools with you, as they are developed. In an effort to share and learn more about how you are getting involved in your local non-profit hospitals’ community benefit planning process, we will be hosting a learning community call on September 26, 2014 from 1:00-2:00pm EDT. If you would like to participate, please click here.

For more information about the Putting People First curriculum and resources, please contact Michele Craig, Hospital Accountability Project Outreach and Training Coordinator at mcraig@communitycatalyst.org.

Almost two decades ago, the National Association of Insurance Commissioners (NAIC) adopted a model state law to regulate the adequacy of health plan provider networks. The model law contained a general standard that services be accessible without “unreasonable delay.” Seventeen years later, the federal government adopted this as the standard for qualified health plans (QHPs) in the new health insurance Marketplaces created under the Affordable Care Act (ACA).

Why update the model law now?

The NAIC’s model law – as reflected in federal and most state rules for Marketplace QHPs – did little to curb insurers’ rush to narrow their provider networks in the plans they sold for 2014. Fully 48 percent of QHPs came into the Marketplaces with narrow networks. The media published stories about consumers who were upset that physicians and hospitals they were used to seeing were no longer in their plan networks. Politicians weighed in, asking for more robust oversight of networks. The truth is, leading up to 2014, very few states had adopted the NAIC’s model law and fewer still did any proactive regulation to ensure networks were adequate.

Into this regulatory vacuum stepped the federal government, which indicated in March that it will conduct a review of network adequacy for 2015 QHPs, and signaled a future rulemaking in which they would adopt a tougher standard, perhaps modeled on the regulation of Medicare Advantage plans. This got the attention of state regulators, who immediately fired off a letter to HHS, asserting that the regulation of network adequacy was best handled by the states. Yet they also acknowledged that the NAIC model law needs to be updated to reflect changes in health plans and in the health marketplace, which has evolved since the 1990s to include an alphabet soup of plan network designs.

What is the process and timing for updating the model law?

Early in 2014, the NAIC created the Network Adequacy Model Review Subgroup, composed of state insurance regulators, to revise the model law. The subgroup’s first step was to invite various stakeholders to provide oral testimony. On separate conference calls the subgroup heard from provider groups, consumer advocates, insurance companies and accreditation organizations. The subgroup then asked these groups to provide written suggestions for updates to the model, which staff compiled into a master chart. The NAIC consumer representatives submitted comments that focused on (1) a more robust, quantifiable standard for network adequacy, (2) better oversight of plan compliance, (3) an end to balance billing by out-of-network providers working in in-network facilities, and (4) greater transparency of provider networks.

The subgroup is now engaged in a painstaking series of weekly conference calls, going line-by-line through the model law and attempting to achieve consensus on revisions. NAIC staff estimate that, so far, an average of 100 people have participated on each call, including consumer advocates, provider groups and insurers, as well as state officials. Although progress is slow (on the first call it took 20 minutes to revise the law’s title), the subgroup hopes to complete its revisions before the next NAIC national meeting, scheduled for mid-November in Washington, DC.

Why is this important and how can consumer advocates play a role?

NAIC’s model laws frequently serve as the template for state regulation of insurance products, and many insurance departments and legislatures will look first to NAIC’s language before drafting any network adequacy rules in their state. But it may be difficult to achieve consensus, with many stakeholders resisting stricter standards, more proactive oversight and transparency of plan networks. Ultimately, sometime this fall, insurance commissioners will need to vote on changes to the model, and advocates will need to weigh in to encourage them to include the NAIC consumer representatives’ key recommendations.

-- Sabrina Corlette, Senior Research Fellow & Project Director
Georgetown University's Center on Health Insurance Reforms 

With the November elections looming, many organizations that we wouldn’t normally think of as hubs for engaging voters are playing an important role in ensuring eligible citizens are able to register. Community health centers, trusted spaces for obtaining health care, are among those entering the realm of voter registration. And their work in this area makes perfect sense. Low-income individuals are some of the most frequent clients of community health centers, all too often having been ostracized by other health care providers in their communities because they are uninsured. These health care clinics are well positioned to empower many of their current clientele who come in seeking medical care. Additionally, low-income individuals are disproportionately less likely to  be registered to vote, similarly disempowered from civic engagement because of the belief that the systems in place fail to support their families’ and communities’ needs.

Given this overlap, Nonprofit VOTE has long focused on advising community health centers as they integrate voter registration into their primary goals and responsibilities. With many health centers focused on greater community engagement, Nonprofit VOTE aims to help them recognize voter registration as a tool for empowering low-income consumers. By increasing the number of registered voters, communities can better advocate for their elected officials to respond to their needs—be it changes at the statewide or local level. With local health clinics facilitating the completion of a voter registration form, consumers are empowered to walk out of a health center with their health issues attended to, as well as the tools to participate in the next election.

Community health centers can incorporate voter registration into all aspects of their work, beginning with training and educating staff on the importance of registration. Nonprofit VOTE found that when staff members are informed regarding the direct positive impacts of voter registration on community health, they’re more invested in sharing these benefits among clients, as well as their own family and friends. Getting people registered to vote, and consequently starting a dialogue on the health disparities entrenched by social determinants of health, is a huge step forward in raising awareness on community health needs. These conversations are important in trying to understand complex health issues that aren’t limited to a single household, but are common health problems in the community. Becoming a registered voter can transform an individual’s perception of what she can do to impact her own community, which can, in turn, lead to people taking better care of themselves and their neighbors.

Rather than remaining on the sidelines, community health centers can actively integrate consumers into a valuable set of data on registered voters that will elicit the attention of their policymakers. A recent Nonprofit Vote webinar reiterated that high visibility—such as posters and distribution of  “I Pledge to Vote” buttons or stickers—and enthusiasm were both important to engaging consumers in voter registration opportunities.  Nonprofit Vote emphasized that a great opportunity to synthesize voter registration in health centers exists by tying it into outreach, education and enrollment efforts for health insurance coverage into Medicaid and Marketplaces. Simply by making “the ask,” staff members could inquire, just as they do about health insurance status, whether patients were interested in registering to vote, and subsequently provide the materials to do so. Through reimagining the different ways that health centers can connect consumers to their communities, Nonprofit Vote shares their tips on how these centers can help create a stronger safety net for vulnerable populations.

For more information on how to register voters in your area or work in collaboration with your community health centers, please feel free to read through the slideshow from the webinar or visit http://communityhealthvote.net/blog/.

-- Jessica Liao, Health Equity Intern

21st Century Snake Oil

 ·  PostScript

A pink advertising insert appeared in my local newspaper recently proclaiming that "We can help you Stay Stroke Free for only $149!” The ad by Life Line Screening urges readers to undergo ultrasound examination of their carotid arteries because "80% of stroke victims have no apparent warning signs or symptoms." The ad further asserts that "when detected early, 4 out of 5 strokes can be prevented."

Based on this ad, readers would seem to be well advised to call immediately for an appointment. But if they did so, they would be unnecessarily putting their lives at risk.

What the ad doesn't say is that stokes caused by a blockage of the carotid artery comprise a relatively small proportion of all strokes and that even if severe blockage of the carotid artery is found, surgery to clear that blockage is more likely to cause a stroke or kill you than not doing surgery. That was the conclusion reached by the American Academic of Family Physicians (AAFP) which, as part of the Choosing Wisely campaign, is urging doctors not to screen for carotid artery blockage. The AAFP wrote, "There is good evidence that for adult patients with no symptoms of carotid artery stenosis, the harms of screening outweigh the benefits. Screening could lead to non-indicated surgeries that result in serious harms, including death, stroke and myocardial infarction." Furthermore, the screening test is far from perfect, sometimes indicating that a severe blockage is present when it really isn't.  

The United States Preventive Services Task Force (USPSTF) also recommends against screening   in adults who show no other symptoms of carotid artery stenosis.  And even if a patient has another symptom or risk factor for stroke and other cardiovascular diseases, the recommended response is to practice good health habits like regular exercise, control high blood pressure or diabetes if they are present, and eat healthy—and, if you are older, take a daily aspirin.  So knowing if there was a blockage in the carotid artery would not lead to doing anything different. 

So what motivates Life Line Screening to scare readers into getting the test? I think money has a lot to do with it. Their ad boasts that nearly 8 million people have already been screened. At $149 per person, that's over a billion dollars.

Another screening company, Health Fairs, has been doing a similar form of cardiac screening, which evidence shows is equally unnecessary. This led Public Citizen to write a letter to 20 hospitals and other medical institutions urging them to sever ties with  Health Fairs. Public Citizen writes, "the company’s heavily promoted, community-wide cardiovascular health screening programs are unethical and are much more likely to do harm than good."

In response to Public Citizen’s letters, the American College of Cardiology blogged that “[o]ther than assessing blood pressure and serum cholesterol, being attentive to diabetes and promoting a healthy weight with regular exercise, we do not recommend broad and untargeted screening.”  And an op ed in JAMA supported Public Citizen’s call for hospitals to sever ties to these screening companies if they cannot justify the relationship transparently, and to fully disclose to patients the risks and benefits of the screenings offered.

This fear mongering isn't confined to shady operations conducted from buses or rented VFW halls. Television ads from large commercial clinical laboratories urge viewers to get tested for celiac disease if they have any of a long list of common symptoms that just about everyone has experienced at one time or another like bloating, gas, indigestion, constipation, diarrhea, nausea, vomiting, or decreased appetite.

Pharmaceutical companies are in the "selling sickness" business in a big way as well. TV ads alert men to the symptoms of "Low T" (low testosterone) including fatigue or decreased energy. A recent patient came to me insisting on a prescription for the transdermal testosterone patch based on vague symptoms, while arguing that he didn't need any blood test to confirm the diagnosis. In a January article, AARP warned that new research has linked such testosterone hormone therapy with a significantly higher risk of heart attack, leading FDA to review the safety of this treatment. A physician  AARP interviewed advises men to see a physician that is qualified to make a proper diagnosis, but to avoid medical centers that “seem too promotional”.

America has a long history of hucksterism. "Snake-oil salesmen" sold their patent medicines to gullible consumers throughout the 19th century. The progressive movement in the early 20th century curtailed some of the most outlandish practices through pure food and drug laws and tighter regulation of untruthful advertising. But it seems as if we're now turning back the clock to the days of the Wild West with increasing clamor for less government regulation and an unfettered free market.

Free markets work well when consumers can be armed with the all the information they need to make rational choices.  But in health care, reliable information is complex and hard to come by, and consumers are also patients, who feel personally vulnerable.  Patients should have a voice in treatment choices, but they can also be misled into buying services and products they can’t fully assess, and don't really need.

What we need is more stringent government regulation of advertising of health products and services, not less. Ads should be prohibited not only when they are blatantly false, but also when they are so unbalanced, or incomplete as to become misleading. For instance, if an ad contradicts a recommendation of the USPSTF, then the ad should be required to include the task force's recommendation verbatim.

We also need to do a much better job letting the public know about trustworthy sources of health information, such as Choosing Wisely and Consumer Reports Best Buy Drugs. In this day of iPads and instant information, no one should get snookered into buying 21st century snake oil.

Stephen R. Smith, M.D., M.P.H., Community Catalyst physician consult