To mark Older Americans Month, the Voices for Better Health project has debuted a new video highlighting an important strategy to improve the health and well-being of vulnerable older adults. “Building Bridges to Better Health” tells the story of an innovative collaboration between consumer advocates and providers to infuse geriatrics best practices into the Demonstration Projects for people with both Medicare and Medicaid (dual eligibles).

Working nationally and with Voices for Better Health state partners, this powerful partnership draws on the expertise of leaders in the geriatrics community – physicians, gerontologists, nurses, social workers and other providers and researchers – sharing best practices to improve efficiency, quality and outcomes in the demonstration projects. This collaboration has increased the effectiveness of state advocacy efforts around these demonstrations. With people of color making up a disproportionately large percentage of the dually eligible population, we also see this work as helping to build another important bridge – to health equity for all.

While “Building Bridges” focuses on the dual demonstration projects, it affirms that breaking down silos and strengthening alliances with providers is an indispensable approach to creating a path to a people-centered health system, both for older Americans, and those of all ages.

Back in January, we posed the question How do we get to better, smarter, healthier?” One of the steps we identified was developing better people-centered health quality measures. These measures should (1) enable consumers to determine if they are getting real value for the money they (individuals or communities) put into health care, (2) be meaningful to and intelligible to patients, and (3) focus less on the details of health care processes and more on outcomes that matter to patients. The Institute of Medicine (IOM) recently released a report, Vital Signs: Core Metrics for Health and Health Care Progress, which has the potential to be a game changer in this effort. 

Health system transformation and good measurement of health care quality go hand in hand. The IOM found that quality measurement is becoming as fragmented as the health care system itself, with hospitals, health plans, states and the federal government using thousands of measures. For instance, there are at least 61 different measures being used for smoking cessation alone! This creates a significant time burden on caregivers, confusion for patients and uncertainty in demonstrating the effectiveness of health system transformation strategies in improving patient and community health.

The IOM report gives consumer health advocates a starting point for identifying measures that truly matter and that can lead to “better, smarter and healthier,” especially for populations that experience disproportionately poor health outcomes. The consensus report discusses a proposed set of 15 standardized core measures, along with the best current measures that address each core area, related priority measures and the value of each measure in understanding health disparities. The report also finds that in many cases new, more comprehensive measures and data sources are needed. The core measure set covers four domains: healthy people, care quality, care cost and engaged people—the kind of broad framework we need to really understand the overall health of the individual patient, families and communities.

“This is a thoughtful framework for measuring health,” says Stephen Martin, MD, a family physician on faculty at the University of Massachusetts, Boston University, and Harvard Medical School. “The report shifts away from process and surrogate measures—for instance, a target blood pressure or blood sugar number that may not improve health or even cause harm—to real indicators of reduced illness and improved health. The report also shows a wide gap, both in practice and in research, between current approaches and that those that IOM advocates.” 

The five measures summarized below (out of the 15 overall) are of particular interest to the consumer health advocacy community:

  • Healthy Communities
    Individual health is a function of a wide range of socioeconomic and community factors, and we know that the health of all individuals is closely tied to the health of the community in which they live. The report identified “high school graduation rate” as the best current measure, but proposed developing a composite measure that might include “education, air quality, walkability, socioeconomic status and access to healthy food.”  
  • Care Access 
    Many Americans are still uninsured, underinsured or live in areas with insufficient health care resources and staffing. The report identified “unmet care need” as the best current measure for care access and discussed alternative measures such as “usual source of care, delay in initiation of needed care, lack of health insurance, and underinsurance.”
  • Care Match With Patient Goals 
    This measure expresses the degree to which health care is patient-centered and patients’ values are considered as a factor in clinical decision making. The report identifies “patient-clinician communication” as the best current measure, which is currently used in CAHPS (Consumer Assessment of Healthcare Providers and Systems) surveys, and advocates for the construction of a more ideal measure that would address how the care process “effectively identifies patient and family goals, delivers the information necessary for decision making and works actively and successfully toward attaining those goals.”
  • Individual Engagement
    The level of people’s engagement in their health and the health of others can have important implications for the quality of health and care at the individual, family and community levels. The report identifies “health literacy rate” as the best current measure, but calls for development of additional measures, such as “involvement in personal, family and community health; working actively to improve the health of oneself and others; and active involvement in promoting a health-oriented community culture.”  
  • Community Engagement 
    A health-oriented community culture is important to improving individual and community health and health care, and the IOM asserts that engaging key stakeholders through the places where people live, travel, work and relax is critical. The report identifies “social support” as the best current measure, which is well validated in the CDC’s Behavioral Risk Factor Surveillance System. The report calls for more research and development in this area, suggesting other potential measures, such as “the existence of community-wide agendas, the use of community benefit funds, and opportunity for public input.”

The IOM report makes a valuable contribution to the debate over health care quality measurement, refocusing the conversation on measurement that uses a people-centered approach. Community Catalyst is eager to contribute to that debate and will be helping consumer health advocates weigh in to ensure that these efforts continue to move in the right direction.      

Angela Jenkins, Project Manager, Value Advocacy Project
Marcia Hams, Sr. Policy Analyst, Value Advocacy Project

The most significant development of the week at the intersection of health care policy and politics was the Obama administration’s crackdown on insurers for evading the rules about free preventive services as they apply to contraception. "Free means free" – the carriers were admonished.

In addition to its intrinsic importance, the action this week is a reminder that the consumer protections in the ACA are not self-executing. I don't want to cast aspersions on all insurers, but there has been too much flouting of both the letter and spirit of the ACA so far. In addition to failing to fully cover contraception, we have seen insurers fail to abide by mental health parity rules, and market plans with discriminatory benefit designs and discriminatory networks.

Why No Replace?

There is still no clear replacement strategy from Republicans even as the clock ticks down on the King v. Burwell decision. And guess what? There isn't going to be one. Why not, you may ask? Put yourself in Boehner and McConnell's position. Getting their respective caucuses to agree on anything is a big headache that requires a lot of arm-twisting. Anything they put out immediately becomes a target for Democrats. Plus, its political relevance is entirely hypothetical since without a decision for King, they have virtually no leverage with the President who will almost certainly veto whatever they send up. With all that weighing against them, it really is no wonder that "replace" remains a hypothetical idea five years after passage. Still, lack of a clear strategy has left the anti-ACA crowd open to jibes like this.

More on ACA and Public Opinion

ACA proponents have long been frustrated by the public's reluctance to embrace the law despite growing evidence of its success (though the public opinion needle finally seems to be moving a bit). At the same time, despite massively outspending proponents, the opposition has also been unable to gain much ground. The debate has been more or less a standoff. A new poll sheds some additional light on why. The poll found that the majority of Republicans think ACA has increased the number of uninsured, despite all the evidence showing the opposite.

The bottom line is people's view of the ACA is largely a matter of party identification. (If you like Obama, you like Obamacare; if you don't, you don't.) This is not so much about people placing different interpretations on the facts so much as people simply ignoring the facts that don't fit into their preconceived notion. People aren't making a rational judgment about the ACA, they are making a judgment based on emotion and personal identity and then ignoring facts that conflict with that world view. But proponents should not despair. Hardly anyone wants to actually repeal the main pillars of the ACA, which remains a dilemma for the repeal and replace crowd. We just have to come to terms with the fact that the public is not internally consistent with respect to health policy and understand that full acceptance of the law will take more time as well as a shift in the current hyper-partisan political dynamics.

Our partner, Raising Women’s Voices, shared this great post about new guidance from CMS clarifying what contraception insurance carriers must cover for consumers without any kind of cost sharing. The new guidance also clarifies that preventive care, such as pap smears and mammograms must be covered for transgender consumers needing these services. We’re excited to have clarification on these essential health benefits and are eager to see how they help state advocates and Divisions of Insurance ensure comprehensive coverage for all consumers.

National Women’s Health Week kicked off with an exciting announcement on Monday that the Obama Administration had issued new guidance clarifying that all new health insurance plans have to cover all methods of contraceptive care without charging us anything extra – like a co-pay or deductible.

Raising Women’s Voices and a number of our regional coordinators have flagged problems with contraceptive coverage since last year. Through “secret shopper” surveys and studies of insurance plan formularies, we’ve demonstrated that health plans are refusing to cover more expensive contraceptive methods, such as vaginal rings, and are inappropriately charging women for IUDs and for brand name contraceptives when no generic equivalent exists. These findings were brought to state officials, who asked the U.S. Department of Health and Human Services to clarify what insurers must do to comply with the women’s preventive services amendment to the Affordable Care Act. Two recently-released national studies, from the Kaiser Family Foundation and the National Women’s Law Center, added to the clamor for HHS action.

The Administration finally took corrective action to ensure that women have coverage for the full range of contraceptives and associated services, without additional fees or need for wrangling with their insurers. This week’s announcement is a big step in the right direction, since more than 48 million women in the U.S. will benefit from coverage of preventive services – like contraception – without cost sharing. It’s especially important for low-income women, who cannot afford to pay out of pocket.

Which methods must be covered, and what leeway do insurers still have?

The new guidance, which was issued in the form of a Frequently Asked Questions (FAQ’s) document, clarifies that all new non-grandfathered plans and insurers must cover without cost-sharing at least one form of contraception in each of the 18 methods that the FDA has identified in its current Birth Control Guide. These methods include 1) sterilization surgery for women; 2) surgical sterilization implant for women; 3) implantable rods; 4) IUD copper;  5) IUD with progestin; 6) Shot/injection; 7) combined pill of oral contraceptives; 8) progestin only oral contraceptives; 9) oral contraceptives with extended or continuous use; 10) the patch; 11) vaginal ring; 12) diaphragms; 13) sponges; 14) cervical caps; 15) female condoms; 16) spermicide; 17) emergency contraception (Plan B/Plan B One step/Next Choice); and 18) Emergency Contraception (Ella). The guidance also makes it clear that insurers must cover ancillary services as well – such as patient education and counseling.

Insurers will still be able to use some “medical management” techniques, such as refusing to cover (or charging a co-pay for) a brand-name contraceptive when there is an available generic equivalent that is covered without cost-sharing. So, for example, an insurer may say that it is only covering the Skyla hormonal IUD -- but not the Mirena IUD -- as both are medically-equivalent hormonal IUD methods.

However, the guidance also says that insurers must cover any FDA-approved contraception that a woman’s provider deems medically necessary. Insurers must provide “an accessible, transparent and sufficiently expedient exceptions process that is not unduly burdensome on the individual or a provider” to ensure that woman is able to quickly appeal for coverage of her preferred method of contraception without cost-sharing.

When do these new rules take effect?

This new clarifying guidance is only enforceable beginning on July 10, 2015. In practical terms, this means that most consumers will not see a change in their policy until their insurance plan starts a new “plan year.” For most women, this will not be until Jan 1, 2016.

Looking ahead, we will continue working with our network of state-based allies to monitor compliance and ensure that that the ACA’s contraceptive coverage mandate is fully enforced. You can count on us to make sure that women get the coverage they deserve, no matter where they live.

NY Attorney General proposes even better contraceptive coverage law

New York Attorney General Eric Schneiderman this week proposed a Comprehensive Contraceptive Coverage Act to address coverage gaps identified in research led by Raising Women’s Voices-NY. The Attorney General’s bill would make it the law in New York that all methods of contraception must be covered without co-pays.

The bill goes beyond the new HHS guidance in several ways, including requiring coverage without co-pays for vasectomies, which are not covered under the ACA Women’s Preventive Services provision. The bill would also allow a woman to obtain a full year’s supply of birth control pills at once, avoiding the need to get refills, and would give pharmacists the ability to dispense emergency contraceptives under a “standing” physician’s prescriptive order, thus allowing for insurance coverage of EC.

The New York bill is modeled on legislation adopted in California last year. Research and initial drafting of the bill was done by staff of Family Planning Advocates of NYS, NARAL NY, the New York Civil Liberties Union and RWV-NY.

HHS also clarifies BRCA testing and transgender care rules

The new guidance from HHS this week also clarifies that all insurers must cover BRCA breast cancer mutation susceptibility gene testing and that those who are having a colonoscopy done as a preventive screening tool for colorectal cancer cannot be denied coverage for anesthesia services.

Finally, the guidance makes another huge step forward in the fight for greater trans-inclusive health care by telling insurers they may not limit sex specific recommended preventive services based on an individual’s sex at birth. 

Coco Jervis & Lois Uttley, Raising Women’s Voices

2015 is shaping up to be a pivotal year for non-profit hospital community benefit. Since the IRS final rules came out in December 2014, the Hospital Accountability Project (HAP) team has been closely tracking developments in the non-profit hospital sector and in communities across the nation to understand the activity generated by the final rules. Things are moving quickly in communities across the nation, and we continue to track and share information. While the questions and needs vary across communities, we are seeing some trends in the conversation.

Community Benefit and CHNAs

It seems like everyone wants to know about “best practices” for meaningful engagement in Community Health Needs Assessments (CHNAs). As we continue working to create new tools and resources to support you in your efforts to create your own best practices, we’ve put together materials, that outline some basic facts and terms about community engagement.

We are also working with some of our partners to understand what happened during the first round of CHNAs in 2012 and 2013 and what you think should be done differently in the next round of 2015 and 2016 CHNAs .

Much attention is being paid to the role of about hospitals in population health including the obstacles and opportunities, especially as payment systems around the nation change from quantity to quality. This fact sheet will give you some information and key questions to think about as you plan to partner with your local hospital. We are also creating additional tools and resources to help our community partners build relationships with their local non-profit hospitals, as hospitals transition to the final rules this year. 

A common point of confusion with engaging non-profit hospitals is determining which decision-maker at the hospital should be contacted about these issues. We saw that issue arise first-hand during our pilot site work last year, as well as in some of our other national work. Even once that person is identified, additional questions arise about how to prepare for those meetings. Finding common language and bridging cultures can be challenging for both the hospital and the community, as community members struggle to find the resources necessary to engage in community benefit work and as hospital staff navigate institutional barriers and begin to appreciate the benefits of these partnerships. As a downpayment toward addressing those challenges, this fact sheet may help you understand the opportunities for and benefits of engagement. Our pilot site work over the coming months will help to develop some tools and resources that will help with those challenges.

Financial Assistance Policies (FAPs) and Billing and Collections

Medical debt and financial assistance are being heavily covered by the media of late, and we know that many are concerned about it in their locale. We frequently receive questions about the overlap (or lack thereof) of state financial assistance laws and the federal rules specific to these issue areas. Our partners at the Hilltop Institute have a great interactive state comparison table that can help you find out what your state community benefit laws are and compare yours to other states.

Our community partners often tell us that hospitals aren’t really paying attention or changing their behavior related to financial assistance/charity care, as there are still numerous loopholes in the final rules in this area. As hospitals spend 2015 getting their FAPs in order, we are tracking what we’re hearing and will be delving more deeply into this. We encourage you to help us monitor what is happening in your community and we would love to reach out to some of you to take part in efforts to develop some tools and resources that will help encourage hospitals to follow the spirit of the law.

Next Steps

We continue to monitor, track and plan how we can help community groups and hospitals work better together. We will host additional learning community calls/webinars and develop resources to will help you make change with your local hospital. If you have not done so already, please sign up for our email list (and be sure to indicate you are interested in Free Care & Community Benefits) so that you don’t miss out on these opportunities.

Hospital community benefit promises a lot of change in the near future, and it is important that opportunities are leveraged to improve your community’s health. Be sure to check out our community benefit resources and learn more about the Hospital Accountability Project by visiting our webpage.