Navigators, assisters, and certified application counselors are the unbiased people who are there helping consumers understand what the Affordable Care Act means for them and the new insurance options available to them through the law. We want to elevate their voices to share the experience of enrolling people and asked enrollment specialists to share their experiences with us in their own words. You can learn more about our work on Outreach and Enrollment here.

As a Navigator working for Planned Parenthood of Northern New England in New Hampshire (PPNNE), I have had the pleasure of connecting many consumers to health insurance for the first time. These experiences have allowed me to see firsthand the positive impact the Affordable Care Act has had on people who were previously locked out of the health care market. Nevertheless, there are still populations that are unable to fully benefit from the law. One population that I’m currently working with is the LGBT community, and particularly transgender people.

During this second open enrollment period, PPNNE developed a partnership with Out2Enroll, a national initiative to connect the LGBT community with new health insurance options under the Affordable Care Act. All of our assisters attended Out2Enroll’s LGBT cultural competency training, which covered enrollment questions and issues that frequently arise for LGBT community members. Our organization is now recognized as an LBGT-friendly assister on Out2Enroll’s enrollment assistance webtool, where LGBT individuals can search by zip code for assisters in their area.

Since PPNNE became a recognized LGBT-friendly assister organization, I have met with various consumers who recognize my office as a “safe place” that offers reliable and confidential assistance. Consumers have felt comfortable disclosing their HIV status during their enrollment appointments, or discussing their concerns about getting affordable coverage for their same-sex partner. In these instances, I guide consumers through the ACA’s non-discrimination provisions to educate them on affordable options that will not exclude them due to a pre-existing condition or their sexual orientation. Here in New Hampshire, we are fortunate that our expanded Medicaid program covers individuals living with HIV/AIDS, who previously would have had to wait until they were sick enough to qualify for coverage.

Despite these important non-discrimination provisions, transgender people looking to find coverage for hormone therapy, surgeries, or other important transition-related health care needs, often still must navigate a challenging process to find accessible and affordable options, especially if they are low-income consumers. It’s one of the reasons that we wanted to participate in Out2Enroll’s training- to ensure we could effectively communicate what coverages (and limitations) LGB and especially transgender people now have available under the ACA.

As I continued working with members of the LBGT community, I wanted to learn more about LGBT issues so I could offer better assistance. My research led me to wonderful resources offered by organizations such as Out2Enroll and the Gay and Lesbian Medical Association (GLMA). Through this process, I discovered some exceptional publications developed by Gay and Lesbian Advocates and Defenders (GLAD) that not only help consumers understand their rights regarding health care, but also provide best practices for successfully updating documentation. Furthermore, I learned that the work conducted by GLAD helped ensure that five of the six New England states now offer legal protection for all transgender persons. Regrettably, New Hampshire still lacks this explicit anti-discrimination protection, but progress is being made by the ongoing engagement of GLAD and New Hampshire’s Medicaid program as they aim to eradicate trans-exclusion policies.

As an LGBT-friendly assister, I realize there are still many consumers across my state who lack the knowledge and resources to advocate for their coverage needs. I know this situation is not unique to New Hampshire, so I wanted to share a few resources that improved my ability to assist consumers still facing barriers in the health care marketplace such as GLAD’s Transgender Legal Issues, the ACLU’s map of state non-discrimination laws, and PPNNE’s ACA for LGBTQ people flyer.

For more information on how your organization can participate in Out2Enroll’s LGBT cultural competency trainings, please visit http://out2enroll.org/training/ or email Kendall Bills (kendall@out2enroll.org).

Katie Mae Stewart, Planned Parenthood of Northern New England

With 2015 and the 114^th Congress underway, it is time to get thinking seriously about the Children’s Health Insurance Program (CHIP). CHIP serves about 8 million kids nationally, providing them with benefits similar or equivalent to Medicaid, in some cases including early periodic screening, diagnosis, and treatment (EPSDT), the gold standard of children’s coverage.

The Affordable Care Act (ACA) funds CHIP through the end of federal fiscal year 2015—that’s September 30 of this year. For the program to continue, Congress must approve new funds before this deadline. This might sound like a lot of time, but in reality, this federal deadline is not the only factor at play: state budgets for 2016 are being developed and must be finalized well before September, and governors need to know the future of the federal funds upon which CHIP relies before their budget cycles end. (P.S., Look here to see if your governor sent comments to Congress about the importance of CHIP in your state.)

In case you need a refresher on the importance of CHIP for its 8 million enrollees, now is a great time to brush up on the case for CHIP. Here is the highly abridged version: on average, for kids who are eligible for CHIP, it is their best coverage option in terms of benefits, affordability, and network adequacy. CHIP is also a crucial backstop for families that might otherwise be subject to the family glitch, which prevents dependents from obtaining tax credits for Marketplace coverage in some cases. Moreover, we are learning more about the effects of unstable coverage on families, and it will come as no surprise that uncertainty about the future of CHIP can be a major challenge for families.

Over the coming months, we will post periodically with updates and reminders of the many reasons we need Congress to act to continue CHIP. With your help, we can ensure that children continue to have access to this successful program that provides them the high-quality coverage they need.

Yesterday The Department of Health and Human Services (HHS) announced a new initiative to accelerate the shift in how we pay for health care from one that relies primarily on pay for volume (fee-for-service--or the more you do the more you get paid) to one that emphasizes value (ideally the better outcomes you achieve, the better you do financially).

Community Catalyst embraces this effort because we see too clearly the failings of the current system. Despite the huge sums we spend on health care, quality is uneven and often varies dramatically by geography, income, and race or ethnicity. Far too often patients end up in a hospital bed, emergency room or nursing home because they didn't receive the right care at the right time in the community. In fact, the Institute of Medicine identifies failure to deliver the right care as the biggest source of unrealized value (and biggest opportunity for savings) in our health care system.

That said, this is far from a risk-free venture. As Alan Weil cogently argued in a Health Affairs blog in December payment reform carries with it many challenges, including the fact that it is far easier to measure cost than quality, that payments tied to outcomes can create an inducement for providers to avoid harder-to-treat patients and that standardized outcome measures may not promote the best care for patients who may have very different needs and goals.

We believe that Weil's critique is well-founded and we recall clearly the shortcomings of an earlier generation of payment reform initiatives (the "managed care" efforts of the 90s). While we think these risks and shortcomings can be overcome, we also believe that this will only happen with concerted effort and commitment. From our perspective, the recipe for "better, smarter, healthier" must include these five ingredients:

1) Robust consumer engagement

As we outline in our paper the Path to a People-Centered Health System consumers must be active partners in the transformation at three levels:

First--as individual patients the system must move to assess and improve what has been variously called patient activation or patient confidence—the ability of patients to understand and manage their own health care. Higher levels of patient confidence have been found to correlate with both better outcomes and lower costs and boosting the patient confidence of lower income patients could be an important tool to reduce health disparities in the U.S.

The second level of consumer engagement is at the level of health plans or integrated delivery systems. Our Meaningful Consumer Engagement Toolkit outlines the elements and steps that plans and delivery systems need to take in order to make their patients/members partners in delivery quality care.

The third level requires consumer engagement in the policy-making and monitoring process. While the voices and expertise of other stakeholders are essential, it is almost certain that reform efforts will go astray if consumer voices are absent from the table or are relegated to token status. Effective consumer voice in the transformation will require resources and building connections across all three levels of consumer engagement, so that consumer representatives at the delivery system and policy making levels are informed by the experiences of individual patients.

2) Getting the financial arrangements right

Financial incentives create a powerful gravitational pull, influencing the behavior of clinicians, health systems and plans. If payment arrangements are not carefully designed, there will be incentives to under-treat or avoid certain patients. Providers who see a disproportionate share of sicker or poorer patients could be disadvantaged--exactly the opposite of what we are trying to achieve. Although there is much reason to be encouraged by the current initiatives that HHS is promoting such as payment incentives to reduce readmissions and medical errors, there are still some bugs in these payment initiatives that need to be worked out. Expanding value-based payment is the right thing to do, but moving aggressively in this direction without taking into account the greater degree of difficulty faced by some plans and providers will compound the challenges that lower-income populations are already facing.

It is also important to make financial incentives intelligible. A blizzard of conflicting public and private sector incentives will create signals that are impossible for providers to interpret and will fail to nudge the system toward better performance. 

3) Strengthening due process rights and patient support

While financial incentives do much to set the direction of the delivery system, no set of arrangements can ever be perfect. That is why as we move further into systems where providers bear financial risk, we also need to make sure that we have robust grievance and appeals processes and complaint resolution programs such as ombudsman initiatives. New systems of integrated care and changing plan designs can also create a dizzying array of choices for patients. Patient navigators, support for health care and health insurance literacy and help with picking a Medicare Advantage plan or understanding what it means to be receiving care from an Accountable Care Organization are all crucial.

4) Developing better consumer-centric quality measures

We all want better value for our health care dollar, but how do we know when we are getting it? A lot of the current quality measurement and reporting efforts are not meaningful to patients or intelligible to them. Many measures focus on processes and too few on outcomes. Although HHS has made great strides in promoting transparency on cost and quality in recent years, we still have a long way to go. In some areas likely to be both understandable and meaningful to patients, such as diagnosis errors, there is almost no information available.

Measuring and reporting on patient confidence, preventable events such as readmissions and medical errors will take us part of the way forward but more needs to be done to make quality measurement accessible to patients--especially if we are going to rely on patient/ consumer choice as a tool to drive performance and reduce costs. At the same time, a blizzard of overlapping and conflicting quality measures is likely to prove self defeating. As we move forward to harmonize public and private sector quality measurement simplicity, intelligibility and, outcomes need to be our touchstones.

5) Improving data collection and transparency

Obviously data collection and reporting is a thread that runs through the entire effort to promote better outcomes and smarter use of health care dollars. In addition to developing measures that better reflect consumer concerns, we have to do a much better job at presenting and disseminating data in a way that is intelligible. In particular, because of the risks inherent in the effort, it will be essential to strengthen data collection and reporting that could reveal disparities in treatment and outcomes based on race, income and disability. Enrollment and treatment patterns must be scrutinized for evidence of under-treatment or avoidance. 

The good news is that many of the elements described above already exist at least in rudimentary form or in some specific location or system. Others have been explicitly flagged for action by HHS as part of the new initiative. Moving forward on these fronts will ensure that what we get from the transition to value-based-payments is not just cheaper care, but better care.

This entry was originally posted on the Sullivan Alliance's Leadership Blog. 

Change is hard. Change takes time. Change is worth fighting for especially when it relates to improving access to oral health care. Faced with an oral health crisis, a decade ago the Alaska Native Tribal Health Consortium (ANTHC) turned to a nearly century-old dental provider model to provide care to their underserved residents. Yet, rather than being championed for employing an innovative and cost-effective approach to address their dental crises, the ANTHC was sued by the American Dental Association. The ANTHC prevailed and as a result, introduced a proven, culturally-competent and patient-centered approach to delivering dental care in the United States. Today, dental therapists are helping 40,000 previously unserved people get care where they live, when they need it.

The innovative approach adopted by ANTHC has become the most disruptive policy solution offered in oral health policy in a generation. As a result of Alaska’s example, Minnesota authorized dental therapists to provide routine and preventive care to the state’s underserved residents. Now, over a dozen states and tribal organizations are pursuing policy change to authorize dental therapists.

After nearly a decade in existence in the United States, the movement to establish the practice of dental therapy is gaining significant momentum despite the strong and well-financed opposition from the American Dental Association. In 2014, we saw great progress:

• ANTHC celebrated 10 years of dental therapy and dental therapists increasing access to over 40,000 Alaska Natives
• The Minnesota Department of Health issued a report highlighting that dental therapists that have practiced in Minnesota since 2011 and have expanded access to care, reduced wait times for rural patients, and can potentially reduce hospital ER visits for dental problems. They’ve also improved how dental teams function and as result are making care better for patients.
• Maine passed legislation to establish the practice of dental therapists
• The Washington Post editorialized in support of dental therapists
• The New York Times featuring dental therapists in Social Fixes Column and then a month later noting that dental therapists are “changing the world.”
• The Albuquerque Journal endorsed using dental therapists to address New Mexico’s unmet health needs.

As we start 2015, over half a dozen states are pursuing legislation to expand access to dental care by adding dental therapists to the dental team.

In New Mexico, which nearly established dental therapists last year, we’re seeing public health leadership such as Secretary of Health and Human Services Dr. Alfred Vigil highlighting the need for better care.

The reason there is so much momentum is the growing body of evidence highlighting the efficacy of the model in providing care to vulnerable populations and the significant unmet oral health needs in the nation, for example:

• More than 181 million Americans go without regular dental visits
• More than four out of ten children go without regular dental care
• 51 percent of children on Medicaid did not receive any dental care in 2011, and
• 45 million people live in areas where they can’t get dental care – and millions more can’t afford it

Now policymakers and the media are recognizing that dental therapists are part of the solution because the evidence that mid-level dental providers increase access to care and provide care at the same level of dentists is undisputed – with more than 1,100 articles showing that dental therapists increase access to quality, safe care.

Even the ADA’s own study found that “[a] variety of studies indicate that appropriately trained midlevel providers are capable of providing high quality services.” The same report noted that dental teams with mid-level providers were more successful at providing services to populations with untreated decay than dental teams with dentists alone.

Thankfully, state legislatures across the country are poised to make mid-level providers part of the solution to our lack of affordable dental care. We expect more to be launched this year. We also expect more states to authorize mid-level dental providers because, like Maine in 2014, policymakers will recognize how essential dental health is to maintaining overall health in their communities. Change is imminent.

Learn more about the Sullivan Alliance here. 

You can almost set your clock by it: at least once a year, a major piece of investigative journalism documents the struggles of uninsured and underinsured people who carry heavy medical debt and are facing collection actions from hospitals and other providers. (See “From the ER to the Courtroom: How Nonprofit Hospitals Are Seizing Patients’ Wages,” ProPublica and NPR, 2014; Steven Brill’s 2013 article “Bitter Pill: Why Medical Bills Are Killing Us,” Time, 2013 (subscription required); “Prognosis: Profit” series, Charlotte Observer, 2012.) Without fail, these stories cut to the quick of why access to affordable, high-quality health care is a moral issue. They also highlight the tensions that exist between profits and patient care, especially the long-lasting problems that arise for patients when hospital billing and collection practices don’t acknowledge patients’ financial realities. 

Just before the new year, the Treasury Department and IRS issued long-awaited final rules that directly address hospital financial assistance, billing and collections. The regulations finalize the details for a broader ACA mandate that governs how tax-exempt hospitals provide community benefit. Historically, hospital community benefit programs—including financial assistance or free care—have been a mixed bag in terms of content, governance, and level of investment; and states have taken an uneven approach to regulating hospital behavior. While the new regulations leave most of the details to hospitals to decide, they set a new federal floor that greatly increases transparency on financial assistance and collections, provides some protection against medical debt and overcharging, and offers communities greater insight and potential influence on the way hospitals understand and address broader health issues.

What Do the Rules Change?

Transparency. Transparency is at the heart of these new rules. Financial assistance, billing and collection policies will now be available for public review, with hospitals required to disclose detailed information about eligibility, how to apply for help, and how they use third-party data to screen patients for presumptive eligibility. Translation standards for printed and online financial aid materials improved, with hospitals required to translate policies into the primary language of populations to 5 percent or 1,000, whichever is less, of people “likely to be affected or encountered by the hospital facility.” Hospitals must publicly post their community benefit planning documents for public comment. These simple requirements have been hard to come by at the state level. Now, they’re the law of the land. 

Curbing no-holds-barred billing and collections. Unfortunately, the new rules don’t include an outright ban on some of the most aggressive collection actions in use today, nor do they require hospitals to observe a minimum threshold for eligibility for financial assistance—two things advocates were hoping to see. But, they do provide patients with more procedural protections against collection activity than they’ve had in the past. In addition to notifying patients and the public that financial assistance is available, hospitals have to assist patients with the application process (hospitals can perform this function themselves or outsource it to a non-profit organization or government agency). Patients have a minimum of 120 days from the first post-discharge bill without having to worry about “extraordinary collection actions,” and hospitals that begin these collection activities must suspend them if they receive an application for financial help up to 240 days after the post-discharge bill. Critically, if a patient is deemed eligible for financial help under the hospital’s policy, they can no longer be charged sticker price—“gross charges’—for care. Instead, they can only be charged the “amount generally billed” to an insured patient receiving the same services. (They’ve got to disclose their methods for determining this amount in their financial assistance policy.) This introduces some parity into a billing system that often perversely penalizes those who can least afford to pay hospitals’ high mark-ups.

Community input and better health planning. The ACA requires tax-exempt hospitals to use a health planning tool, the community health needs assessment (CHNA), to better understand community health needs. It also requires hospitals to develop an “implementation strategy” for meeting those needs. One implication is the potential to streamline community benefit investments toward priority issues within a community, avoiding an ad hoc approach that dilutes precious resources. The process encourages collaboration among hospitals, public health and community advocates, providing opportunities to take a deeper dive on systemic issues (like financial barriers, environmental problems, housing, nutrition) that impact health but defy easy solutions. The final rules mostly mirror earlier proposed rules here, though hospitals now have to include evaluation data for previous efforts in their CHNAs. Hospitals must solicit community input and consider the input they receive, though they are not required to make drafts of the CHNA or implementation strategy available for public comment. (NOTE: Most hospitals, relying on the proposed rules, have already completed one CHNA, which should be available on their websites and/or on request. Hospitals do need to consider written comments they receive in the next round of their community benefit planning.)

The buck stops here. Despite pushback from some quarters, the IRS held firm that tax-exempt hospitals can’t absolve themselves of responsibility by outsourcing their billing and collection responsibilities to third parties or selling patient debt. Furthermore, hospital boards bear ultimate responsibility for compliance with these new standards. This should raise the internal profile of community benefit, financial assistance and billing—a critical move, since so many details are left to hospitals to decide.

What Does This Mean for Our Work?

There is no question that the final rules are a step in the right direction. They provide an important tool—in some places, like many states that have not closed the coverage gap, the only tool—for addressing health and improving access to care for low- and moderate-income people and others facing high-cost care. And, they offer hospitals clarity and consistency on the federal level (states can go further than the federal rules and some have). As our health care system moves toward integrated care and capitated payment, the CHNA requirements provide a great opportunity for communities and hospitals to work together to achieve better outcomes. On the financial front, hospitals can still choose to be miserly, but the new public reporting may dampen enthusiasm for the “old ways” of collecting. 

Effectiveness will ultimately depend on hospitals making a good faith effort to comply with the spirit of the law, not just the letter. And that means advocates and community organizations must remain engaged with local hospitals, monitoring their compliance and taking advantage of opportunities to shape policy to meet local needs.

Patient-friendly billing practices don’t just help patients. Hospitals can benefit, too, from adopting better methods to collect.