In July, the Ocean State became the thirteenth state to sign a Memorandum of Understanding (MOU) with the Centers for Medicare and Medicaid Services (CMS) to move forward with integrating services and financing for its Medicare-Medicaid population (dual eligible). While many challenges have surfaced with the twelve demonstrations already underway, we see some improvements in this MOU. For instance, the Rhode Island MOU:

  • includes the strongest provisions of any MOU to promote rebalancing from nursing homes to community care
  • is the only MOU that, from the start, offers protections in the form of risk corridors for all three years
  • contains strong policies on assisting enrollees with transitions between care settings.

Still, as with the other ongoing demonstration projects, “the devil is in the details.” And there are still a lot of details to get right for Rhode Island, as outlined in this fact sheet. Rhode Island advocates are hard at work nailing down these details, including ensuring that enrollment goes smoothly and that older adult enrollees receive geriatric-competent care, as our state partners emphasized in a recent Op-Ed in the Providence Journal.  These details will be part of a three-way contract which is currently under negotiation between CMS, the State and the participating health plan (Neighborhood Health Plan of Rhode Island). Most of all, their work ensures that consumers and their advocates are at the table as these decisions are being made.

As we’ve learned over the past two years, getting these demonstrations right takes time, vigilance and course corrections. The RI MOU signifies a cautious step in the right direction. But the hard work starts now. The readiness review process and details of the three-way contract will be important to watch. As with any new health system transformation initiative, ongoing transparent collaboration with consumers and their advocates will be vital to getting it right. 

And by drug cartels I mean the big pharmaceutical companies. Recently, there was an interesting confluence of drug industry-related stories. The first comes from the Kaiser Health Tracking Poll, which found drug companies rank low in popularity, and Americans believe the price of prescription drugs is unreasonably high and industry profits are too steep. There is strong support for allowing the federal government to negotiate drug prices, reimporting drugs from Canada and limiting the prices charged for expensive medications. People’s views of the drug industry would probably take even more of a beating if they knew research that shows a drug as ineffective is often simply suppressed, as reported by the watchdog group Health News Review. Suppression of evidence is contributing to excessive spending and poorer clinical outcomes. Finally, a Forbes story probes the possible reasons behind the unusually high drug approval rate at the FDA, including the possibility the agency is being unduly lenient in the approval process.

Taken all together, it seems the time is ripe for Congress to take action to rein in excessive drug spending. However, they may be poised to move in the opposite direction since the “21st Century Cures” bill, which enjoys support across partisan and ideological divides, could weaken the standards for drug approvals. At a minimum, even as we work to expedite the development of new medicines we should ensure all data on clinical trials is made available to the public as demanded by the recently launched All Trials campaign.

When Is Enough Enough?

CBO just came out with its regular update of the long-term fiscal outlook and as sure as the sun rises in the East, it was accompanied by calls to reduce spending on social insurance programs, primarily Medicare and Medicaid. The ritual nature of the call and response got me wondering if there would be any circumstance in which a CBO report wasn’t greeted with a demand to reduce health spending and dire warnings of what would occur if we didn’t. Has anyone noticed the level of spending reduction the Simpson-Bowles’ plan called for has been far exceeded? I thought not. I am in no way declaring victory over health spending growth, it just seems new developments ought to factor into how we approach the question.

No News Is Good News

For more evidence that ACA repeal is an issue that is losing its political salience, see the response, or lack thereof, to the “replace” plans released by several presidential candidates. Maybe it has something to do with the fact the rate of uninsured Americans has just hit a low not seen since Reagan was president?

This entry was originally posted on the OSPIRG Foundation Blog

According to a new study (pdf), Oregon’s efforts to transform health care are not yet delivering on their potential to improve the consumer experience. The Consumer Confidence Project, a volunteer-led effort overseen by the Oregon Public Health Institute, with support from OSPIRG Foundation, has released a review that raises tough questions about the state’s approach to holding the health care industry accountable to the needs of consumers.

We all know that health care still costs too much and delivers too little. To their credit, Oregon policymakers have taken important steps in recent years to contain costs and improve quality, led by landmark reforms to the Oregon Health Plan, the state’s Medicaid program. These reforms created Oregon’s Coordinated Care Organizations (CCOs), with financial incentives designed to cut waste, spend tax dollars more efficiently and encourage the development of new ways of delivering care focusing on prevention and keeping people healthy.

To ensure that CCOs deliver cost savings without sacrificing patient care, the state regularly measures their performance using a set of accountability metrics. On that score, the news to date is mostly good: State data suggest that many CCOs are succeeding keeping costs down and improving quality in key areas like reducing unnecessary ER visits.

However, to serve their members and their public mission, CCOs also have an obligation to help their members navigate the health care system and provide accurate and complete information about how the CCO is structured and how decisions are made. If CCOs do not live up to their promise in these areas, progress in other areas may come at the expense of the consumer experience of care, and the public may have no way of knowing whether CCOs are using public dollars wisely.

Unfortunately, the state doesn’t measure and track CCO performance along these lines. To fill this void, the Consumer Confidence Project reviewed the publicly available information, both printed and online, and found that Oregon’s 16 CCOs are doing an uneven job at best of empowering their members and informing the public about their operations.

For example, they found that CCO websites and member handbooks have only incomplete information about a CCO’s benefits and services, and that members would generally have to consult both to get the full picture, a lengthy and frustrating task. This has been the focus of much of the media coverage of the findings so far.

More troublingly, though, the report found that Oregon’s CCOs are largely failing to provide meaningful transparency. CCOs, through providing Oregon Health Plan benefits at a local level instead of centralizing all decisions at the state level, were meant to be closer and more accountable to their members and the communities they serve, but few CCOs appear to be making an adequate effort to provide information about their decision-making processes and opportunities for the public to weigh in. For example, no CCOs provided any information about how members or the public could bring issues of concern before the governing board of the CCO, and few provided adequate information about their Community Advisory Councils. These councils were created to give local communities an opportunity to have a say in decisions that affect their health and how their tax dollars are spent, but that only works if the public knows about them.

Oregon deserves better. While these issues are of special concern to Oregon Health Plan members, CCOs are funded by public dollars, and all Oregonians should have the right to know how their hard-earned tax dollars are being spent. We urge all 16 CCOs, and state policymakers, to take a close look at the Consumer Confidence Project findings and work together to deliver better results.

Jesse Ellis O'Brien
Health Care Advocate
OSPIRG Foundation 

Since partnering with the Voices for Better Health project in 2014, I have spoken to nearly 500 older adults and people with disabilities. The stories I have heard are compelling, often heartbreaking, accounts of people struggling to stay healthy and in their community. It is these stories that we are working to bring to policymakers to make fundamental changes to Rhode Island’s health care system, especially for the most frail and vulnerable populations who are often overlooked and underrepresented in the health care debate. With the recent announcement of the Memorandum of Understanding between the federal Centers for Medicare and Medicaid Services and Rhode Island’s Medicaid program to begin a demonstration project to coordinate care for beneficiaries with both Medicaid and Medicare, there is change ahead.  The stories below share some of the challenges that need to be addressed.

Stories from the Field

The most pervasive and profound stories I hear relate to isolation, the lack of family support, and loneliness. Today’s families are often fragmented and far-flung, making it impossible for many older adults and people with disabilities to depend on relatives for support. This is why the health care system and community-based services network is so vitally needed to work in a coordinated way to provide support services.

Mary is 90 years old and owns a small duplex in need of repair. I met her through a Meals on Wheels (MOW) outreach campaign. She is bright and talkative. She was overjoyed when I came to her home to chat. Mary hadn’t spoken to another human being in over two weeks; that’s when her “friend” and caretaker left for vacation, canceling Mary’s MOW delivery service during her absence. Someone was supposed to come and help her with her daily activities, but never showed up, leaving Mary to fend for herself. Mary’s limited mobility makes it impossible for her to take public transportation. She desperately needs dependable social services, but she’s afraid she will lose her house if she applies. Mary lives on less than $750.00 a month, however, she receives no Medicaid, LTSS nor is she on the SNAP program. Meals on Wheels is the only program she participates in. Mary admitted that the food is just okay, it’s the daily interaction with the volunteers that Mary craves and is her saving grace.

Many other older adults I have met with are similarly struggling to cope with loneliness, isolation and lack of a support system. They live in private single or multi-family housing, have no means of transportation or family support. Many live with undiagnosed mental illness or dementia. They rarely get out, don’t belong to any civic group, organization, church or senior center, and as a result, many crave human interaction. The real challenge has been how to make an initial contact with more people like Mary. Many seniors live in private housing where their isolation may go totally unnoticed until a tragedy occurs. Reaching this population would give us a more complete understanding of the most fundamental needs of those aging in the community.

Discharge plans are another area where poor, often isolated, older adults all too easily fall through the cracks.

Amanda is recovering from an unusual mid-brain stroke. She spent more than week in the hospital and then several more in rehab. Although she was told she would be receiving at-home care, it never materialized. It took countless calls for Amanda to obtain durable medical supplies such as a bath seat, grab bars and a walker that were essential for her to live safely at home. By the time she was contacted regarding Home Based Health Care after nearly four months, she was well on her way to recovery. Discharge planning requires good communication between the patient, a family caregiver or friend, if available, and all health care providers involved to ensure the best possible outcomes for the patient.

Relationship-based Organizing as an Effective Tool in Health System Transformation

So why is reaching isolated consumers so important in transforming our health care system?  What are effective ways to do this kind of outreach? Here are strategies I’ve used in my work:

  • Relationship-based Organizing is an approach that starts by building connections between individual members of a community or interest group, such as a church congregation, senior centers and residences. Its initial building blocks are house meetings. These are purposeful public sessions where participants share their stories of important events in their lives. This is the first step in building trust and deeper relationships around common values. The second step after a series of house meetings is a research phase, which turns broad, often-voiced concerns into specific, immediate and winnable issues and develops proposals to address those issues.
  • The final step is to organize public action meetings with turnout of consumers and allies, where decision-makers are asked to give a public response to our proposals.

Organizing is distinct from advocacy in that you are teaching the community how to effectively come together to advocate for itself to change social policy. For poor and minority seniors, providing avenues for participation and ways to gain a “seat at the table” with those who have the authority to make change can be a new and empowering experience. Small victories build the community’s confidence that they indeed have power and encourage them to take on bigger challenges.

The Rhode Island Organizing Project (RIOP) is a community organization dedicated to promoting justice and the common good. RIOP’s organizing strategy places a premium on community outreach, participation and empowerment, leadership development, and grassroots organizing. RIOP’s most significant achievements include expanding state funding for affordable housing and leading an effort to redevelop one of Rhode Island’s poorest neighborhoods. RIOP began working on elder issues in 2009 and began conducting house meetings, listening to low-income seniors talk about their health care experiences and desire to age in place.

Marjorie L. Waters
Community Organizer
Rhode Island Organizing Project

A few weeks ago, the U.S. Preventive Service Task Force released a new proposal recommending that all women who are pregnant or within one year of giving birth be screened for depression. This is a positive development. Maternal depression encompasses the spectrum of depressive disorders that can affect mothers from the prenatal period to up to one year postpartum, including prenatal and postpartum depression, and postpartum psychosis. These disorders also frequently coincide with additional conditions and risk factors including other mental health disorders, substance abuse, chronic medical conditions, domestic violence and poverty, which can exacerbate depressive symptoms. Community Catalyst has recently completed a brief examining many of these issues and opportunities for positive policy changes.

Untreated maternal depression not only impacts the health of mothers, but also the health and well-being of their infants and young children. Maternal depression can negatively affect birth outcomes, parenting behaviors, and child development and school readiness. There are additional consequences for health plans including increased costs related to complicated deliveries, poor birth outcomes, and psychiatric hospitalizations. At least 15 million children in the United States are living with a parent who suffers from depression.

Maternal depression disproportionately affects low-income women and women of color, and they are also the least likely to receive treatment. Closing the coverage gap is an important step toward connecting depressed mothers and their children to health care coverage and additional services, but we also need to begin to think more creatively about transforming our approaches to maternal depression screening and treatment. For maternal depression treatment programs to have the greatest impact, providers must consider the needs of the mother as an individual and as a parent as well as the needs of her infants and young children, a concept known as a two-generation approach to care. The idea behind this model is that “…when opportunities for children and parents are addressed in tandem, the benefits may be greater than the sum of the separate parts.” Unfortunately, maternal depression is rarely considered within the two-generation context because health care for adults and children and for physical and mental health are frequently separated, at least in part due to lack of financial incentives for clinicians.

There are several services that already use a two-generation approach and are tailored to reach vulnerable, low-income families who face the greatest risk for maternal depression and its effects on children. These services offer excellent opportunities to incorporate maternal depression screening and referral to treatment. The Maternal, Infant, and Childhood Home Visiting Program, Head Start and Early Head Start Programs, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and the Supplemental Nutrition Assistance Program (SNAP) could all be leveraged to increase depression screening and to refer mothers with depressive symptoms to clinicians and additional services. Two-generation approaches can also be employed in the clinical setting by eliminating the division between primary and mental health care and between adult and pediatrics.

The way we care for pregnant women, mothers, and children is a good measure of the success of our health care system as a whole. We have major deficiencies in the way we address maternal depression, and we must rethink the way we support affected women and families in need. Better screening is an important step forward, but it must also be linked to treatment and services that incorporate a two-generation approach.

For more on this issue, check out the full brief, “Maternal Depression: Implications for Parents and Children and Opportunities for Policy Change.”

Taylor Lauren Frazier
Intern
Community Catalyst Children’s Health Team