Julie Darnell University of Illinois at Chicago Collaborators: Christina Andrews, University of South Carolina Teri Browne, University of South Carolina Sarah Gehlert, Washington University in St. Louis Robyn Golden, RUSH November 19, 2013 University of Chicago Outline I. II. III. IV. V. Strengths of social work that align with the goals of the ACA Social workers’ role in assuring access to health insurance coverage Heightened focus on integration and care coordination: Implications for social workers Expanded coverage for behavioral health services: Implications for social workers Resources in Illinois Five Health Social Work Strengths that Align with the ACA 1. Individuals are situated within social contexts. 2. The systems perspective considers & connects multiple intersecting spheres: health, education, employment, and child welfare. 3. Physical & mental/behavioral health are integrated. 4. All efforts and actions are guided by a base of evidence that is informed by research within communities. 5. Social Work historically has targeted services to disenfranchised groups. Why is Help in Enrolling in Insurance Programs Needed? Huge numbers of uninsured: ~50 million in 20111 Historically modest rates of participation in Medicaid among eligible populations2 32%-81% in studies Many individuals don’t know about insurance coverage3-4 Unaware or skeptical they would qualify or would find affordable coverage 48% have heard “nothing” and 28% “only a little” about exchange 78% have “not heard enough to say” whether state will expand Medicaid Sources: 1U.S. Census. (2012). Income, Poverty, and Health Insurance Coverage in the United States: 2011.; 2Sommers, B. et al. (2012). Understanding Participation Rates in Medicaid: Implications for the Affordable Care Act. U.S. Department of Health and Human Services; 3Perry, M. et al. (2012). Faces of the Medicaid Expansion: Experiences of Uninsured Adults Who Could Gain Coverage. Kaiser Commission on Medicaid and the Uninsured; 4Kaiser Family Foundation. Kaiser Health Tracking Poll: March 2013. Types of Consumer Assistance Consumer assistance programs Navigators In-Person Assisters Certified Application Counselors Exchange/Marketplace Medicaid Champion for Coverage Status of State Exchanges Declared state-based exchange Planning for partnership exchange Default to federal exchange Consumer Assistance State-Based Exchange Partnership Exchange FederallyFacilitated Exchange Statewide Consumer Assistance Programs (CAPs) OPTIONAL OPTIONAL OPTIONAL Navigator REQUIRED REQUIRED REQUIRED In-Person Assister (IPAs) OPTIONAL REQUIRED NONE Certified Application Counselor (CAC)-Medicaid OPTIONAL OPTIONAL OPTIONAL Certified Application Counselor (CAC)-Exchange REQUIRED REQUIRED REQUIRED Program Sources: Enroll America. (March 2013). How can Consumers Get Help Enrolling in Health Coverage; Kaiser Family Foundation. (April 2013). Consumer Assistance in Health Reform. Darnell, J.S. (2013). “Navigators and Assisters: Two Case Management Roles for Social Workers in the Affordable Care Act.” Health and Social Work; Robert Wood Johnson Foundation. (March 2013). Navigators and In-Person Assistors: State Policy and Program Design Considerations; Brooks, T. In-Person Assistors May Look a Lot Like Navigators. Retrieved from http://ccf.georgetown.edu/all/in-person-assistors-may-look-a-lot-like-navigators/. Duties of Navigators & Assisters Consumer Assistance Programs Navigator In-Person Counselor/ Assister Education/Outreach Enrollment in QHPs Duty Certified Application Counselors Medicaid Exchange State option State option State option or Refer State option or Refer State option or Refer State option Mid-year changes State option Culturally/linguistically appropriate Grievances and complaints State option or Refer Data collection and reporting State option State option State option To be determined Enrollment in Medicaid Sources: Kaiser Family Foundation. (April 2013). Consumer Assistance in Health Reform; Robert Wood Johnson Foundation. (March 2013). Navigators and In-Person Assistors: State Policy and Program Design Considerations. = Yes; = No IL: In-Person Counselor $27 million distributed to 44 organizations in Illinois http://www2.illinois.gov/gov/healthcarereform/Documents/Health%20Benefits%20Exc hange/FINAL%20IPC%20Grant%20list%20071713.pdf Navigators http://www.cms.gov/CCIIO/Programs-and-Initiatives/HealthInsurance-Marketplaces/Downloads/navigator-list-8-15-2013.pdf Challenges and Opportunities Opportunity: Consumer assistance roles align closely with social work case management functions Consumer assistance programs (CAPs) Navigators In-person assisters (IPAs) Certified application counselors (CACs) Challenge: Social work is swimming against the tide as other health professionals (nurses) and nonprofessionals (lay individuals) have assumed these roles Additional Challenges Additional Challenges: 30 million uninsured in 2019 60 55 50 44 40 Uninsured (millions) 30 37 31 30 30 30 30 31 31 20 10 0 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Who are they? The How many? Uninsured Unauthorized/Undocumented 11 million Medicaid eligible but not enrolled Next largest Unaffordable coverage *3 million (net): Not eligible for Medicaid -Supreme Court *Some of the 18-19 million+ who are exempt from penalty *6 million not exempt from penalty, of whom: .6 million < 100% FPL 2.4 million 100-300% FPL In between coverage ? Source: Congressional Budget Office. (2012). Payments of Penalties for Being Uninsured under the Affordable Care Act. Free Clinic Patient Free Clinic Patient How to Get More Involved: Eligibility & Enrollment Advocate for Medicaid For coverage expansion Against cuts in benefits Advocate for immigration reform, coverage of unauthorized and newly-arrived immigrants Advocate for continuous coverage Join (or form) oversight bodies (e.g., boards, advisory groups) that oversee exchanges Become certified/trained as: Navigators, Ombudsman, Assisters, Application counselors How to Get More Involved: Eligibility & Enrollment Advocate for Medicaid For coverage expansion Against cuts in benefits Advocate for immigration reform, coverage of unauthorized and newly-arrived immigrants Advocate for continuous coverage Join (or form) oversight bodies (e.g., boards, advisory groups) that oversee exchanges Become certified/trained as: Navigators, Ombudsman, Assisters, Application counselors ACA, Social Work, and Care Coordination ACA creates opportunity for new social work roles Avenues to sustainable care coordination by social workers increasingly available Provisions include Changing incentives Changing payment structures Move away from fee-for-service ACA provisions of note: Penalties for hospital readmissions Value-based purchasing Bundled payments Patient-centered medical homes Accountable care organizations Second Curve First Curve Second Curve Direct Contracts with Employers Traditional Fee-for-Service Payment System Option on the Health Exchange Medicare Advantage Plan Readmission Rate Penalties Accountable Care Organizations Population Health Per Capita Payment System Bundled Payment Pilots Adapted from Ian Morrison Patient Protection and Affordable Care Act of 2010 Reform component What it means What we need to work on Readmissions Financial penalties for Quality and patient excess readmissions safety Value Based Purchasing Payment based on performance on core measures Hospital Acquired Conditions 1% reduction in payment if in top quartile Care coordination Evidence-based care maps Clinical documentation Patient Protection and Affordable Care Act of 2010 Reform component What it means What we need to work on Coverage expansion More patients with insurance Manage access Bundled payments Lump sum payments to multiple providers for designated conditions Alignment and partnerships Accountable Care Organizations Patient-centered medical home Manage quality and cost Manage care of specified beneficiaries; Manage populations quality/cost; share of cost savings Care coordination Services, structures and Informatics access for continuous & comprehensive care Avoidable Readmissions Penalty Incentive to improve care transitions and reduce avoidable readmissions Lost reimbursement to drive performance improvement Penalty for each hospital based on risk adjusted actual 30-day readmission rate compared to expected readmission rate Reduced Medicare DRG payments by 1%, rising to 3% in 2015 3 target conditions starting in FY 2012, expanding to 7 in FY 2015 Hospital-specific readmission rates posted on Hospital Compare website for public viewing Expand to skilled nursing homes and HH agencies Community Based Care Transitions Program (3026) Provides funding to hospitals and community-based entities that furnish evidence-based transition services to Medicare beneficiaries at high risk for readmission Preference for medically underserved areas, small communities, rural areas and AoA programs Services must include at least one of 5 interventions Arranging post-discharge services Providing self-management support (or caregivers support) Conducting medication management review Funding up to $500 million over 5 years started in 2011 Bundled Payments Bundled payment pilot began January 31, 2013 Single Medicare payment to cover all services for an episode of care to be distributed among care providers: Acute hospital services Physicians’ services Care coordination and transitional care services Post-acute services Home health care Skilled nursing facility services Inpatient rehabilitation services Pilot testing four variations on bundling model over 3 years to assess efficacy Medical Homes Change in outpatient care delivery toward coordinated, chronic care, including the following supportive services: Care coordination Case management Health promotion Transitional care Patient and family support Referral to community services Additional funding available for coordination through greater reimbursement Accountable Care Organizations Medicare Shared Savings Program (3022) creates incentive for the establishment of Accountable Care Organizations (ACOs) Networks of physicians and other providers Integrated, cooperative services designed to foster collective accountability Share savings resulting from the ACO’s coordinated care Reduced Medicare expenditures Improved beneficiary health outcomes No consensus on vital components of an ACO Will have to address social issues to see true cost savings Opportunity for social work to achieve savings and quality improvement The CMS Innovation Center Test innovative payment and service delivery models To reduce program expenditures To preserve or enhance the quality of care furnished to Medicare and Medicaid beneficiaries Preference given to models that improve health care coordination, quality, and efficiency Authority to expand any model Funding of $1 billion per year for 10 years Released through ongoing Funding Opportunity Announcements Targeted distribution within priority areas Budget neutrality requirement waived during testing PCORI Patient-Centered Outcomes Research Institute governed by 21-member Board of Governors “Patient-Centered Outcomes Research (PCOR) helps people and their caregivers communicate and make informed healthcare decisions, allowing their voices to be heard in assessing the value of healthcare options.” Research priorities: Assessment of prevention, diagnosis and treatment options Improving healthcare systems Communication and dissemination research Addressing disparities Accelerating PCOR and methodological research Thrive Under Reform Key elements to making the ACA successful Engaging patients Prevention and wellness Not transactions but a journey Transparency of performance Focus on burden of treatment, not illness Cost and quality in the same breath Where does social work fit? Getting to the Table What can social workers do to get to the table? Find cross-institutional ways to collaborate Learn to communicate and market social work Frame social work from other perspectives Speak the language of other professions Vary the message to fit the mission of the team Find ways to partner with other disciplines Example: Delegating tasks to community health workers so social worker can focus on skilled activities Share evidence about effective social work interventions Focus on Social Needs of Patients: A Look at the Evidence Shier et al. March 2013. Health Aff vol. 32 no. 3 Enhanced Discharge Planning Intervention for Older Adults Outcome Odds ratio 95% CI lower 95% CI upper Patient stress 0.85 0.61 1.19 Caregiver stress 1.02 0.73 1.42 Physician appointment made* 2.70 1.64 4.45 Physician appointment kept* 2.09 1.51 2.89 General health rating (excellent/very good vs good/fair/poor) 1.27 0.85 1.88 30-day mortality (N = 906) 1.54 0.76 3.10 Readmission within 30 days 1.11 0.76 1.62 Altfeld, Susan J., et al. "Effects of an Enhanced Discharge Planning Intervention for Hospitalized Older Adults: A Randomized Trial." The Gerontologist 53.3 (2013): 430-440. Older Patients with Advanced Illness Challenge: “Hospital social work departments, which traditionally had the primary responsibility for addressing problems affecting a patient’s life in the community after discharge, have been deprofessionalized, shrunk, or eliminated altogether in the last generation.” Opportunity: “Hospitals and health plans wishing to practice dignity-driven decision making have invested additional resources in social workers to manage the task of working effectively with the home and community-based service network.” Bruce Vladeck Erin Westphal “Dignity-Driven Decision Making: A Compelling Strategy For Improving Care For People With Advanced Illness,” Health Affairs. June 2012 Complex Discharge Panel May Heave Influenced Decline in LOS Percentage Of Discharges With Long Length-Of-Stay Among Adult Patients At Denver Health Medical Center, January 2007–August 2011. MacKenzie T D et al. Health Aff 2012;31:1786-1795 ©2012 by Project HOPE - The People-to-People Health Foundation, Inc. Impact on Behavioral Health Insurance coverage for behavioral health will expand significantly under the ACA through two key provisions: Medicaid expansion Creation of the marketplace Impact on Behavioral Health The ACA requires that behavioral health be included in “essential benefits” offered by all private insurers All state Medicaid programs will also be required to provide behavioral health coverage However, public and private insurers will have some discretion in the types and volume of behavioral health services covered Impact on Behavioral Health The ACA also aims to enhance the quality of coverage by extending the reach of the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 Medicaid and newly-established HIEs will be required to offer behavioral health benefits that are no more restrictive than benefits for medical services Behavioral Health Workforce Increase in coverage for behavioral health services is expected to lead to increased demand for behavioral health services Demand for Medicaid-covered behavioral health services is expected to increase most, as a higher proportion of low-income individuals have untreated behavioral health disorders Behavioral Health Workforce ACA also emphasizes integration of physical and behavioral health through ACOs and PCMHs Great overlap among behavioral health disorders and chronic and acute medical conditions Many ACOs and PCMHs are emphasizing identification and treatment of these “high risk” populations Behavioral Health Workforce Bureau of Labor Statistics estimates significant increase in demand for behavioral health services providers Increase in demand of 34% for healthcare social workers and 31% increase for behavioral health social workers between 2010 and 2020 (16% for other SWs) Implementation Challenges Service systems may not be ready to address rapid growth in demand for behavioral health services At present, only 50% of substance abuse treatment providers accept Medicaid Immediate access to truly integrated services may be limited to health care “innovators” engaged in early ACO/PCMH efforts Implementation Challenges Case of Massachusetts: Enrollment difficulties; co-pays as deterrents to help seeking; loss of presumptive eligibility clause (Capoccia et al., 2012) Some left out of ACA coverage expansions, including undocumented residents Among those with coverage, great variation across states in the generosity and scope of coverage for behavioral health services Opportunities for Social Workers Assume leadership roles in systems expansions of behavioral health services Demonstrate capacity to contribute to integrated care models by assisting patients with co-occurring behavioral health conditions Patient Navigation: A Lit Review Study Year Patients Design Disease Social Worker Role Results Peacher, Palomino, Lo & Woodruff 2013 100 mostly Latinorural CA Observational Cancer Convert uninsured or inadequately insured to adequate insurance --Improved insurance status for all but 2 patients Tejeda, Darnell, et al. 2013 250 mostly AA, Latina uninsured, public ins.-Chicago Quasiexperimental with controls Cancerbreast/cervical Supervisor & navigator Identified and resolved barriers --Intrapersonal barriers are the most frequently identified barrier --System barriers persist beyond first encounter with navigator Markossian, Darnell, and Calhoun 2012 897 mostly AA, Latina uninsured, public ins.-Chicago Quasiexperimental with controls Cancerbreast/cervical Supervisor & navigator Identified and resolved barriers --Intervention subjects had shorter time to resolution than controls Ell, Lee & Xie 2010 3 pooled analyses Depression, Cancer, Diabetes Communication/system navigation, referral to community resources --Patients perceived navigation services as helpful --Physicians viewed navigation tasks as new Ferrante, Cohen and Crosson 2010 75 mostly female, elderly, white, insured Qualitative Unknown Choosing, understanding and using health coverage, providers, and services Making decisions about treatment Managing conditions & care received by multiple providers --Navigators helped patients obtain ancillary & social services --Navigators arranged appointments --Navigators provided emotional support DwightJohnson, Ell and Lee 2005 55 Latio Randomized to collaborative, usual care Cancerbreast/cervical Problem solving therapy Rx adherence System navigation --Improvements in depression and emotional well-being Tingen, Weirich, Heydt et al. 1998 1,522 mostly AA Correlational Cancer-prostate Navigate health system --Perceived benefits predicted participation in screening --Demographic factors predict screening Illinois Health Matters Illinois.gov Getcoveredillinois.gov Consumer Assistance A Cautionary Tale?