January 14, 2019

2019 State of Reform Conference Highlights

Greater Columbia ACH staff divided and conquered the various break-out sessions at the State of Reform on January 10, 2019. Below are a few of the highlights and ideas from the sessions that GCACH staff attended:

  • Governor Inslee has set aside $90 million for a variety of behavioral health initiatives.
  • Beacon Health is expanding capacity within the crisis system by financially supporting local domestic violence services, schools, and volunteer organizations that respond to suicides and deaths for community members.
  • In order to make progress on behavioral health, we need to come up with and agree on some meaningful outcome measures.
  • 2018 experienced the highest voter turnout for any midterm in a century.
  • The most important issue facing the country according to the latest poll of US citizens is healthcare.  It’s not always about the economy, stupid.  A recent Elway poll supports mental health as top issue for Washington residents.
  • The uninsured population has flattened out after 3 years of decline. Washington State uninsured rate is 5.5%.
  • The federal government is moving away from their commitment to healthcare reform.
  • Need to expand our partnerships, especially to business to create a more robust culture of health.
  • Starting to see hospitals getting into housing, but we should take steps to not over medicalize it.
  • Data and analytics should be part of ACHs sustainability plans.
  • Value Based Payments are successful when there is a robust collaboration between the providers and the payers.
  • Providers are struggling with workforce retention and recruitment for Home Car Aides, they are trying to get creative in funding a solution.
  • In regards to federal and state healthcare policy, it’s best for the state not to anticipate what the administration does. It’s best to be reactive, such us when the administration limited open enrollment periods and reduced funding for ACA marketing for 2018-2019, Washington extended open enrollment and used state funds for marketing.
  • There is considerable uniformity in the belief that addressing Social Determinants of Health is vital to improving the health of our populations. However, there seems to be a consensus that the lack of data and measures around them constitute a challenge to gauge ROIs. “Measures generate funding.” – Leanne Berge, CEO, Community Health Plan of Washington.
  • There are currently 80 million baby boomers who are retiring over the next 10-15 years and taking their workforce skills and experience with them. There are not enough people coming into the workforce to backfill their positions.    
  • The life expectancy difference between north King County (relatively wealthy) versus south King County (relatively poor) is, on average, 13 years.  This is mainly due to differences in the social determinants of health, such as the availability of affordable housing.  To have good health outcomes, we need to go deeper into the “roots of health.”  Currently there is a public health problem and a resource allocation problem.
  • The way healthcare institutions, and their systems and processes, are currently designed favors providers and administrators, but this design doesn’t work so well for patients.  Currently, the system and processes (e.g. EHR) favor billable transactions over health outcomes.
  • Recent incentive systems (e.g. CMS MACRA MIPS) haven’t been sufficient enough to drive behavioral and system change.
  • We create alignment across systems and providers when we put the patient at the center of care at least 80% of the time.
  • Putting more money into the healthcare system to address the social determinants, when this is not part of providers’ skillset, is not necessarily a good idea.
  • At least 50% of referrals made for low-income individuals never get filled.  The system is not adequately incented to coordinate this kind of work.
  • Cuba: This country consistently has better outcomes than the US.  Every two years, the government does deep-dive needs assessments to address each community’s needs, which usually includes planning around social determinant needs as well as healthcare needs.  For example, when food insecurity affects a particular community, the government steps in to build a food market.
  • The biggest social determinant of concern is affordable housing. And this has a direct effect on health outcomes.  The homeless visit the emergency department for issues that could be treated elsewhere around 80% of the time. And the average lifespan of a homeless person is 42-52 years.  This population also has a much higher incidence of mental health and substance use issues, but treatment for these is rarely effective if they don’t have permanent or supportive housing.
  • The healthcare system must bring care to where the high-cost, high-needs population exists if it is to improve outcomes.  For example, providing healthcare services in homeless shelters has been shown to reduce 911 calls. However, there is limited funding for this type of service.
  • Health Information Technology: Telehealth is still emerging as a technology but is becoming more robust.  Services include live synchronous visits with a provider (tele-chat, scheduled visits), asynchronous visits (e-consult with a delayed response), remote patient monitoring (healthcare “Fitbit”), and provider education.  Telehealth can provide lower costs, more convenience and reduced wait times.  But will it reduce overall utilization and costs?  This is still uncertain.
  • Top use cases for telehealth: follow-up from surgery, primary care follow-up, and behavioral and mental health consults. Top diagnoses include bronchitis and dermatitis. There is an opportunity in expanding this to Medication-assisted treatment (MAT) as well.
  • The challenges to widespread adoptions include issues around reimbursement. Also some patients don’t trust telehealth providers as much as a provider in a live visit. It is sometimes difficult to develop rapport with telehealth provider.
  • Wait time for the average telehealth visit is 8 minutes; average visit time is 20 minutes. CMS has recently approved 2 new reimbursement procedural codes for e-consults.
  • Trends for the future: Artificial Intelligence, Machine Learning, “Big Data”, Blockchain technology (used with cryptocurrency).
  • Consumers are coming to expect and even demand Amazon style service (transparency, access and convenience) in healthcare, which is driving change. Consumers want ratings on how well their doctors perform and all of their healthcare information in one place. This can also reduce out-of-pocket costs, which is significant with increasing patient cost-sharing.
  • The future of healthcare is likely to be more complicated and include a myriad of sites-of-service: provider office, hospital, urgent care, texting, email, retail clinics, telehealth and more.
  • In terms of digital health, the first big push was around the implementation of EHRs.  The next wave that is coming soon will be around interoperability between provider systems.  The ONC, which certifies EHRs for Meaningful Use, is now forming new interoperability policies and guidelines.
  • Patient no-shows (failing to meet an appointment) is a large issue for Medicaid clients. Using interactive text messaging for patient reminders in an FQHC environment has shown to be more effective than phone call or postal reminders.
  • The Opioid Problem is almost uniquely an American one. America and Canada fill more opioid prescriptions than the rest of the world combined.
  • Patient benefit plans need to be better aligned with the stated goals of reducing opioid prescribing.  Low cost shares for opioid prescriptions, versus higher cost shares for alternatives to pain management (e.g. acupuncture, physical therapy), is a problem. Consider going to McDonald’s and being charged $1.50 for a double cheeseburger while a salad is more than $5.00.
  • A large part of the solution to this problem is integrated care: incorporating behavioral health into primary care. There also needs to be collaboration between health plans, communities, schools, providers and more. The stigma surrounding people with substance use disorder also needs to be addressed; addiction must be treated and viewed as a chronic illness.  In addition, every PCP office should have at least one provider who has received MAT training, whether or not they go through the waiver process. Finally, incorporating wraparound services is an essential part of the treatment process.
  • For many people with substance use disorder, ineffectively treated trauma (physical or behavioral) is a major source of pain and the reasoning behind the substance use disorder.
  • There are recent changes to reimbursement for the collaborative care model, with new codes coming online for 2018.
  • SE IU775- formerly Group Health – WA has the lowest insured rate through the Affordable Care Act however the complaint is affordability of healthcare because of high premiums, coinsurance and copays.
  • WA Health Alliance-approximately 341m dollars and over 1m people affected on wasted low value care
  • “Health is so much more than Healthcare!”
  • Consumer Center Exchange Design- Typically correlation for providers to insurance and insurance to providers with the consumers behind the scene. Looking at ways to bring what is important to the consumer with insurance to consumer and consumer to insurance value-based design. i.e., tiers on pharmacy and incentives if they choose generic first. Affordability for healthcare is a huge consumer issue- premiums in many states is based upon inflation.
  • Providers should focus on 3-5 measures at a time and bring value to those specific patients as opposed to just “a measure”.
  • Good Value based contracts are subject to the patient population and the percentage in highest risk.
  • It was mentioned that Social Determinants of Health,SDH, as a whole should not be held at the healthcare system level- way too expensive and a much broader issue. Will never get ahead of the SDH of an individual if healthcare if focusing on the big picture of overall SDH i.e., provider provides care to the patient with a focus on their individual SDH at the patient level.
  • It was mentioned that Payers have more than enough money to provide healthcare to all individuals at a cost-effective rate.
  • VBP Panel- Providers need to do what needs to be done based on their patient population and quit waiting on the insurance companies to set metrics, incentivize, reimburse, etc.
  • Performance measures should be focused on family/community as the core i.e., Blue Zone