Rx: Lawyer

Meeting the Challenges of Health Care Reform

Presented to the SIU School of Medicine

Carolyn A. Pointer, JD

April 14, 2014

Financial Disclosure

Neither my husband nor I have a personal or professional financial relationship or interest in any proprietary entity producing healthcare goods or services.

PPACA Goals

• Increase quality and affordability of health insurance

• Lower the uninsured rate• Reduce health costs for individuals and the

government• Improve healthcare outcomes• Shift healthcare system to quality over quantity

Insurance Coverage

• 342,000 Illinoisans newly eligible for health insurance through Medicaid expansion• Illinoisans who earn up to 138% of the federal

poverty line• $15,860 for an individual or $32,500 for a

family of four • 957,000 residents will be eligible for subsidized

health insurance in the form of a federal tax credit via Illinois Health Insurance Marketplace

Medical Malpractice

• Demonstration grants for alternatives to current tort litigations.• Consultation with relevant stakeholders • Enhance patient safety by reducing medical

errors and adverse events • Likely to improve access to liability

insurance.

Reimbursement Changes

• Accountable Care Organizations

• Shared Savings Plans

• Global Payment Plan

Medicare as a model

• Allow providers organized as accountable care organizations (ACOs) that voluntarily meet quality thresholds to share in the cost savings they achieve for the Medicare program.

• ACOs must agree to be accountable for the overall care of their Medicare beneficiaries, have adequate participation of primary care physicians, define processes to promote evidence-based medicine, report on quality and costs, and coordinate care.

ACO management strategy

Goals:

• Improve population health• Lower individual

health care expenses

Methods:

• Prevention• Super-utilizers•Medical Home• ?

Super-utilizers

Health care spending in the United States is unevenly distributed, with the sickest 5%of patients causing more than 60% of health care costs. - RWJF

Rx: Super-utilizer Savings?

• The Camden Coalition – Camden, New Jersey• 36 super-utilizers averaged 62 hospital and E.R. visits per

month before joining the program and 37 visits after• Their hospital bills averaged $1.2 million per month

before and just over $0.5million after• Does not take into account personnel costs, or the costs of

the medications the patients are now taking as prescribed.

Medical Homes

 Patients have long-term partnerships with clinicians, not a series of sporadic, hurried visits.

 Clinician-led teams coordinate care, especially for prevention and chronic conditions.

 Medical homes coordinate other clinicians’ care and community supports, as needed.

 Medical homes offer enhanced access through expanded hours and online communication.

 They promote shared decisions, so patients make informed choices and get better results.

 Medical homes coordinate care and improve quality but do not deny care.

Rx: Medical Homes?

Not the answer

• PACCI –Utilization did not significantly differ between pilot and comparison sites.

• Total costs also did not significantly differ between the groups.

Part of the answer

• PACCI based on outdated NCQA PCMH standards

• Contradicts several other studies that have shown improvement in cost, quality, access and patient experience.

Family Worry Budgets

Social determinants of health

The circumstances in which people are born, grow up, live, work, play, and age, as well as the systems designed to improve health and treat illness – have a significant impact on the health and well-being of individuals and communities.

WHY DO I NEED A LAWYER?This sounds like social work to me…

What is a MLP?

A medical-legal partnership addresses the multiple needs of low-income patients

Make individual and systemic changes to switch legal and medical care to a preventive model

The MLP Mission

To build a better healthcare team that can identify, address and prevent health-harming legal needs for patients, clinics and populations.

Legal Aid in IL

• 1 legal aid lawyer for every 4,752 legal problems faced by low-income Illinoisans in 2006• 2,080 work hours in a year

Legal aid attorneys are facing the same resource issues as medical providers.

JDs and MDs share goals

• Prevention and early intervention maximize benefits • Improve systems for clients/patients• Provide direct services as efficiently as possible

UTILITIES SHUT-OFFSA Case Study In MLP Advocacy at

UVA Medical Center

NICU Multi-disciplinary rounds

• John is a former 26 week preemie, and is ready to be released after a 14 week stay in the NICU

• His temperature stability is improving, and he will be going home with an apnea monitor

• John’s parents have been out of work while staying at the Ronald McDonald House

• The electricity will be disconnected for lack of payment

Options considered

• Local charities• Referral for LIHEAP• Keeping John in the NICU to watch for

apnea improvement• Ask utility company for payment plan

Public Utilities Access

• States regulate public utilities

• The Low-Income Home Energy Assistance Program (LIHEAP) is a federally-funded program that helps low-income households pay their home heating and cooling bills.

• Most states protect consumers from utilities shut-off seasonally and for at-risk individuals

• Utilities access impacts ability to regulate medicines, temperature

Virginia MLP Meeting

PCPs did see lack of utilities shut off as a problem

Goal: Utilities Shut-Off law

Building the dream team

•Statewide effort•Law and Medical Students•Physicians and Attorneys•Lobbyists

Student Roles

Law Students

• Research other state laws• Learn who in Virginia

regulates utilities• Draft potential new

law

Medical Students

• Gather compelling real-life stories • Survey patients in

waiting rooms about utilities problems

Selling the Idea

• Met with the statewide poverty law lobbyists• Learned we had only needed a few key

legislators on board• Told consumer advocates had failed to get

these protections for years.

Where does the buck stop?

Legislature

Committee Chairs

State Corporation Commission

Stakeholders

Power Company

Virginia’s shutoff policy

• An electric utility, or public utility providing water service shall, upon request from a residential customer who has a Serious Medical Condition Certification Form filed with the utility, delay termination of service for a minimum of 30 calendar days beyond the expiration of the disconnect notice.

• Service termination will be delayed for 10 calendar days pending receipt of the Serious Medical Condition Certification Form.

• Permits two delays in a 12-month period. The 30-calendar day delays may be consecutive.

Next steps

• Adding shut-off protections based on seasonal dates• Standardize seasonal shut-off

protections across the state• Advocacy coming from “not the usual

suspects”

BREASTFEEDINGChanging the Culture

Initiatives

•Business Case for Breastfeeding•Baby-friendly hospital designation

in one Virginia hospital•Donor Banked Milk for Preemies

Barriers

• Pump cost• Time to pump on the job• Cost of donor milk• The Golden Hour for NICU moms• Lactation support

Pump availability options

Hospital grade

• Added hospital grade pumps to rental equipment when entering a new preferred rental contract

• Pumps available via charity care

• Increase # of WIC pumps

Home Use

• Change Medicaid/WIC rules to distribute pumps

Time to pump at work

Stick

• PPACA amended FLSA (Fair Labor Standards Act)

• Requires employers to provide reasonable time and place to pump.

Carrot

• Business Case for Breastfeeding

Golden Hour

• Educating L&D nurses on importance of the Golden Hour for future milk supply• Getting NICU moms pumping within

that hour to boost milk supply

Lactation Support

• Breastfeeding Medicine Department created• Lactation consultants visit with every new

mother after delivery. • NICU provides support to families on a variety

of breastfeeding issues unique to NICU babies.• Follow-up phone calls to all breastfeeding moms

for ongoing support.• Services are offered seven days a week.

Next steps

• EPSDT argument for donor milk• Finding the best test case•Will private insurance pay?

SSI AND EMRBreaking the Red Tape Barrier

SSI &

Medicaid

Better Housing

Health Insurance

Prescription DrugsBetter Food

Transportation to MD visits

SSI and Patient Compliance

Frustrations

• Average 18 month wait for SSI•Multiple requests for documents from

SSA to physicians• Patients often give up• Time consuming cases for legal aid-

limited capacity to accept appeal cases

Medical school, internship, residency, fellowship… I’ve been a pediatrician for 15 years. I know what a disabled child looks like.

Solutions

• Pediatric Grand Rounds on SSI Rules• Translate SSA regulations• Create form letters to show providers

what SSA is looking for them to provide• Harness power of new EMR system

by adding form letters

• A medically determinable physical or mental impairment or combination of impairments that causes

• marked and severe functional limitations, and that can be

• expected to cause death or that has lasted or can be expected to last for a continuous period of not less than 12 months.

SSA defines Childhood Disability

On date, Name had a FEV1 of ____ (must be equal to or less than the value specified in Table I). Name’s height (without shoes) was xx centimeters on that date.

On 9/26/2010, Jose had a FEV1 of .65. Jose’s height (without shoes) was 128 centimeters on that date.

Asthma – Option A

Cognition/communication:• Ability to retain and recall information._mild or no limit  _moderately limited  _seriously limited  _extremely limited

• Ability to solve problems through intuition, perception, verbal or nonverbal reasoning.

_mild or no limit  _moderately limited  _seriously limited  _extremely limited

Limitations Checklists

Next steps

• Evaluate difference in time from application to SSI approval in patients with/without MLP assistance• Track time required by medical and legal

attorneys

CONCLUSIONSHow to meet the health care reform challenges?

3 take-aways

• Health care reform requires addressing the social determinants of health• Building the right health care team will

improve the efficacy of the Patient Centered Medical Home• Medical providers need advocacy skills

to successfully treat patients

Building the Right Team

• Primary Care Provider• Nurses• Specialist Medical Providers• Social Workers• Attorneys

Goals of Doctor Advocacy

• Access appropriate services for patient

•Minimize time needed for advocacy

• Develop good relationships with community partners

Physician Advocacy

Anyone who can learn the Krebs cycle can learn how to be a child advocate.

-Dr. Jerome Paulsen