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Blog Posts from 2014

Welcome to the blog for Health & Medicine. We're a 33-year old 501c3 nonprofit that operates as an independent, freestanding center driven by a singular mission: formulating health policy, advocacy and health systems to enhance the health of the public.

2014

Dec 23, 2014 Written By: Sharon Post

Quality Matters: Risk Adjustment

At the November 2014 Illinois Medicaid Advisory Committee meeting, the Department of Healthcare and Family Services announced that it had suspended auto-enrollment for three managed care entities. This action has led to increased interest in the technical details of quality measurement and in risk adjustment and stratification in particular. Even within Medicaid beneficiaries, there are variations in clinical severity, race, ethnicity, education level and income. To the extent that these differences affect quality outcomes, they should be factored into measures used to hold Medicaid contractors accountable, but never to create double standards for more vulnerable individuals. The space between accountability and double standards is where the dry topic of risk adjustment becomes fraught and contestable.

Within a month of the MAC meeting, Medicare announced penalties against hospitals for healthcare-associated conditions, and concerns were raised that hospitals that served the poorest, sickest, or most remote patients were hit hardest by penalties. Once again, questions arose about how to modify quality measurement calculations to be fair and avoid unintended, harmful  consequences to safety net providers.  As public and private payers expand value-based purchasing, we can expect more calls for adjustments to quality measurements to account for differences in patient characteristics.

Quality measurement is crucial to guiding health policy decisions. It depends on accurate, timely data and careful validation of the calculation and use of each measure. While we depend on researchers with technical expertise to develop measures, collect and evaluate data, and interpret the results, anyone who has a stake in the health care system has an interest in getting quality measurement right. As an organization with such a stake in health reform, and without claiming deep technical expertise, we offer this policy brief on risk adjustment of quality measures, the first in a series on health care quality measurement.

The series of policy briefs will examine particular issues in quality measurement and their policy implications. While we believe firmly that measurement matters and that good data should drive policy decisions, we also understand that building evidence-bases and perfecting data analysis rarely rise to the same level of urgency as other topics, like securing revenue to fund Medicaid services and protecting enrollees from barriers to necessary care. With that in mind we aim to make these papers topical and timely, responding to events that arise in the State as they come up.


Dec 19, 2014 Written By: Sharon Post and Bonnie Ewald

Exploring Inequities in Care Transitions

In 2010, 29.9% of African American Medicare beneficiaries in Chicago who were hospitalized were readmitted within 30 days of discharge, more than 50% higher than the national average readmission rate of 19.2%. The stark disparity in this statistic led our Health & Medicine Center for Long-Term Care Reform team to dig deeper on readmissions-related statistics and learn about any best practices to address the gaps that could lead to such a disparity. We are pleased to share our findings in a new report, “Addressing Inequities in Care Transitions.” What follows here is a brief explanation of our approach to this investigation, and a report of our findings.

As ACA  implementation proceeds, 30-day readmission rates have been getting a lot of press due to the Medicare reimbursement penalties levied on hospitals  that have high readmission rates. We have also seen more attention to critiques of the use of the readmission rates as a quality metric. The Center for Long-Term Care Reform has been watching the debate over readmission rates with interest because, since 2008, Health & Medicine has partnered closely with some Illinois hospitals and community agencies on the Bridge Model of transitional care. The Bridge Model aims to improve the experience for older adults and their caregivers when leaving the hospital and going home – which includes trying to prevent readmissions. Transitions from one care setting to another present a lot of challenges for the patient, their caregiver(s), their family and friends, and the system. People can fall through the cracks at any number of junctures. For that reason, it is very important to be aware of trends that suggest who may be more likely to experience a difficult transition, and to develop ways to improve the system so they do not experience unnecessary, disruptive hospital readmissions.

We have learned from direct experience with Bridge that many things impact whether an older adult is readmitted to the hospital; some reasons are medical in nature, while others are related to psychosocial, community, or environmental issues – and in any given readmission case, it is likely that more than one of these factors was at play. When conducting our research for this report, we found that the literature confirms this list of influences.

Our report highlights many of the socioeconomic correlations in readmission rates. Patient characteristics such as race and income have been shown in study after study to be correlated with differential readmission rates. (Spoiler alert: being African American or low-income means you have a higher risk of readmission.)

On top of patient-level characteristics, the setting in which patients receive care has also been shown to impact readmission rates. We looked at readmission penalties of Chicago-area hospitals, and found that hospitals serving a majority of African Americans as their patient population were more likely to have a higher readmission rate. Other hospital characteristics, such as being public or having low nurse staffing levels, were also correlated with higher readmission rates.

Finally, in recognition that many things impact one’s health beyond one’s own characteristics or those of the place where one receives care, we looked at readmission rates in connection with community statistics. Not surprisingly, living in an area with low median income increases readmission risk. One study stated that the readmission risk associated with living within the most disadvantaged neighborhoods was similar to that of having chronic pulmonary disease.

These sobering trends deserve to be highlighted and addressed. Because the disparities in readmission rates are inextricably linked to socioeconomic status, we opt to use language of inequities. (The CDC says that the difference, or “disparity,” in rates becomes an “inequity” if it can be tied to “differences in social, economic, environmental or healthcare resources.”)

While the literature clearly shows inequities in readmission rates, it is severely lacking in evidence showing ways to mitigate these very inequities. Because of this, we decided to look more broadly at types of interventions that have been shown to reduce disparities in a variety of health-related metrics. We summarize these approaches in the report, and analyze these lessons for how they might translate to transitional care and the Bridge Model specifically.

This lack of evidence regarding mitigating strategies mirrors challenges that we have had in our work with the Bridge Model: while Bridge has shown success in reducing readmissions among those the model works directly with, we have had challenges in teasing apart Bridge impact data in regard to race or class. Moreover, the setting of care and the community one lives in are critical in supporting individuals and preventing readmissions, so a singular intervention like Bridge may not be adequate to reduce the inequities we see in the numbers. Therefore, we highlight certain policy approaches that hold promise but need testing.

To highlight some data found in this report, and more broadly on trends in hospitalization rates in general, Bonnie Ewald of Health & Medicine will be speaking at the American Society of Aging’s 2015 Aging in America conference on trends and inequities in hospitalization patterns. Health & Medicine looks forward to continuing to investigate the factors that impact one’s ability to transition home safely from the hospital, and we hope that you will reach out to us with any questions, comments, or ideas for future work.

Contact us:
Sharon Post: Director, Center for Long-term Care Reform, spost@hmprg.org
Bonnie Ewald: Program Coordinator, the Center for Long-term Care Reform and Bridge Model National Office, bewald@hmprg.org

Read the report below, or click here to download. You may also down-load a one page summary here.

Dec 09, 2014 Written By: Health & Medicine Policy Research Group (HMPRG)

Health & Medicine at APHA

In November, members of the Health & Medicine staff and board joined health professionals from across the nation for the American Public Health Association’s (APHA) Annual Meeting & Exposition. This year’s conference was held in New Orleans and centered on the theme Healthography: How where you live affects your health and well-being. The conference was an invaluable opportunity for our staff and other public health professionals convene, learn, network and engage with peers.

Each year, after the conference, the Health & Medicine community comes together to reflect on what they’ve learned. We’d like to share some of those reflections from our staff and board so you can see some of the thoughts and ideas we found to be most memorable.



The Health & Medicine team at APHA: (from left to right) Bonnie Ewald, Erica Martinez, Wesley Epplin, Margie Schaps, and intern Renee Dubois.

Margie Schaps, Executive Director
For me, the most powerful session I attended at the 2014 APHA convention was titled Counting to Make People Count for Health Equity.  The session began with a discussion of the 2020 US census and conversations around the country about how to make the census and other population surveys reflect the reality of the US population. 

Counting all people can have profound implications for political representation and resource allocation.  These data affect our understanding of population distributions of health, disease, and well-being in ways that can promote health equity or worsen inequity.  A couple of interesting areas explored included the huge numbers of unauthorized Latino immigrants who came to the gulf coast after Hurricane Katrina to help rebuild and how difficult it is to count these people because of their mobility and their desire to remain unobserved.  These people are especially vulnerable to wage theft (in which their employers deny them earned wages) and crime victimization, especially street robbery, on-the-job injuries and lack of access to health care. Finally Becky Pettit from the University of Washington gave a powerful talk about the fact that most national surveys do not account for prison inmates, resulting in a misrepresentation of US political, economic and social conditions in general and black progress in particular.

Joseph Zanoni, PhD, Health & Medicine Board Secretary
The Occupational Health and Safety Section celebrated our 100 anniversary with looking back to the past and taking action for the future. We created a resolution on addressing the needs of temporary workers that was approved by APHA. Historian David Rosner offered a moving talk on efforts to address recognized hazards such as silica and lead and stated that we need to be able to define and express the collective narrative about workers and their health.  Linda Rae Murray, a fellow Health & Medicine Board member and former president of APHA, provided a moving response calling us to action given the high stakes for our families' health and that of the planet.

Bonnie Ewald, Program Coordinator
This was my first time attending APHA, and it was a very inspiring experience. It was great to be surrounded by folks with a belief in the systemic approach to improving health, and to hear about the wide range of academic work and program development that is happening around the country and the world.

In much of my work at Health & Medicine, I work on “transitional care”, by which we mean intensive support and care coordination, typically for older adults who are leaving the hospital and transitioning back into the community. There was one session at the conference focusing on care transitions, which I happily attended and saw some familiar faces at. Two of the speakers at the session were focused on transitional care as I described before. However, I was pleasantly surprised that the other two speakers were talking about care transitions in a completely different sense. One spoke of the transition that occurs when a young adult moves from seeing a pediatrician to seeing a family practice or internist as his/her primary care provider, and the other focused on the transition that occurs when a woman becomes pregnant and transfers from her primary care provider to her midwife or OB/GYN for prenatal care and labor and delivery care, and then back to her primary care provider after her post-partum follow-up is done.

In each of these cases, the speakers stressed the importance of collaboration and open communication among patient and providers in order to ensure vital information was not lost, and they each showed evidence that long gaps in the time it takes for a patient to connect with the new provider after a transition can be problematic and dangerous. Attending the session was very helpful in broadening my understanding of why transitions in general are a challenging time that the health system should be focused on.

Wesley Epplin, Policy Analyst
During a breakfast one morning during APHA, a student at the University of Illinois at Chicago School of Public Health shared her thought that every session ought to include a community activist, organizer, or other community partner.  Her conviction was strong on this point and it made me reimagine a conference at which, by design, most every session directly included the voices from communities who are impacted by public health problems and intervention, and those who are seeking to address health inequities within their own communities. 

Many APHA conference sessions already have such community partners included, and a great many researchers and practitioners engage in community-based or community-engaged participatory research.  Still, for me, I cannot help but imagine the potential positive ripple effects—of APHA making it a goal to consistently increase the number of sessions that directly include community voices—on learning, research, and practice.  This change could significantly influence the field to be even more deliberate about forming more equitable, long-standing, and authentic partnerships with communities our field seeks to help, which may help build more trust and power equity, both necessary for health equity. 

A couple of questions come to mind regarding prioritizing this type of change for future conferences: 1) Does/Should the process of reviewing abstracts provide scoring for whether or not community partners are involved (and thus encourage such partnerships)? 2) Do we allow enough spaces for free or reduced conference fees, and travel/lodging awards to make it affordable for community partners to attend?

Erica Martinez, Policy Analyst
The “Public Health Care – Post-Katrina” tour (organized by Spirit of 1848/Praxis Project APHA radical history) was the most impactful experience for me during this year’s APHA conference. On the tour we learned more about the closing of Charity Hospital, the city’s public hospital, and what that meant for the most vulnerable in New Orleans.  After Hurricane Katrina, Charity Hospital did not re-open. This meant the Safety Net Hospital for the city was stripped away—it wasn’t simply that health care access was inadequate, it actually didn’t exist anymore. Those who needed care had nowhere to go, the place many people knew as their medical home was closed. Standing outside the massive, empty art deco building that had over 500 beds, provided me with a greater appreciation for the Cook County Health and  Hospital System which continues to be the safety net hospital for many underserved communities .

Nov 25, 2014 Written By: Health & Medicine Policy Research Group (HMPRG)

Advocates Letter to Governor-Elect, Bruce Rauner, and Transition Team

Health & Medicine recently took the lead in organizing a sign-on letter to Governor-Elect, Bruce Rauner, and his transition team.  The letter was meant to introduce the Rauner team to health advocates, to share some of our concerns and available expertise, as well as to help start building new relationships between advocates and Illinois’ new administration.  

A great many health reform efforts are ongoing and advocates are committed to remaining engaged with the issues we care about.  Importantly, as the letter notes, health reform must include achievement of the central goal of health equity.

In total, 37 organizations signed on to the letter, which was mailed on November 24, 2014.  Click here to download the letter or read it below.


Oct 24, 2014 Written By: Health & Medicine Policy Research Group (HMPRG)

2014 HMPRG Awards Honor Health Leaders

On October 14, 2014 Health & Medicine welcomed over 100 guests to our 5th HMPRG Awards. The event, held at Chicago’s Prairie Production, celebrated the achievements of our nine inspiring winners representing leaders in the fields of medicine, policy, public health, and advocacy. You can read more about this year’s winners here.



Since their inception in 2006, the HMPRG Awards have recognized 28 individuals and organizations whose work exemplifies Health & Medicine’s mission to promote social justice and challenge inequities in health and health care. The award categories –Health, Medicine, Policy, Research, and Group–reflect key prongs of Health & Medicine’s work and policy research efforts. In addition to honoring established health professionals, the awards also recognize an “emerging leader” under 30 and a “young activist” between the ages of 16 and 20.

This year’s event paid special tribute to a past award winner, Steve Whitman, PhD, who passed away this July. The Founder of the Sinai Urban Health Institute, Dr. Whitman was a true warrior in the quest for social justice whose tireless scientific, policy and political contributions have made a lasting impact in Chicago and beyond. In 2007, when we decided to begin giving awards to health leaders who shared our vision of health justice, Dr. Whitman was our first “Research” awardee. For our 2014 event, to celebrate Dr. Whitman’s legacy, we renamed our Research Award in his honor.

As we look back on this year’s event, we’d like to share the tribute to Dr. Whitman which was part of the Awards’ presentation. We look forward to continuing to honor his visionary work in the years to come.

Steve Whitman, PhD was an inspiration to all who believe in challenging health inequities.
 
After earning a PhD in biostatistics from Yale, Dr. Whitman worked from 1978 to 1991 as a senior epidemiologist at Northwestern University where he carried out multi-disciplinary research about epilepsy in the urban environment and supervised the epidemiological aspects of an effort to reduce breast and cervical cancer in poor Black women in Chicago. He also collaborated on a groundbreaking study on the dumping of emergency room patients, which helped end the practice.
 
In 1991, Dr. Whitman joined the Chicago Department of Public Health to direct the epidemiology program. He worked on public health issues such as infant mortality, HIV/AIDS, tuberculosis, lead poisoning, cancer, sexually transmitted diseases, and immunizations. Dr. Whitman was working for the city during the July 1995 heat wave; his work mapping the deaths by neighborhood demonstrated how conditions such as poverty and racial segregation contributed to over 700 deaths that summer.
 
From 2000 until his untimely death in 2014, Dr. Whitman created and led the Sinai Urban Health Institute, a unique research organization housed not in a university but within a critical safety net hospital serving Chicago’s west side. Under his leadership, SUHI conducted evaluations of innovative community health interventions and completed a groundbreaking health survey of the City of Chicago that led to numerous projects to improve the health of vulnerable neighborhoods.  As one of our country’s foremost epidemiologists, he will be remembered in the scientific community for his over 100 publications and over 400 presentations on public health topics.  
 
At Health & Medicine, we will also remember Steve for his tireless and passionate work using data to confront racism, social injustices and health inequities in all forms.  A true radical, Steve drew inspiration from revolutionaries across the globe; in describing the interconnectedness of the fights for human rights he often quoted the Puerto Rican poet Consuelo Lee Corretjer who urged a philosophy of “Live and help to live."  Steve challenged his friends and colleagues to be fearless and outspoken in the cause of justice, and in naming our HMPRG Whitman Research Award in his honor, we hope to preserve his rich legacy of robust science and lifelong activism.


Oct 10, 2014 Written By: Guest Author

Delivering Better Outcomes: Midwives in Illinois

We’re pleased to share a guest post this week, from Health & Medicine Board Member Gayle Riedmann, CNM. In addition to her work at Health & Medicine, Ms. Riedmann is a midwife at West Suburban Midwife Associates in Oak Park.

An interesting article from the Huffington Post this week notes the shortage of maternity care providers in the U.S.  Yet only 11% of U.S. births are attended by midwives.

In Illinois, there are just under 300 Certified Nurse Midwives (CNMs) licensed to practice, most of whom are in the greater Chicago area.  The number of births attended by Illinois certified nurse midwives is about half of the national average.  Almost 99% of Illinois births occur in the hospital, the remaining 1% at home.  

Alternate choices for place of birth—birth centers or home birth—are severely limited in Illinois, contributing to difficulty in accessing maternity services. Limitations and restrictions of midwifery practice also contribute to the problems in provision of maternity services. Here are three of the main issues we face:
  1. It took 25 years to pass legislation establishing freestanding birth centers in Illinois, and there is still only one birth center on target to open in 2014. Birth centers are ideal for safe, accessible, quality care for women throughout Illinois. Illinois needs more birth centers in maternity service shortage areas and rural areas.
  2. Planned home births are legal in Illinois, but the only providers allowed to deliver babies are physicians and certified nurse midwives. Due to a requirement for written collaborative agreement (WCA) with a physician, there are only a few home birth nurse midwifery practices addressing the demand for home birth.  Pregnant women are turned away from the few home birth practices that exist.  Some of these women choose to have unattended home birth, which is unsafe.  We need to remove the WCA requirement for certified nurse midwives (and all advanced practice nurses) to eliminate the obstacles facing CNMs attending out-of-hospital birth.
  3. Certified Professional Midwives (CPMs), who primarily attend home births, are practicing in many other states but are not legally allowed to practice in Illinois. This further restricts access and choice for women across the state. CPMs have been trying to gain legislative approval to practice in Illinois for over 20 years. We need to recognize the safe practice and value of CPMs and pass the necessary legislation to allow this practice in Illinois.
The advice I often give to my pregnant patients when they are unsure about midwives, natural birth, place of birth, and the safety is this: "When in doubt, think globally and think historically."

First, the global perspective:
  • Midwives attend 90% of births outside of the U.S.  
  • Home birth and birth centers are commonly accepted alternatives to hospital birth in most countries.  
  • Cesarean section rates and infant mortality rates are lower in other countries.  That is the global perspective.  
Conclusion: We need more midwife-attended births in the U.S., and particularly in my home state, Illinois. And we need more birth centers and home birth options.

For the historic perspective…I like to recall the reading from a very popular source: Exodus 1:16-20.
The king of Egypt said to the Hebrew midwives, whose names were Shiphrah and Puah, 16 "When you help the Hebrew women in childbirth and observe them on the delivery stool, if it is a boy, kill him; but if it is a girl, let her live." 17 The midwives, however, feared God and did not do what the king of Egypt had told them to do; they let the boys live.18 Then the king of Egypt summoned the midwives and asked them, "Why have you done this? Why have you let the boys live?"19 The midwives answered Pharaoh, "Hebrew women are not like Egyptian women; they are vigorous and give birth before the midwives arrive."20 So God was kind to the midwives and the people increased and became even more numerous.21 And because the midwives feared God, he gave them families of their own.

Conclusion:  Midwives have been attending births since the beginning of time… lets bring them back in great numbers to practice at their fullest capacity and scope.

Happy National Midwifery Week!
Oct 03, 2014 Written By: Health & Medicine Policy Research Group (HMPRG)

What We’re Reading - October 3, 2014

A rundown of the articles and stories that caught our eye this week:

Fighting to Honor a Father’s Last Wish: To Die at Home
“…she was determined to fulfill her father’s dearest wish, the wish so common among frail, elderly people: to die at home. But it seemed as if all the forces of the health care system were against her — hospitals, nursing homes, home health agencies, insurance companies, and the shifting crosscurrents of public health care spending."
The New York Times, September 25, 2014

Medicare Fines Record Number Of Hospitals For Excessive Readmissions
“Over the next year, 2,610 hospitals will lose some of their payments for each Medicare patient they admit, Medicare records show. This is the third year the industry faces these penalties, which were created by the Affordable Care Act. This year potential fines are the highest: up to 3 percent of Medicare bills."
NPR, October 2, 2014

The Local Perspective: Illinois Hospitals Face Fines Over Readmissions from The Chicago Tribune

Costs Can Go Up Fast When E.R. Is in Network but the Doctors Are Not
“It never occurred to me that the first line of defense, the person you have to see in an in-network emergency room, could be out of the network,” said Ms. Hopper, who has spent months fighting the bill. “In-network means we just get the building? I thought the doctor came with the E.R.”
The New York Times, September 28, 2014

Further Reading: What should the law do about out-of-network ER docs? from The Incidental Economist

Why Do Babies in America Die More Often Than Babies in Other Rich Countries?
"The reasons for the differences aren’t clear. Researchers suggest social circumstances affect both the rate of premature births and infant deaths after the first month of life. Earlier CDC research shows wide disparities (PDF) in infant mortality by race in the U.S.: Black babies are more than twice as likely to die before their first birthdays as white babies. Whites in the U.S. still have higher infant mortality rates than European countries do. Other research points to gaps in wealth that may explain much of the difference."
Bloomberg Business Week, October 1, 2014

More on infant mortality: So why is our infant mortality so bad? from The Incidental Economist

What Your Education Says About Your Health
"Access to health care alone isn't the great equalizer you might think it is. Analyzing 2011 data among Kaiser Permanente of North California patients, researchers at the Virginia Commonwealth University Center on Society and Health found that even when people have access to the same kind of care, educational achievement still played a huge role in whether people are in good health."
The Washington Post, September 23, 2014

In Protecting the Elderly, California at Last Takes Steps to Catch Up
"Many things about the industry, to which America has entrusted the lives of some 750,000 people, proved to be shocking, not least of all how bad things appeared to be in California. The state's regulatory apparatus, our reporting showed, had deteriorated so drastically that the assisted living industry was actually lobbying the state to police it more aggressively."
ProPublica, October 2, 2014


Sep 17, 2014 Written By: Wesley Epplin and Sharon Post

Fitting Together the Pieces of State Health Reform



A common refrain in health policy circles is that it takes a great deal of effort just to know about and keep track of the “alphabet soup” of health reform. Each sector—primary care, health systems, safety net providers, long-term services and supports, behavioral health, and so on—has its own jargon and acronyms, making communication and collaboration difficult.

Yet the various programs, policies, and initiatives aimed at reform are often overlapping and interconnected, each accelerated at times and constrained at others by Federal, State, and local government regulations and funding opportunities.  All of this is happening within a context of changing needs and demands of patients, providers, and payers.  

Implementation of the Affordable Care Act (ACA), the rollout of a great many concurrent state health initiatives, and the ongoing struggle for adequate resources compete for advocates’ attention. Stakeholder meetings multiply and simply keeping track of the latest developments is a daunting task. All of this has led more than a few among our fellow advocates and colleagues at providers, health plans, and government agencies to express confusion and frustration and highlighted the need for more information about these initiatives.  

In that spirit, Health and Medicine Policy Research Group has prepared a draft report, State Health Reform in Illinois: Fitting the Pieces Together, describing the many reforms rolling out in Illinois.  Our report suggests that advocates engage with each initiative as part of a comprehensive whole, rather than seeing them as stand-alone reforms.

Is something missing?  
This report is currently in a draft form, and we know that our project is impossible without considerable partnership and mutual support among advocates and stakeholders.  We eagerly encourage your feedback and comments, and will happily revise it if there is interest in maintaining it as a resource going forward.

Some areas for which we are already aware of missing pieces and welcome others to share their expertise and experience include:
  • Challenges and opportunities facing Illinois Health Information Exchange (ILHIE) and more detail on how ILHIE projects connect to many other reform initiatives, as well as the role of improvements to the Medicaid Management Information System (MMIS)
  • How providers and health plans will delivery recovery-oriented mental health services within a reformed system, from short-term and longer-term perspectives
  • How the enormous need for housing assistance will be managed
  • The role of Medicaid rate reform for hospitals and nursing homes in the overall reform project
  • The role of Medicare and commercial Accountable Care Organizations in overall delivery system reform
  • Relevant oversight groups and websites for stakeholders to be involved and engaged in these different initiatives
  • Additional initiatives focused on public health and community health improvement, including Community Health Needs Assessments (CHNAs) and formation of Regional Health Improvement Collaboratives (RHICs)
  • Making sure that the expertise and services offered by smaller community based programs are included in new models of care when appropriate (e.g. domestic violence providers, school based health services)

Please email your comments to Sharon Post and Wesley Epplin or call: 312-372-4292.

Related to this, check out these two blog posts from earlier this year:
Sep 05, 2014 Written By: Health & Medicine Policy Research Group (HMPRG)

Videos of Keynotes from Education and Health Equity: Everybody In, Nobody Out

Health & Medicine hosted a forum, Education and Health Equity: Everybody In, Nobody Out at Malcolm X College on August 14, 2014.  Below are three videos from the keynote presentations, which include an introduction of the forum by Jesús "Chuy" García, Cook County Commissioner and the keynote presentations by Karen Lewis, President of the Chicago Teachers Union and Dr. Linda Rae Murray, Chief Medical Officer, Cook County Department of Public Health (and Health & Medicine board member). 

Approximately 200 people attended the forum, which focused on the inextricable links between education and health.  The three speeches below provide valuable perspectives focused on the theme of equity in both education and health and from three great leaders and speakers in their respective fields.  We are excited to be able to share these excellent speeches!







Learn More:

To learn more about Health & Medicine’s perspective on the importance of education to making progress on the social determinants of health, you can read our recent blog post, Money, Power, and Resources: The Struggle for Health and Education Justice published in advance of the forum.  Also, members of Health & Medicine’s staff and the forum planning committee developed this reading list, a selection of readings that were influential in developing the forum

We think that these resources provide a valuable starting point for anyone interested in investigating how having an equitable system of public education and achieving health equity are both part of a common struggle for social justice.

To connect with us and stay informed about our upcoming forums and events, please join our mailing list.

Aug 29, 2014 Written By: Health & Medicine Policy Research Group (HMPRG)

What We're Reading - August 29th, 2014

A rundown of the articles and stories that caught our eye this week:

Medicare Star Ratings Allow Nursing Homes to Game the System
“The Medicare ratings, which have become the gold standard across the industry, are based in large part on self-reported data by the nursing homes that the government does not verify. Only one of the three criteria used to determine the star ratings — the results of annual health inspections — relies on assessments from independent reviewers. The other measures — staff levels and quality statistics — are reported by the nursing homes and accepted by Medicare, with limited exceptions, at face value.”
The New York Times, August 24, 2014

Two neighboring states, one big financial gap: Illinois struggles with debt while Indiana sits pretty with a surplus
"'We do have $2 billion in the bank and we are in a much better position in Indiana than they are fiscally in Illinois, but at the same time, I think Illinois streets might be in better shape than our streets right now,’ McDermott said. ‘I think Illinois is providing better services during crisis than we are because they have more tools available. It cuts both ways.’ McDermott’s point is this: What’s the use of a surplus if some basic services aren’t being met?'"
Curios City via WBEZ, August 27, 2014

Baby’s Drug Co-Pay Jumps, and a Health Reporter Is Stumped

“It’s not easy being an educated health care consumer.

I was reminded of this when I went to refill a prescription this month for an asthma and allergy medication for my 9-month-old son, Holden. The first time I filled his prescription for Montelukast granules — the generic version of Singulair from Merck — my insurance co-payment was $15. A month later, the co-payment had risen to $30 (and my insurance was paying $85.94, rather than $118.53). Why?"
The Upshot via The New York Times, August 29, 2014

40 Percent of Restaurant Workers Live in Near-Poverty
“The industry's wages have stagnated at an extremely low level. Restaurant workers' median wage stands at $10 per hour, tips included—and hasn't budged, in inflation-adjusted terms, since 2000. For nonrestaurant US workers, the median hourly wage is $18. That means the median restaurant worker makes 44 percent less than other workers. Benefits are also rare—just 14.4 percent of restaurant workers have employer-sponsored health insurance and 8.4 percent have pensions, vs. 48.7 percent and 41.8 percent, respectively, for other workers.”
Mother Jones, August 27, 2014

More on the wage gap: A Look at Income Inequality, Hour by Hour from The Wall Street Journal

Long Read: Thousands with Mental Illness End Up Homeless, but there are Approaches that can Help Out
"More than 124,000 – or one-fifth – of the 610,000 homeless people across the USA suffer from a severe mental illness, according to the U.S. Department of Housing and Urban Development. They're gripped by schizophrenia, bipolar disorder or severe depression — all manageable with the right medication and counseling but debilitating if left untreated. In the absence of such care, their plight costs the federal government millions of dollars a year in housing and services and prolongs their disorders."
USA Today


Aug 22, 2014 Written By: Bonnie Ewald

Care Connections: How Providers and Advocates in Chicago are using the ACA to Improve Health

Those of us working on health systems transformation understand that for change to occur we need to reevaluate every aspect of how we provide care – from how we train future practitioners, to how and where we treat patients, to how that treatment is funded. A recent article in the Chicago Tribune (8/10/14) spotlights a number of Chicago-area projects—several with Health & Medicine connections—that are transforming health in our community through the Affordable Care Act (ACA).  

The article addresses one important aspect of the ACA: real world research that tests new approaches and payment structures to figure out how to best serve certain populations. These initiatives include the Person-Centered Outcomes Research Institute (PCORI), which funds comparative effectiveness research projects and places a great emphasis on engaging consumers themselves throughout the research process. Other demonstration projects are housed in the Center for Medicare and Medicaid Innovation – initiatives such as the Community-based Care Transitions Program, which tests ways that community-based organizations can partner with hospitals to help discharged patients get settled safely in the community and not readmit to the hospital.
 
The  Tribune article highlights a couple of Chicago-area projects utilizing this funding. One of the highlighted projects is taking place at the University of Chicago’s Center for Health and the Social Sciences. Led by Dr. David Meltzer, this project tests a model called the Comprehensive Care Program, where multidisciplinary teams led by a “comprehensive care physician” care for patients in both outpatient and inpatient settings. These comprehensive care physicians have a lower caseload of patients, enabling them to visit those patients in the hospital if they happen to be hospitalized. This is a shift from care as usual, where oftentimes the primary care provider is not even aware that his/her patient had to be hospitalized. However, the patients they are working with are at high risk for hospitalization. Dr. Meltzer and his team are exploring a number of strategies to better meet the needs of community members, including performing home visits.



Comprehensive care "is not just about prescribing medication and ordering tests," Dr. Krishnamoorthi, a member of the Comprehensive Care Program team, said in the article. "It's about the very practical problems of making sure people can get to their appointments. Do they understand what's happening at the appointment? Do they have behavioral problems or cognitive issues? Are they homebound? Do they have to take three buses in a dangerous community? All these issues affect medical care."

Dr. Meltzer's work also has a Health & Medicine connection. In May 2014, he and his team decided to become trained in the Bridge Model of transitional care, which Health & Medicine, in collaboration with other stakeholders, helped develop. While the Bridge Model focuses on supporting older adults and their caregivers during a transition from one care setting to another (say, from the hospital to home), its structured approach to incorporating psychosocial aspects into healthcare can be applied to primary care. Dr. Meltzer’s team recognizes the need to not just address patients’ medical needs, but to also focus on things like their goals, what their social life is like, and what environmental factors might be impacting them; in addition to the comprehensive care physician, a social worker also plays an important part in their care team.

In a neat twist that shows just how interconnected the world of activists and providers working to create a more just and functional health system is, Dr. Krishnamoorthi is also the alumni of one of Health & Medicine’s longstanding Chicago Area Schweitzer Fellows Program. The Schweitzer Fellows program supports graduate students as they design and implement service projects, with the aim that they will become leaders in service and will continue to work to reduce health inequities in their future. Dr. Krishnamoorthi was a Schweitzer Fellow in 2001-2002, during his time as a joint medical and public health student at Northwestern University. Completing his residency in internal medicine at Loyola University, Dr. Krishnamoorthi is now working with individuals at high risk for hospitalization as a member of the Comprehensive Care Program team at the University of Chicago.

The Center for Medicare and Medicaid Innovation has a number of exciting projects like this around the country that are testing ways to provide better care to those who need it, while also aiming to reduce overall costs. For our part, we’ll keep looking for innovative ways to improve care in Illinois—from the Schweitzer Program, to the Bridge Model, to our health policy research. And we’re excited to see how these efforts will continue to impact healthcare on the ground through the work of people like Dr. Meltzer and Dr. Krishnamoorthi and the many other providers, students, and community members impacted by these projects.

Aug 08, 2014 Written By: Health & Medicine Policy Research Group (HMPRG)

What We’re Reading – Education and Health Edition

As we prepare for our Education and Health Equity: Everybody in Nobody Out forum next week we'd like to share some articles and reports that have helped us better understand the intersection of education and community health.

We've included some highlights below, and you can click hear to view the full reading list. Also, be sure to check out our recent blog post, Money, Power, and Resources: The Struggle for Health and Education Justice. If you’re interested in learning more, we hope you’ll join us for the forum!


The Schools Chicago’s Students Deserve: Research-based Proposals to Strengthen Elementary and Secondary Education In the Chicago Public Schools

“Every student in Chicago Public Schools (CPS) deserves to have the same quality education as the children of the wealthy. This can happen, but only if decision-makers commit to providing research-based education that is fully-funded and staffed in an equitable fashion throughout the city.”
Chicago Teachers Union, February 2012

Death By A Thousand Cuts: Racism, School Closures, and Public School Sabotage
“Closing a school is one of the most traumatic things that can happen to a community; it strikes at the very core of community culture, history, and identity, and… produces far-reaching repercussions that negatively affect every aspect of community life. It has been nothing short of devastating to the health and development of many of our children and youth, has put a strain on our families, has contributed to the destabilization and deterioration of our communities, has undermined many good schools and effective school improvement efforts, has destroyed relationships with quality educators, and has contributed to increased community violence.”
Journey For Justice Alliance, May 2014

Educational Attainment as a Social Determinant of Health
“Unfortunately, our system of mass public education does not work equally well for everyone. Those with poor academic performance are likely to have lower educational attainment. This in turn decreases upward mobility and affects a person’s health status.”
North Carolina Medical Journal, October 12, 2012

Differences In Life Expectancy Due To Race And Educational Differences Are Widening, And Many May Not Catch Up
“We found that in 2008 US adult men and women with fewer than twelve years of education had life expectancies not much better than those of all adults in the 1950s and 1960s. When race and education are combined, the disparity is even more striking.”
Health Affairs, August 2012

Jul 30, 2014 Written By: Wesley Epplin

Money, Power, and Resources: The Struggle for Health and Education Justice

This year marks the 60th anniversary of the landmark Brown v. Board of Education decision, providing an important opportunity to take stock of the status of public education in the United States, the progress we’ve made, and the enduring challenges we face.  

Health and Medicine Policy Research Group (Health & Medicine) recognizes the vital importance of education and educational attainment to improved health status and outcomes.  Joining education professionals in calling for guaranteed access to high-quality, equitable education fits squarely within our mission of promoting social justice and challenging inequities in health and health care.

To engage local health and education professionals on this topic, Health & Medicine will host a forum, the first of its kind in Chicago, entitled Education and Health Equity: Everybody In, Nobody Out, on August 14, 2014, examining the intersection of health and education.  This forum represents a unique opportunity to examine the reciprocal relationship between these two areas: just as education is closely linked to health status, people’s health, well-being, and socioeconomic position are linked to their ability to further their education.  

This event comes at a critical moment for public education in our country and in our state. Recent research has documented that in 2008, “US adult men and women with fewer than twelve years of education had life expectancies not much better than those of all adults in the 1950s and 1960s.”1  The Centers for Disease Control and Prevention (CDC) have prioritized both education and the social determinants of health within its Healthy People 2020 objectives.  One of the overarching goals in this national health agenda is achieving health equity, eliminating disparities, and improving the health of all groups.2 Yet, as the Robert Wood Johnson Foundation points out, “the United States is the only industrialized nation where young people are less likely than members of their parents’ generation to graduate from high school.” 3

Education in Illinois
These facts are playing out in a particularly dangerous way in Illinois.  According to the Center for Tax and Budget Accountability, despite having the 15th highest per capita income among the States, Illinois ranks 40th in the US in per-capita education spending (based on data from the National Association of State Budget Officers).  Illinois funds public K-12 education below even the recommendations of the State’s own Education Funding Advisory Board. 4

Since 2001, Chicago Public Schools (CPS) has closed, “phased-out”, “turned around”, and consolidated 159 schools, drawing the ire of impacted students, teachers, community members, and advocates (more on that below).   Furthermore, CPS’ closure of 49 elementary schools and one high school in May 2013 further threatens Chicagoans with the problems of inequitable access to high-quality education and concomitant unfairly distributed socioeconomic and health status and outcomes.

Further reductions in state funding for school and other vital public services are likely as Illinois is scheduled for its current flat income tax of 5% to recede to 3.75% in January of 2015.  Legislative efforts for a fair tax in Illinois could provide needed revenue to adequately fund education, public health, Medicaid, public safety, and infrastructure, all of which contribute to the public’s health.

At this juncture, we must ask ourselves, what role can and should health professionals play in promoting health through advancing equitable educational access? Crucial as safe routes to school policies, healthy vending, school lunch, physical education, sex education, nursing, and counseling are to health, so is advocacy for the fundamental human right of all children to access high-quality education.

When large numbers of schools are being closed, what are the community health impacts?  How can public health practitioners support the communities, schools, families, children, and educators whose objections have often gone unheeded? These questions deserve answers, and, as the decisions impact community health, a response from those tasked with improving public health—informed by impacted communities, educators, and history—to the divestment from and dismantling of public education infrastructure, is warranted. 

Education as a Social Determinant of Health
The Centers for Disease Control and Prevention (CDC) uses the following definition for the social determinants of health, which is from the World Health Organizations (WHO) Commission on the Social Determinants of Health, and may be a useful frame for considering equitable, high-quality education as a contributor to health equity:

Social Determinants of Health: The complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities. These social structures and economic systems include the social environment, physical environment, health services, and structural and societal factors. Social determinants of health are shaped by the distribution of money, power, and resources throughout local communities, nations, and the world [emphasis mine].  



For institutions and individuals that have explicitly expressed the importance of making progress on the social determinants of health, a given structure, system, or policy should be judged by the degree to which it promotes or hinders a more equitable distribution of money, power, and resources. The World Health Organization’s (WHO) A Conceptual Framework for the Action on the Social Determinants of Health: Discussion Paper 2 places a strong emphasis on strategies to address context, intersectoral action, social participation, and empowerment. 8

This WHO paper also states:

In this context, human rights embody a demand on the part of the oppressed and marginalized communities for the expression of their collective social power.  The central role of power in the understanding of social pathways and mechanisms means that tackling the social determinants of health inequities is a political process that engages both the agency of disadvantaged communities and the responsibility of the state.

With this framing, we must reconsider the assumptions that underpin our education policy and ask: Is the agency of disadvantaged communities being honored and are the relevant government agencies acting responsibly vis-à-vis public education?  How can our society provide an equitable, high-quality education—a human right—to all students?  Are decision makers paying adequate attention to the vociferous objections and protest from impacted communities against the agenda driving many changes in public education?  

Education “Reform” and Public Outcry
A major, national education “reform” agenda has emphasized a neoliberal approach to our education system. This agenda has led to advocacy for and implementation of significant modifications including increased funding competition among schools through the Federal No Child Left Behind and Race to the Top initiatives, using high-stakes testing to rank schools, and deeming some schools to be “failing” and then “turning around” or closing them. We’ve also witnessed the opening of privately operated—but publicly funded—charter schools that beyond seeking “innovations,” have increasingly been used to privatize public schools.

Across the country, many teachers, students, and community members have countered these changes through negotiation, community meetings, formal complaints, protests, and strikes, such as the Chicago Teacher’s Union 2012 strike, which received national attention.  The ideas and rationales for these changes are discussed and strongly refuted in The Journey for Justice Alliance’s  Death by a Thousand Cuts: Racism, School Closures, and Public School Sabotage.13  

What have been some of the complaints regarding this neoliberal education agenda’s impact on people’s control of education within their own communities, on community health, and on racial justice?  Considering the social determinants of health framework briefly outlined above, what impacts on distributions of money, power, and resources have been observed and can be expected?

The Death by a Thousand Cuts report states:

… All of these changes have been implemented despite widespread and passionate opposition from the affected communities. Time and time again, the extraordinary wealth and power behind these policies have been used to override the will of our communities; to bully our communities into accepting these changes.  Why our communities? Largely because it was perceived that we lacked the political power to withstand such bullying, and that there would be limited public outcry over such dramatic changes within low-income communities of color [emphasis mine].13

On May 13, three civil rights complaints were sent to the Department of Education’s Office of Civil Rights and the Justice Department, challenging that closures in Chicago, Newark, and New Orleans disproportionately impact African American students.

The Chicago complaint, filed by the Advancement Project and accompanied by a letter from the Journey For Justice Alliance and Chicago’s Kenwood Oakland Community Organization, as well as other organizations, stated:

Schools that serve students of color have been the primary target of CPS school actions – of all affected schools between 2001 and 2013, three out of every four of those schools were intensely segregated African-American schools, and 89 percent were of schools serving 98 percent students of color or higher.5

Underscoring the charge of racial discrimination, it also stated:

Even if CPS’s use of school closings, phase-outs, turnarounds, and consolidations is not tantamount to intentional discrimination, CPS is still prohibited from engaging in policies or practices that have the effect of discriminating by race. CPS’s school closure practices cannot survive this disparate impact analysis.5

What about negative impacts on the health and wellbeing of communities? 

The Death by a Thousand Cuts report states:

Closing a school is one of the most traumatic things that can happen to a community; it strikes at the very core of community culture, history, and identity, and… produces far-reaching repercussions that negatively affect every aspect of community life. It has been nothing short of devastating to the health and development of many of our children and youth, has put a strain on our families, has contributed to the destabilization and deterioration of our communities, has undermined many good schools and effective school improvement efforts, has destroyed relationships with quality educators, and has contributed to increased community violence.13

These and countless other objections regarding school closings speak to the very distributions of money, power, and resources emphasized as paramount within the social determinants of health.  For those concerned with achieving health equity—again, an overarching goal set forth within the CDC’s national public health agenda, Healthy People 2020—ensuring that every child has access to an equitable, high-quality education must be on the agenda for health equity.

Intersectoral Collaboration
In order to advance education and health equity, further intersectoral collaboration is needed among health professionals and those working on the ground within our schools, including educators, social workers, counselors, nurses, parents, and students.  Thus far, there have been limited opportunities for these sectors to move beyond their silos regarding the school reforms outlined above, share their knowledge and perspectives, and to chart a course for change. The August 14, 2014 Education and Health Equity: Everybody In, Nobody Out forum will provide one such opportunity.

This forum will include keynote addresses from both Karen Lewis, President of the Chicago Teacher’s Union, and Linda Rae Murray, Chief Medical Officer for the Cook County Department of Public Health (and Health & Medicine Board Member). Several other speakers will address funding, the historical and current policy context related to education, health inequities in Chicago, and perspectives from people who live and work in some of the schools and communities impacted by the dysfunctional education context discussed herein.

Health & Medicine’s Founder and Chairman, Dr. Quentin Young, coined the maxim, “Everybody in, nobody out,” with regard to universal access to high-quality, equitable, and culturally competent healthcare.  We believe that this phrase can be applied to education as well: the health of communities and the wellbeing of our broader society are dependent upon universally accessible, equitable educational opportunity.

Valuing social justice necessitates actions that devalue instances of social injustice. To that end, health professionals can learn from and support the common cause of justice that is shared with educators.  When schools are being defunded and closed down in spite of communities, those of us who are discontented by the current inequitable distribution of money, power, and resources in our society must actively seek opportunities to advocate that community needs become central to education policy and to engage in other such actions for justice.

Registration is open for Health & Medicine’s forum Education and Health Equity: Everybody In, Nobody Out, coming up on August 14!

References:
1 Olshansky, S.J., Antonucci,T., Berkman, L., Binstock, R.H. Boersh-Supan, A.,Cacioppo, J.T. Carnes, B.A., Carstensen, L.L., Fried, L.P., Goldaman, D.P., Jackson, J., Kohli, M., Rother, J., Zheng, Y., and Rowe, J. (2012). Differences in life expectancy due to race and educational differences are widening, and many may not catch up. Health Affairs, 31 (8) 1803--1813
2 Healthy People 2020.  Centers for Disease Control and Prevention (CDC).  U.S. Department of Health and Human Services (HHS). Online. http://www.healthypeople.gov/2020/default.aspx
3 Why Does Education Matter So Much to Health?  Health Policy Snapshot.  Robert Wood Johnson Foundation. March 2013.  Online. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2012/rwjf403347
4 The Illinois State Budget and Tax Primer. Center for Tax and Budget Accountability.  March 2013.  Online. http://www.ctbaonline.org/sites/default/files/reports/ctba.limeredstaging.com/node/add/repository-report/1384883277/R_2013.03_FINAL_FY2013%20CTBA%20IL%20Budget%20and%20Tax%20Primer.pdf
5 Re: Complaint against Chicago Public Schools Under Title IV and Title VI of the Civil Rights Act of 1964. Journey for Justice Alliance.  May 13, 2014. Online. http://b.3cdn.net/advancement/05d51d8dad82f1f1cd_lh1m6sitf.pdf
6 Social Determinants of Health Definitions.  CDC, HHS.  Undated.  Online. http://www.cdc.gov/socialdeterminants/Definitions.html
7 Education and Health.  Issue Brief #5: Exploring the Social Determinants of Health.  Robert Wood Johnson Foundation. April 2011.  Online.  http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf70447
8 Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion Paper 2 (Policy and Practice). Geneva, World Health Organization, 2010.  Online. http://www.who.int/social_determinants/corner/SDHDP2.pdf
9 Nancy Krieger. Epidemiology and The People’s Health: Theory and Context. New York: Oxford University Press, 2011.
10 Why Education Matters to Health: Exploring the Causes.  Virginia Commonwealth University Center on Society and Health.  Robert Wood Johnson Foundation. Online. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf412692
11 Lisa F. Berkman, Ichiro Kawachi, and M. Maria Glymour. Social Epidemiology, Second Edition. 2014. Oxford.
12 Journey for Justice Alliance is an alliance of 36 grassroots community, youth, and parent-led organizations in 21 cities across the country. 
13 Death By A Thousand Cuts: Racism, School Closures, and Public School Sabotage.  Journey For Justice Alliance.  May 2014.  Online. http://www.j4jalliance.com/wp-content/uploads/2014/02/J4JReport-final_05_12_14.pdf


Jul 23, 2014 Written By: Health & Medicine Policy Research Group (HMPRG)

Illinois 1115 Waiver Revisions

The Path to Transformation: Illinois’ 1115 Waiver Proposal has undergone a series of revisions since its inception in the fall of 2013. The final submitted document, dated June 4th 2014, contains a number of changes since the February draft was published and made open for public comment. While an additional draft was released on March 25th, no significant revisions were made between the March  and June 4th documents.  Throughout this process, Health & Medicine staff has been monitoring revisions, and we’re pleased to share this memo which describes the changes from the initial draft proposal to the final submitted version.

As the submitted proposal serves as an outline of the broad goals of the waiver, the continuing stakeholder engagement process this summer will synthesize input on more specific implementation issues to prepare the state should the waiver be approved.  The Governor’s Office of Health Innovation and Transformation (GOHIT), with  support from Health & Medicine, is coordinating this stakeholder engagement through five workgroups. The five workgroups cover Services and Supports, Integrated Delivery System Reform, Data and Technology, Workforce, and Public Health Integration. In addition to the support we are providing to GOHIT, Health & Medicine is also a participant in each of the workgroups. Information on those workgroups is available here. Additional details and other changes are to be expected as well, given the continuous feedback from CMS following their review of the proposal.

Below are sections of the waiver that were revised in between drafts that we expect to resurface during the workgroup and implementation process and are worthy of special attention. You may also click here to view our chart detailing all revisions between the February and final drafts.

Cost Sharing
Although the original January draft of the waiver application stated that Illinois was not requesting cost sharing, the February draft contained a significant amount of content discussing plans to maximize cost sharing with reference to requirements embedded in the SMART Act. The cost sharing in the February draft was proposed pending an update to the Medicaid Management Information Systems (MMIS). While federal law requires cost sharing to not exceed 5% of the family’s income, this version proposed waiving the requirement to track each family’s incurred cost sharing and also the requirement to notify beneficiaries when they meet this cost sharing limit. Those tracking requirements, the February draft explains, are beyond the existing capacity of the State’s MMIS.  

In the final version, however, all heading sections under “Cost Sharing” (Aggregate Limits, Native Americans, and Non-Emergency Services Furnished in an Emergency Department) have been taken out, and replaced with a statement that no changes to cost sharing are being proposed. However, in response to public comments, the document later notes an overall “misunderstanding of the intent of this waiver,” and details how the State plans to “follow up with stakeholders and may modify this request pending those discussions.” At a May 9, 2014 Illinois Medicaid Advisory Committee meeting, HFS explained that the request to waive some cost sharing rules was in response to a change on the federal level that applied the same tracking requirements to nominal co-payments as it had to higher ones. These discussions warrant additional attention as any similar alterations to cost sharing will prove to be an exacting task  due to the high volume of public comments.

Specialized Mental Health Rehabilitation Facilities (SMHRFs)  
Responsive to stakeholder feedback on the February draft, the final version seeks to claim CNOM dollars for SMHRF services, not waive the IMD exclusion.  The request for federal match on SMHRF services was removed from the enumerated list of services in the “Expenditure Authority Waiver Requests” section and added to the section on the designated state health programs (DSHP) in the final version.
University of Illinois Hospital and Health Sciences System
This section was reorganized with a new section discussing goals for Delivery System Incentive Payments that are currently reflected in the distinct work groups. It does not reflect all of the current projects under consideration so these revised topics and more will be open for discussion with stakeholders and with CMS.  

Children with Medical Complexity
Responsive to previous stakeholder comments, Pathway 1 has been revised to address the new development of integrated systems for this specific population. The State proposes to implement such a program without amendment to the waiver, potentially building on the nascent Coordinated Care Entities for Children with Medical Complexity currently starting up in Illinois. The waiver language suggests that Illinois and CMS would jointly develop and approve quality metrics and shared savings/risk methodologies that are consistent with CMS' guidance. This is in response to existing CCE’s requesting recognition of a pending bill in Congress, HR 4930, that would create federal standards for pediatric health care networks. If the waiver is approved, the State is agreeing to review such a program.

Costs Not Otherwise Matchable (CNOMs)
Many significant changes occurred regarding the Costs Not Otherwise Matchable (CNOMs) amount totals. Although smaller than in the original draft, the final five-year variance between the ‘without waiver’ and ‘with waiver’ budget calculations allows for some financial cushion in meeting budget neutrality.  

Part of the increase in CNOM is from new programs to be funded by the waiver.  Appendix C identifies new funding to the DHS DD Grant in UIC Family Care ($1,789,900), DASA Addiction Treatment ($6,299,060), and the Illinois State Board of Education Birth-To-Three Initiative ($42,000,000). Public comments on earlier drafts of the waiver had noted the need for more investment in DD services, substance use disorder treatment, and maternal/child health programs.

Public Notice of Waiver Application
Additional responses to the public comments were made, noting general support for the waiver. Concern regarding the restoration of adult dental care under the waiver was raised, but those services have since been restored through SB 741.

A detailed summary of the January 2014 public comments was organized by Health & Medicine with responses made by the State. This document can be viewed here.

Jul 18, 2014 Written By: Guest Author

Community Health Workers in Illinois – we ain’t seen nothin’ yet!

We’re pleased to share a guest post this week from Health & Medicine Board Vice President Steven K. Rothschild, M.D. Dr. Rothschild is a family physician and researcher in the Departments of Family Medicine and Preventive Medicine at Rush University Medical Center. You can follow Dr. Rothschild on twitter @comunidadysalud.

Advocates for Community Health Workers (CHWs) were cheered on May 29th of this year when HB5412 was passed by both house of the Illinois General Assembly.   Although CHWs have been working in the US for over forty years, this bill advanced the field in Illinois by creating an Advisory Board to advise the Department of Public Health, the Governor, and the General Assembly on matters concerning training, certification, and implementation of CHW programs. Health & Medicine was a leader in supporting this legislation, including the critical point that over half of the Board be composed of CHWs.
 
Of course, what happens next remains to be seen.   Professionalization and regulation can lead to unintended negative consequences such as excluding CHWs with low English literacy, disenfranchising undocumented CHWs, and disempowering the workers by drawing them into the more narrow medical model of care. All of us need to be vigilant in monitoring implementation to make sure that core values of empowering people to live healthier lives through community advocacy are preserved.
 
With that caveat, though, I am confident that in the next few years the health care community will be pleasantly surprised to see the impact of CHWs in our state. As a family physician, I first began working with CHWs in the early 1980s, in Cleveland. On the east side of the city, neighbors were trained to look in on frail elderly residents to make sure they were taking their medications and attending clinic appointments.  
 
Since then, here in Chicago, I have watched CHWs educate parents about asthma management, visit clients in their home to educate about diabetes, promote diet and physical activity to reduce the risk of diabetes in Humboldt Park, advocate for a safer environment in a CHA senior building, and establish an exercise program for seniors in Pilsen. In each and every setting, I saw community members provide education that was caring, creative, and effective. Visiting patients in their homes, CHWs often see things that doctors and nurses never see, and have to help patients in all kinds of innovative ways.    

I recall one CHW who visited a family who was getting their electricity from a wire strung directly to a street lamp – and who then helped them get safer affordable electricity through a public assistance program. In another case, a CHW visited an apartment, only to find her client lived with a brown bear in the bathroom (long story). Most often, though, the CHW's work has focused on helping neighbors overcome social barriers to health, including poverty, racism, lack of access to healthy foods, unsafe parks, low literacy, language barriers, transportation difficulties, and major stress and trauma. They have taught clients about their illnesses and how to adhere to their medications when the person's own doctor was too busy to do so. Some of the home situations they addressed were frustrating, sad, and on occasion even frightening – but the CHWs found ways to help their clients solve problems and live healthier lives.

Research evidence of effectiveness is growing as well;  the August 2014 issue of the American Journal of Public Health has a paper from my research group, demonstrating how a CHW program could result in sustained improvement in diabetes control over 2 years among Mexican-Americans here in the city.

What will happen next in Illinois, now that the legislature has recognized the field of Community Health Workers? I don’t know that anyone can say for sure, but I am confident that CHWs will exceed our expectations, awe us with their energy and creativity, and help reduce health disparities in our state.

Jul 03, 2014 Written By: Health & Medicine Policy Research Group (HMPRG)

What We’re Reading - July 3rd, 2014

A rundown of the articles and stories that caught our eye this week:

Poor Health: Poverty and scarce resources in U.S. cities
"Hospitals and family doctors, the mainstays of health care, are pulling out of poor city neighborhoods, where the sickest populations live. A Pittsburgh Post-Gazette/Milwaukee Journal Sentinel analysis of data from the largest U.S. metropolitan areas shows that people in poor neighborhoods are less healthy than their more affluent neighbors but more likely to live in areas with physician shortages and closed hospitals.

At a time when research shows that being poor is highly correlated with poor health, hospitals and doctors are following privately insured patients to more affluent areas rather than remaining anchored in communities with the greatest health care needs."
Pittsburgh Post-Gazette

The Illogic of Employer-Sponsored Health Insurance
“The [Burwell v. Hobby Lobby] ruling raises the question of why, uniquely in the industrialized world, Americans have for so long favored an arrangement in health insurance that endows their employers with the quasi-parental power to choose the options that employees may be granted in the market for health insurance.”
The Upshot via The New York Times, July 1, 2014

Social and Economic Benefits of Reliable Contraception
"Contraception extends well beyond a woman’s decision whether and when to conceive, and access to reliable family planning goes deeper than a woman’s personal wellbeing. It plays a pivotal role in the financial, physical and emotional health of children, and data suggest that effective contraception and positive social outcomes are mutually reinforcing. In the end, empowering women—regardless of socioeconomic status—with more options to control pregnancies has benefits for everyone."
The Atlantic, July 2, 2014

The Supreme Court Would Prefer People With Disabilities Receive Care from Disgruntled, Low-Wage, High-Turnover Workers
"With its decision in Harris, the Supreme Court has torpedoed a practical and equitable partnership. People with disabilities could receive the in-home personal assistance they need. The men and women who perform this important work could receive a fair day’s wage for the work they do. Now that arrangement—and the well-being of both groups—is in jeopardy."
New Republic, June 30, 2014

Further Reading on Harris v. Quinn: Supreme Court Rules Disadvantaged Workers Should Be Disadvantaged Some More from The American Prospect

Behind The Civil Rights Act: How it was made and what it means today
"It’s been 50 years since President Lyndon B. Johnson signed the Civil Rights Act. Since then, the country’s demographics have shifted, and the conversations about race and culture have continued. In this project, journalists, lawyers and civil rights activists explore the historic legislation— pulling the language out of history and telling us how it’s relevant today."
NPR, July 2, 2014

Approach trauma as an urgent public health problem

"A new Plan of Chicago can both brighten the prospects for youth and interrupt the cycle of violence by fully addressing the impact of these traumatic events on our youth. There is need for a coordinated and concerted effort across the city to respond and treat youth who have been affected."
Chicago Tribune, June 3, 2014


Jun 27, 2014 Written By: Christine Head

Reconnecting the Pathways: How far have we come in creating a united and accountable system?

The juvenile justice system in Illinois has a rich history of contradictions.

In 1899, Chicago pioneered the first juvenile court in the United States under the premise that children were profoundly different than adults and could be rehabilitated. This innovation can arguably be considered one of the most lasting and powerful achievements of the Progressive Era.

More than one hundred years later, Illinois juvenile courts have garnered the attention of the nation, but for all the wrong reasons. The system has been riddled with issues ranging from racial and ethnic disparities, overcrowding, and, as of 2013, a skyrocketing rate of sexual assaults. As time has passed, it has become clear that there is a disconnect between the intent of the courts and their actual function.

In an effort to combat these systemic issues, in 2007 the Illinois Juvenile Justice Commission, the Association of Juvenile Justice Council, and other stakeholders convened the Connecting the Pathways conference in Springfield, Illinois to address the measures needed to improve the juvenile justice system. Though this event laid the foundation for a number of avenues for reform, change was slow moving. The recently held Re-Connecting the Pathways conference, the seven year follow-up event, aimed to pick up where its predecessor left off by giving leaders in reform the know-how necessary to recreate the system. 

As the LGBTQ Youth Task Force Coordinator of Health & Medicine’s Court Involved Youth Project, I had the opportunity to attend the conference and gave a presentation focusing on LGB/T issues, disproportionate minority contact (DMC), and racial disparities in the justice system. The event provided a great opportunity to bring stakeholders together to discuss these and other pressing issues facing our broken juvenile justice system, and I was particularly struck by the conference’s emphasis on providing effective tools.

My presentation focused on pathways that lead to the over representation of LGB/T youth of color in the juvenile justice system as well best practices for providing competent care. Though LGB/T comprise 15% of the detention population, there is very rarely training around sexual orientation and gender identity (SOGI) competence for detention and probation.

The inclusion of LGB/T youth of color in the programming of a general state conference, like Re-Connecting the Pathways, is a huge and progressive step towards positive system reform. Besides the growing call for SOGI competence training, attendees were given the opportunity to learn more about restorative practices in schools, trained on adultism and how it affects their work and, more importantly, were challenged to address the racism that plagues the system. Overall, the conference was able to effectively touch on major movements and faults in the system while attempting to bridge the gap between Cook County and our downstate colleagues.

That said, there were stumbling blocks that still need to be addressed. It was strikingly obvious that two key stakeholders were not present in our discussion: law enforcement and families of incarcerated youth.  Historically, these two groups have always been tough to reach but more efforts need to be made to make these convenings more accessible in order for policy change to be lasting.

Additionally, addressing our own biases still remains a point of contention. Though people were able to agree that racism plays a huge role in incarceration, making the final step and taking an introspective look at how we all contribute to racial and ethnic disparities has yet to be accomplished. 

Though we have a long way to go before we can confidently say they we have a healing and transformative system, it was clear that we are entering a moment in history where profound change is on the horizon. Leaders both at the local and state level have taken positions promising to promote the creation of places where youth can be transformed.

Only time will tell if they make good on their promises, but convening events like Re-Connecting the Pathways are important for providing accountability, revealing our contradictions, and laying the foundation for positive change.  

Jun 18, 2014 Written By: Guest Author

The Impact of Mentorship: The Chicago Area Schweitzer Program

We’re pleased to share a guest post from one our recent 2013-14 Schweitzer Fellows, Bernice Man, a student at Chicago State University’s College of Pharmacy. This article originally appeared in the Official Newsjournal of the Illinois Council of Health-System Pharmacists.



I have regularly visited Chicago’s Chinatown neighborhood with family and friends since moving to Chicagoland in the early 1990s. My reasons for coming to Chinatown have expanded from eating the delicious food to improving the health literacy of older adults who live there. I am currently serving as one of thirty-two 2013-2014 Chicago Area Schweitzer fellows. The Albert Schweitzer Fellowship is a service fellowship with a goal to cultivate future healthcare leaders who will address health disparities and improve health outcomes for underserved communities. The 2013-2014 Chicago Area Schweitzer fellows include students from medicine, nursing, optometry, social work, public health, art therapy, dentistry, psychology, law, and disability studies. Each fellow is required to create and complete a yearlong, 200-hour service project that addresses a health need in an underserved community under the guidance of multiple mentors.

My Schweitzer project takes place in Chinese American Service League (CASL) Senior Housing, which is a government subsidized, residential housing complex near Chinatown Square. The project’s goal is to improve the health literacy of Chinese older adults by providing disease state presentations, medication reviews, and health screenings. The site population’s main barrier to healthcare is language. The vast majority of the residents speak various dialects of Chinese and have very limited English proficiency. For this reason, I have presented all materials in Cantonese, and have included topics such as arthritis, cholesterol, blood pressure, eye disorders, and cold/flu symptoms.

The Schweitzer Fellowship requires that each fellow have four different mentors, including an academic mentor, student mentor, advisory council mentor, and site mentor, who all serve to provide guidance on various aspects of the fellow’s project:
  • My site mentor is Virginia Lai, the social service coordinator at CASL Senior Housing. Because she is the person most familiar with my site’s population, Ms. Lai has provided great insight into what health topics would be of most interest and of most use for the CASL Senior Housing residents. She has also helped me to foster a bridge of trust between the residents and myself by introducing me to the residents and promoting my project’s services.
  • The academic mentor is an educator at the fellow’s academic institution. My academic mentor is Dr. Diana Isaacs, one of my professors at Chicago State University College of Pharmacy and the Chair of the Illinois Council of Health-Systems Pharmacists (ICHP) New Practitioners Network. She has provided vital guidance on the health education and pharmacy practice aspects of my project, as she reviews all of the disease state information and medication reviews before I present the material at my project site.
  • The student mentor is a current healthcare student who served as a Chicago Area Schweitzer Fellow in previous years. My student mentor is Jordan Becerril, a third-year medical student at Rush Medical College. Because he recently completed the Schweitzer Fellowship, Jordan has been very helpful in providing feedback on different aspects of my project.
  • The advisory council mentor is a healthcare professional who serves as a resource for the fellows. My advisory council mentor is Dr. Mark Stoltenberg, a former Chicago Area Schweitzer Fellow who is a current second-year resident physician at Northwestern University McGaw Medical Center. He has been helpful in my project’s development, as he has suggested further ways in which I can expand my project.
  • Ray Wang, the Chicago Area Schweitzer Fellows Program Director, and Bonnie Ewald, the Chicago Area Schweitzer Fellows Project Coordinator, have both served as informal mentors for my project. They both have provided valuable suggestions on how I can improve my project and have helped me access various healthcare resources.

The mentorship provided to me has been invaluable, as I truly believe that I could not have made my project a success without my mentors’ advice and support. When I applied for the fellowship, I had theoretical ideas on what I wanted to do for my service project and hypothetical ideas on how I wanted to complete it. Putting my project ideas into practice would have been much more difficult and time-consuming had I not had mentors who had previous experience in different facets of my project and who were willing and able to guide me through my project’s development. I have grown because of my mentors’ experiences and their willingness to share the knowledge that they possess.

Because of the Schweitzer Fellowship experience and because of my mentors, I have become confident that I can tackle any project going forward and that I will find a way to make that project successful. Because of the relationships that I have developed with my mentors during the fellowship, I anticipate that my mentors will continue to be resources that I will contact in the future when I need counsel. During the past year, I have learned how important it is to have mentors who can help guide me not only in how to tackle a project, but also in how to direct my career path both during and after pharmacy school. Because of the great experiences that I have had with my mentors, the Chicago State University College of Pharmacy Student Society of Health System Pharmacy (SSHP) chapter started a P1 – P3 mentoring program where P3 students can give advice to P1 students about school. The American Society of Health-System Pharmacists (ASHP) currently offers the Mentor Match program, where any ASHP member can be matched with a mentor or mentee based upon their preferences and profile. I encourage everyone to find mentors for themselves, and I hope to serve as a mentor for pharmacy students in the future.

Jun 06, 2014 Written By: Health & Medicine Policy Research Group (HMPRG)

What We’re Reading - June 6th, 2014

A rundown of the articles and stories that caught our eye this week:

Cook County releases first snapshot of new Medicaid patients
“The data, shared with the Tribune by Cook County Health and Hospitals System, cover enrollees from when CountyCare launched in early 2013 through April 2014. And they reveal the deep challenge that the state, hospitals and insurance networks face to help many of these patients get their health under control and, in turn, hold down costs.”
Chicago Tribune, June 2, 2014

What climate change means to Chicago
“Climate change is not only about the loss of glaciers: it's also about human health. Carbon pollution from human activities is impacting food security, water resources and the occurrence of disease. Climate change in our part of the world is about more than just a few uncomfortably hot days.”
The Daily Herald, May 13, 2014

What’s In A Name? Global Warming vs Climate Change
“We found that the term "global warming" is associated with greater public understanding, emotional engagement, and support for personal and national action than the term "climate change.”
Yale Project of Climate Change Communication

Redesigning Care For Patients At Increased Hospitalization Risk: The Comprehensive Care Physician Model
“Successful health reform requires innovative care models that can improve outcomes and lower costs. Patient-centered medical homes emphasize the role of the physician as the director of a team approach to care. However, the failure of many care coordination models to reduce total costs of care provides a cautionary tale. In this context, the potential of the Comprehensive Care Physician model to improve coordination of inpatient and outpatient care of high-cost patients at lower cost deserves careful study.”
Health Affairs, May 2014

Take This Apartment and Call Me in the Morning
“Supportive housing is more than just a place to live. [It] has social workers, security, a doctor, and even an event planner. The goal is to provide safe, secure housing for people who were once homeless, while also reducing the overall costs of expensive emergency room visits and other services utilized by people who are chronically homeless.”
WNYC News, June 4, 2014

The 4 biggest reasons why inequality is bad for society
“The great inequality of income and wealth in the world, and within the United States, is deeply troubling. It seems, even to many of us who benefit from this inequality, that something should be done to reduce or eliminate it. But why should we think this? What are the strongest reasons for trying to bring about greater equality of income and wealth?”
Ideas.TED.com, June 3, 2014

May 29, 2014 Written By: Bonnie Ewald

Older Americans Month – Preventing Falls, Supporting Seniors

As we approach the end of May, we’re also coming to the end of Older Americans Month. This year’s theme - “Safe Today. Healthy Tomorrow.” – has focused on the steps we can take as a community to help prevent falls, an initiative that ties into several of our projects here at Health & Medicine.

Over one-third of the older adult population falls each year. Falls are a serious public health concern that can result in fractures, traumatic brain injuries, loss of independence, and fatality. In addition to the physical toll falls take on older people, they also contribute to hospitalizations, Emergency Department utilization, and rehabilitative therapy costs. Falls can particularly be an obstacle for vulnerable seniors - studies have found that older adults who are low-income, live in rural areas, and live alone have higher falls risks

Whether from lack of access to healthcare, costs of healthcare, physician time restrictions, or patient non-compliance, too many older adults are not properly screened for risk of falls.

As part of my work at Health & Medicine, I support two program areas that work directly to prevent falls among older adults: our Chicago Area Schweitzer Fellows Program – a year-long service learning program for health professions graduate students – and the Bridge Model, a social work based approach to working with older adults as they discharge from a hospital and return to life back in the community.

Through the Schweitzer Program, each year 30 exceptional students design and implement service projects to improve the health and well-being of underserved Chicago communities. This year, Fellow Timothy Kosiba, a physical therapy student at Northern Illinois University, has designed a program that specifically works to prevent falls.

“Over one third of adults 65 years and older fall each year which has become the leading cause of death by injury for older adults.  As the population ages, this number will only increase without strategies to help prevent it.  After seeing the impact falls have had on the independence and health status of my family and in my profession, this has become a major area of interest for me,” Tim said. 

Through the Fellowship, Tim has partnered with Northern Illinois University Health Wellness and Literacy Center to develop a project called Rise Up Against Falls. This falls prevention program is focused on working in communities of the DeKalb/Chicagoland area and providing free fall prevention screening, education, and wellness activities aimed at helping older adults maintain their independence and safety against fall-related issues.

“More times than not, therapists usually handle the aftermath of what falls can do. This could result in months or more of therapy working to regain as much function as possible that has been lost. I believe this project gives me the opportunity to advocate for my patients, helping them maintain their independence instead of trying to regain it,” he said.

In addition to supporting Tim and other Schweitzer Fellows with their projects, I also work with the Bridge Model through our Center for Long Term Care. Like the Schwietzer Fellowship, this transitional care program is focused on developing community-centered solutions to public health problems. In this case, the Bridge Model helps older adults age in place by supporting them as they are discharged from the hospital and return to their communities.

Hospitalizations often present a lot of changes for an individual, including changes in physical mobility, cognitive ability, newly prescribed medications, and emotional status. If older adults are not properly supported through this transition back to their homes, these changes can lead to a readmission.

Bridge Care Coordinators apply a thorough assessment and use social work clinical skills to address the many biopsychosocial factors that may challenge clients and their caregivers in their transition home from the hospital. Bridge emphasizes collaboration among hospitals, community-based providers, and the Aging Network in order to ensure a seamless continuum of health and community care across settings.

Bridge Care Coordinators work closely with on-the-ground partners such as Aging Network case managers and home health nurses to monitor the safety of in-home environments. They can help connect individuals in need with falls and readmission prevention services that address in-home safety concerns, hearing and vision loss, physical mobility challenges, and medication reconciliation concerns.

Like Schweitzer Fellow Tim Kosiba, our Bridge Care Coordinators understand that falls are not a “normal” part of aging, and they can be prevented through a combination of interventions. These include exercising, getting a falls risk assessment, reviewing medications, having vision and hearing checked, and making the home environment safe.

Below we’ve highlighted three important interventions that can help prevent falls, as well as health policy initiatives that could make these interventions more effective:

  • Reviewing Medications: Commonly prescribed medications, including antidepressants and insulin, increase the risk of falling by causing changes in cognitive and physical function, dizziness or lightheadedness, balance difficulties, confusion, and sedation. Therefore it is important for health plans and providers to complete a medication review upon prescription or a hospital discharge. However, a literature review revealed that many healthcare facilities include pharmacy review of medications only after a patient falls or is screened and identified as having a high risk for falling.  
  • Hearing screenings: Individuals with “mild” hearing loss have been found to be three times more likely to experience a fall.  Original Medicare does not cover many hearing tests or hearing aids, and Medicaid coverage varies by state, so individuals often need to pay for costs out of pocket or by reaching out to local community-based organizations.  According to the Hearing Healthcare Alliance for Underserved People (of which Health & Medicine is a member), just 5 of 40 surveyed Chicago-area hospitals, audiology clinics, and other health clinics provide hearing aids to Medicaid beneficiaries due to prohibitively low reimbursement rates.  
  • In-home safety: Modifications in the home environment can include installing appropriate lighting, making modifications to uneven flooring, and adding sturdy handrails to stairways and bathrooms. While community-based organizations such as Housing Opportunities and Maintenance for the Elderly can help older adults address these issues, traditional Medicaid does not cover these modifications, so they may be out of reach to older adults in need. In Illinois, older adults who are eligible for Medicaid home and community-based services programs can receive some home modifications that may mitigate fall risk. However, individuals must have enough functional impairment to qualify for nursing home placement in order to be eligible for those services. This requirement excludes many older adults who could benefit from services that could maintain their existing capability to live independently.

Older Americans Month reminds us that there are a number of avenues we can explore to help support older people in our communities – be it through direct service like the Schweitzer Fellowship and the Bridge Model or through health policy initiatives like those touched on above. Working with other advocates, providers, and communities, we can use Older Americans Month to support comprehensive falls prevention services for communities in need long after the month ends.

May 22, 2014 Written By: Ray Wang

Schweitzer Fellow for Life Stays Involved With Community

Chicago Area Schweitzer Fellowship Program Director Ray Wang talks with Schweitzer alumna Sodabeh Etminan about her experience as a Fellow and about how the Program has made a lasting impact on both her health career and the community she worked with.




As a 2012-13 Schweitzer Fellow, Sodabeh (Sue) Etminan partnered with the after school program at Erie Neighborhood House (ENH) in Humboldt Park to provide oral hygiene instruction and screenings for children. At the time, Sue had already been a practicing community dentist and was pursuing her public health degree at the University of Illinois.  She succeeded in teaching and providing screenings and referrals for hundreds of children, and also helped the site obtain funding from the Wrigley Foundation to continue her project after her Fellowship year. Now a Fellow for Life, Sue continues to be involved with ENH and just last month organized an oral health fair that provided screenings and referrals for 160 children. Sue is currently a community dentist at the Heartland Health Outreach Dental Clinic in the Uptown neighborhood.

Ray: Sue, please give us a little background about your connection to the Humboldt Park community and the genesis of your Fellowship project.  

Sue: As a dentist, I frequently see adult patients wishing that someone had reviewed oral hygiene with them at a younger age. By the time they see me, we are discussing tooth extractions or other invasive treatments. Many of my patients were originally from Chicago and lived in Humboldt Park, a community that had difficulties with access to dental care, and Erie Neighborhood House (ENH) was the perfect organization to start a dental program geared towards oral hygiene in children.  ENH has been in existence since 1870, and is a trusted organization in the community that has helped and advocated for families with a variety of needs including affordable housing, workforce development, and programs for children and youth.  My site mentor, Michael Guarrine, and others at ENH were so supportive of me and my Fellowship project, and with their guidance I was able to tailor a curriculum to teach children about good oral health habits, healthy nutrition, and lessen any anxiety they might have had about going to the dentist.  

Ray: Tell us about how your oral health program has continued…Has anything changed at all since when you were a Fellow?

Sue: We found out that we had received the Wrigley Foundation grant towards the end of my Fellowship year. We were able to use it to train staff members at ENH so they could continue incorporating oral health in their lesson plans even with my absence. The grant was especially helpful when it came time to do the screenings because I was able to order everything we needed through some of the companies that were kind enough to donate to my project when I was a Fellow.

Ray: These are cute pictures from your oral health fair last month… tell us about how it went.   

Sue: The health fair went well! I was a little apprehensive going in since I wasn’t as involved in the site this year compared to when I was a Fellow, but some of the kids even remembered me from last year, which was nice. I had fourth year dental students from UIC come and volunteer for the day, and they were instrumental in the success of the screenings. This year, we put in place a system to see how many of the referred children are taken to their dental appointments, and how long it took them to make an appointment. I am going to use that data to improve on next year’s event. Unfortunately, more children had urgent oral health needs this year compared to last year and we will be tailoring our curriculum to hopefully see some improvement next year.

We also just found out that we received grant funding for another year, which is very exciting for us! A project like this sometimes takes years to achieve results, and I am happy that we are given this opportunity to positively impact the community.

Ray: That’s really wonderful news!  Congratulations! Sue, a new class of Chicago Schweitzer Fellows will be starting their community projects soon.  Do you have any words of advice for them, and in particular, do you have any thoughts about how they might build sustainability into their plans?

Sue: I think sustainability is easier if it is always included in project plans, even from the very beginning. Assume that your project is going to continue well after your fellowship is completed. If the framework for sustainability is in place, the details will fill in more easily. However, it takes a lot of planning to find funding, volunteers, and community support. Even if the project ends with your Fellowship, take lessons learned and apply them to your next public health endeavor. Best of luck!

Ray: Thank you, Sue!

May 16, 2014 Written By: Erica Martinez

Update on CHW Legislation – House Bill 5412

Health & Medicine continues to have an active role in the legislative process of monitoring and garnering support for House Bill 5412 (HB5412). HB5412 is a bill that formally recognizes Community Health Workers (CHWs) as an integral part of our healthcare teams. As of this writing, the bill is currently in the Senate, and we anticipate that they will vote on it in the coming days. We would like to take this opportunity to update stakeholders about the bill’s history, its current status in the legislature, and recent amendments.

HB5412 adopts the American Public Health Association’s Community Health Worker section’s definition of a CHW, and establishes an advisory board to provide recommendations and consider essential core competencies. HB5412 was originally introduced by State Representative of the 18th district, Robyn Gabel. Health & Medicine, along with other key stakeholders, such as the Chicago CHW Local Network, the governor’s office, and the Illinois Department of Public Health, helped produce the CHW bill. The bill is currently being considered for a vote in the Senate.  HB5412 was first sponsored in the Senate by Senator David Koehler of the 46thdisctrict.

HB5412 is a vital first step to acknowledging the important contributions in public health and disease management of the CHW workforce and the challenges that CHWs face in our healthcare landscape. The CHW bill in Illinois has gathered numerous co-sponsors in both the House of Representatives and the Senate. The bill currently has 16 sponsors: Rep. William Davis, Rep. Robyn Gabel, Rep. Esther Golar, Rep. Elizabeth Hernandez, Rep. Naomi D. Jakobsson, Rep. Camille Y. Lilly, Rep. Emanuel Chris Welch, James F. Clayborne, Jr., Sen. Jacqueline Y. Collins, Sen. William Delgado, Don Harmon, Sen. Napoleon Harris, III, Sen. Mattie Hunter, Sen. David Koehler, Sen. Patricia Van Pelt , and Sen. Donne E. Trotter. In addition, this bill has 40 supporting organizations.

The CHW bill has had two amendments in the legislative process; Amendment No. 1 was adopted in the House and Amendment No. 2 was adopted in the Senate. HB5412 passed in the House with the inclusion of the changes brought forth by Amendment No. 1. Amendment No. 2, which was introduced in the Senate, included substantial changes. If HB5412 passes in the Senate, the bill must then return for a vote in the House.  Below you will find a summary of the key differences in the bill with the amendments.

Summary of Amendment No.1 Changes to HB5412 in the House:
The key changes to the original bill were made to the deliverables of the CHW Advisory Board (which would be housed in the Illinois Department of Public Health); time frames and includes the additional language listed below.

Amendment No. 1:
  • Added research and oral communication skills to the list of core competencies.
  • The Advisory Board shall be representative of different racial, ethnic, and geographic areas.
  • The Advisory Board will develop and submit a proposed plan (of recommendations) by December 31, 2014 (or 9 months after first meeting).
  • The Advisory Board will serve without compensation (reimbursement for reasonable expenses will be available) and will have the Department’s administrative and staff support.
  • Sunset clause was included and the board would dissolve on January 1, 2015.

Summary of Amendment No. 2 Changes to HB5412 in the Senate:
The key changes were in the composition of the Advisory Board and the timeframe of the deliverables.

Amendment No. 2:
  • Advisory Board would be comprised of 15 members in order to keep a majority of CHWs on the advisory board
  • A licensed physician and a licensed nurse representative are on the Board.
  • CHW Board membership representation outlines different Illinois counties (Cook, DuPage, Bond and others).
  • Possible members of the Board will no longer include training and curriculum specialist or social science professionals, such as anthropologist.
  • Voting members would elect a board chair instead of having one selected by the Director of Public Health.
  • A report of recommendation should be ready 12 months after the first meeting.
  • Removed reimbursement for reasonable expenses incurred for the Board.
  • Sunset clause of board dissolving on January 1, 2015 was removed.

HB5412 with both amendments adopted can be found here. Despite changes to the bill, it continues to be a necessary first step toward formally recognizing the CHW workforce in Illinois. You can stay informed and take action to ensure HB5412 passes and becomes a reality! Find our action alert here and the fact sheet here. We urge you to stay engaged and contact your representatives to vote yes for HB5412!



May 12, 2014 Written By: Sharon Post

SB3450: Nursing Homes Versus Managed Care

One of the founding principles of Health & Medicine is the belief that health care is a human right. Over the course of our 30 plus year history, we’ve found that the corporatization of health care often threatens that fundamental value. This issue is particularly relevant to the work of our Center for Long-Term Care which promotes a just system of long-term services and supports that enables people to live according to their own values and goals without exploiting others.

Therefore, we were apprehensive when Illinois began to contract with mostly for-profit insurance companies to provide Medicaid care coordination, including long-term services and supports (LTSS) which help older adults and people with disabilities accomplish the everyday tasks that many of us take for granted. Although the involvement of those private contractors gave us reason to be skeptical, we believe the State’s goals for care coordination are worthy ones, and many of those goals have too often been stymied by powerful political interests.

This is most stark in the case of the State’s goal to ‘rebalance’ the long-term services and supports system. Illinois uses less than 40% of its Medicaid long term services and supports expenditures for home- and community-based services (HCBS). “Rebalancing” refers to efforts to reduce the bias toward institutional care in the LTSS system and increase access to HCBS. Illinois has taken rebalancing seriously in recent years, and has cooperated in settling and implementing three consent decrees to transition people who wish to live in the community out of nursing facilities.  Under the Colbert consent decree, the State has found that many nursing facility residents had experienced an acute episode that required nursing home care, but as their condition improved they needed little or no assistance with activities of daily living. Many who have successfully transitioned out of nursing homes under Colbert are not using community-based long –term care. While it is important to monitor their progress and provide supports as needed, the experience with Colbert indicates that these individuals did not need to stay in the nursing facility; they simply got trapped once they were admitted.

Managed care organizations (MCOs) provide a mechanism to divert people from nursing homes on the front end and also to transition people out of nursing homes when appropriate. The State pays MCOs a per-member-per-month rate called a “capitated rate.” The MCO must use its capitation payments to provide services for all its members. Therefore they have an incentive to provide the most cost-effective services (while still investing enough in necessary services to meet quality metrics). This incentive can help keep more people out of nursing homes and in their communities because nursing homes tend to be costly compared to HCBS. However, if people’s health status declines in the community, MCOs will lose out on quality incentive payments, so they also have an incentive to ensure that people living in the community are thriving. For more on managed care and rebalancing see our factsheet.

Managed care won’t automatically rebalance LTSS. Incentives are complicated, and Illinois is not using a blended capitation rate for nursing homes and HCBS, which some regard as the strongest incentive for rebalancing. States that do use blended rate with quality metrics have still had difficulty facilitating successful community transition, as in the case of Tennessee. Getting incentives and quality metrics right is crucial, and consumer involvement is key to both because no one knows better what’s working and what isn’t than those experiencing the changes on the ground.

As Illinois works to improve care coordination and health outcomes for older adults and those with disabilities, consumers need to keep a careful eye on implementation of managed long-term services and supports. We also need to watch out for the nursing home lobby’s cynical approach of fighting managed care for all the wrong reasons, using the language of consumer control and anti-corporate rhetoric to entrench their own interests.

This is what is happening with SB3450, the nursing home lobby’s so-called “nursing home residents’ managed care bill of rights.” SB3450 would make it more difficult for MCOs to selectively contract with quality nursing homes—a major concern in Illinois, where significant disparities in quality exist—and, more importantly, to re-integrate residents who wish to live in the community.

Health & Medicine has joined in opposition to SB3450. Our position is not that managed care organizations are trustworthy and nursing homes are not, but that both kinds of these private Medicaid contractors need oversight and accountability. The Medicaid care coordination project must not be distorted by vested interests bent on preserving the very worst aspects of the status quo. Nor can we allow managed care organizations free reign to re-design the system without ongoing, sustainable, meaningful public involvement, especially from the people who actually use the services the MCOs are coordinating.

As it implements reforms to the LTSS system, including coordinated care, the State needs guidance to avoid causing harm and to create opportunities for Medicaid enrollees to live healthier, more independent lives. We may even need legislation to ensure consumer protections and quality assurance.

But the State, MCOs, and most of all nursing home residents don’t need SB3450 or any other obstructions from the same self-interested lobbyists who have always put barriers in the way of rebalancing. The State and the MCOs need meaningful involvement in decision-making and implementation from the people who use the services and systems so we can have the best system to serve them on their terms. We’ve heard enough from the nursing homes in Illinois on this issue.

Apr 30, 2014 Written By: Wesley Epplin

Fact Sheet: Illinois Health Reform, Public Health, and Health Planning Efforts

Health and Medicine has developed a fact sheet that provides brief descriptions of current initiatives that are relevant to health reform, public heath, and health planning in Illinois. 

A description is provided for the following initiatives in the Illinois Health Reform, Public Health, and Health Planning Initiatives fact sheet:
•    Governor’s Office of Health Innovation and Transformation (GOHIT)
•    Alliance for Health: State Innovation Model Grant
•    Health Care Reform Implementation Council (HCRIC)
•    “Path to Transformation” Medicaid Section 1115 Waiver (1115 Waiver)
•    Illinois Workforce Investment Board (IWIB) Healthcare Task Force
•    State Health Improvement Plan (SHIP)
•    Balancing Incentive Program (BIP)
•    Budgeting For Results (BFR)

The descriptions for these efforts were collected from the initiatives’ webpages, condensed, and edited, as needed.  The purpose of this fact sheet is to provide readers with a basic understanding of this group of projects and direct them to the associated webpages for further reading and engagement.

This fact sheet will also be available at Health and Medicine’s upcoming forum, Health Reform, Public Health, and Health Planning in Illinois: Current projects and how they fit together, to be held May 5, 2014 from 9:00 – 11:00 a.m. at UIC Student Center West. 

At this forum, speakers from the Governor’s Office and the Illinois Department of Public Health will discuss each of the efforts in the fact sheet, how they overlap, barriers and gaps, and how stakeholders can engage with these projects.  For more information about the forum and to register, click here.



Mar 12, 2014 Written By: Health & Medicine Policy Research Group (HMPRG)

Health and Medicine Supports A Better Illinois

Health and Medicine has signed on as a supporter of A Better Illinois’ campaign for a Fair Tax because we think it will help support the health of all Illinoisans.  Below is our statement explaining why we signed on.  You can learn more about A Better Illinois and individuals and organizations can sign on at their website: A Better Illinois.

Health and Medicine’s Statement in favor of A Better Illinois:

The State of Illinois is facing a significant revenue shortfall that has led and is projected to lead to further cuts to human services, including Medicaid, as well as K-12 Education, Higher Education, Public Safety, and General Services.  These cuts to services have severe negative consequences for the health and well-being of all Illinois residents, especially our most vulnerable people, and negatively impacts our economy overall.  Recent budgets have cut many state services to the bone, so much so that in many cases there is no room to cut without sacrificing federal matching payments or violating legal requirements to provide basic services. The State also pays a huge sum of its funds on debt services, which further indicates a need for increased revenues.

A Better Illinois’ campaign for a Fair Tax in Illinois – one that provides a lower tax rate for lower income people and a higher rate for higher income people – is a sound policy position that would help Illinois meet its health, education, public service, and infrastructure needs that support more equitable provision of services for the needs of all Illinoisans.  A progressive tax structure could generate adequate revenue to meet Illinois’ necessary service obligations and withstand economic downturns, while providing for strong public infrastructure that the entire economy, including private businesses, needs to thrive.  A fair tax structure improves the economy by helping support public sector jobs for working and middle class families who spend money at Illinois’ small and local businesses, ensuring a well-educated and trained workforce, and supporting spending that strengthens public infrastructure, such as roads and bridges, while helping create new jobs in the private sector, all of which support the State’s broader economy.  

Very important to Health and Medicine, by providing the necessary funding, a fair tax would help to improve health and reduce health inequities in Illinois, by providing the necessary human and social support, public services, education, and infrastructure that benefit all Illinoisans – especially helping the most vulnerable who can least buffer their unmet needs through personal funds – as well as a more robust Medicaid program for those who benefit from this life-saving safety net program.

Mar 11, 2014 Written By: Wesley Epplin and Sharon Post

Health and Medicine's Comments on Illinois' 1115 Waiver Application

Health and Medicine submitted additional comments on the final Illinois Medicaid 1115 waiver application on Monday, March 10.  Check them out here.

Here are some of the topics covered in our comments:

•    Privatization concerns
•    Positively impacting the social determinants of health through the 1115 Waiver
•    Access assurance and provider taxes
•    Regional Public Health Hub funding going to MCOs rather than public health departments
•    Cost sharing being added to the final waiver application

Other relevant materials regarding the 1115 waiver:

•    From the blog: Key Changes and Notable Provisions of Illinois’ 1115 Waiver: A First Look
•    Health and Medicine’s comments on the 1115 draft application
   
Feb 20, 2014 Written By: Wesley Epplin and Sharon Post

Key Changes and Notable Provisions of Illinois’ 1115 Waiver: A First Look

On Monday, February 10th, the State released Illinois’ Path to Transformation 1115 waiver proposal, an update from a draft waiver proposal that received feedback from dozens of stakeholders.  Below are some key changes and issues of support and concern we’ve identified from the draft and other notes on the latest 1115 waiver proposal. We encourage advocates to engage with the issues and questions raised in this post.
 
The waiver application includes a new goal: decoupling HCBS and institutional eligibility (page 11):

The waiver lists 11 goals, one of which (#6) is consolidating the nine 1915(c) waivers that Illinois currently uses to provide home and community-based services. The final waiver application adds to that goal the promise of “thoughtful review and adjustments to current institutional eligibility thresholds, allowing HCBS waiver services to be provided to individuals who meet specific program eligibility criteria that may be less stringent than the institutional threshold.”  This would be an important move away from existing eligibility criteria that require individuals to demonstrate a need for a ‘nursing facility level of care’ in order to qualify for home and community-based services.  As Illinois expands community-based alternatives, it should also consider going a step further and raising the standard for nursing facility level of care as well as reducing the threshold for HCBS eligibility.

Advocates who attended the Governor’s Conference on Aging in December 2013 may have heard Mike Hall of the National Association of States United for Disability and Aging explain how requiring individuals to meet a nursing facility level of care threshold before they may receive home and community-based services means we intervene too late; people need to be sick or impaired enough to be eligible for the intensive services of a nursing facility before they can receive the home and community-based services that could prevent them from becoming so sick or impaired to begin with. Illinois has missed opportunities to prolong independence and enhance long-term quality of life for seniors and people with disabilities, and naming this eligibility reform as a goal of the 1115 waiver is a step in the right direction.

Access Living called for decoupling HCBS and institutional eligibility standards in its comments on the 1115 Waiver Concept Paper, so this change also demonstrates responsiveness to stakeholder input.

Delivery System Reform Incentive Payments (DSRIP) to Cook County (pages 17-19):

The Cook County Health and Hospital System DSRIP section on pages 13-15 of the first draft of the waiver application included provisions for: 1) Redirecting resources to more appropriate locations for primary care, subspecialty consultation, and diagnostics; 2) integrating behavioral health and primary care; 3) addressing food security; and 4) promotion of continuity of care for the justice-involved population.  The final waiver application has three additional initiatives that were not in the first draft:

  • Form a public-private partnership to consolidate selected resources across organizations.
  • Collaborate with the University of Illinois College Of Nursing to Improve CCHHS workforce capacity and competency.
  • Develop a community health worker residency program and collaborate on other training programs to address workforce shortages.
We would like to call attention to two of the total seven initiatives under CCHHS’ DSRIP proposal:

  • The concept of forming a significant new public-private partnership that will bring “a full array of comprehensive services to the delivery of patient care, including highly specialized interventions,” as noted in Appendix B, raises serious concerns.  Given that there are many examples of privatization that have led to very serious problems, including in health and healthcare services, any effort to privatize any part of public systems should be heavily scrutinized.  Illinois’ own experience using private contractors in its new Medicaid managed care programs is still in its early stages, and we have yet to fully draw the lessons we need to know how private sector enterprises can and cannot intersect with public sector missions.  Past experience provides a cautionary tale of private contractors violating public trust. Even with coverage expansion, public health systems will always play a key safety net role that is incongruent with private sector contractors’ business model. The waiver should not be a vehicle for privatization of public hospitals’ services or administration.
  • Another item to highlight is that in the draft application, the provision for promoting continuity of care for the justice-involved population included the creation of “a patient registry of justice involved patients”.  Health and Medicine supports the intention of this initiative, which seems to be focused on the stable living, continuity of care and medication, and reductions in recidivism; however, we did raise concerns about this in our 1115 comment submission.  Our comment stated that this “raises serious concerns about privacy and stigmatization related to people who have a background with the criminal justice system. Any effort to improve services and care coordination for people who are justice-involved must ensure patients' privacy, dignity, and equitable treatment” (page 4 of Health and Medicine’s comments).  We are pleased to see that this provision has been changed and that the “registry” language has been removed from the waiver application.  We do remain cautious about this initiative and, as we also noted in our comments, recommend that advocates continue to be engaged to protect the justice-involved patients’ rights, privacy, dignity, and equitable treatment, both as the waiver is negotiated with CMS and during the later implementation phases.
DSRIP Payments to University of Illinois Hospital and Health Sciences System (pages 19-20 and Appendix B):

A welcome change in the new 1115 waiver application is the expanded detail on the University of Illinois Hospital and Health Sciences System’s Delivery System Reform Incentive Payments (DSRIP) provisions.  The 1115 waiver application and Appendix C contain detailed proposals for the following projects:

  • Medication therapy management services for patients outside of coordinated care networks or in rural areas to better identify and prevent drug-related problems.
  • Patient-centered medical homes for individuals with sickle cell and for individuals with HIV.
  • Expansion of the Emergency Patient Interdisciplinary Care Coordination (EPIC) Model to address medical and social determinants of health for frequent ER visitors.
  • Building telemedicine capacity in psychiatry and dermatology and expanding hepatitis C and HIV telemedicine clinics.
One of the U of I Health System DSRIP projects raise specific concerns:
  • Medicaid care coordination network at UI Health. Health and Medicine supports building the U of I system into an integrated delivery system and leveraging its successes to improve service delivery statewide.  However, the reliance on a decade-old report on managed care savings--commissioned by the health insurance trade association— to set metrics for this project is worrisome.  The U of I health care coordination project assumes an average per patient per year cost reduction of 10% based on the Lewin Group’s 2004 report, “Medicaid Managed Care Cost Savings:  A Synthesis of Fourteen Studies,” prepared for America’s Health Insurance Plans. The goal of building an integrated delivery system must be first and foremost to improve the quality of care available to the population the U of I system serves. With that starting point, a much more serious consideration of opportunities for cost savings and more recent research should guide assumptions for annual cost reduction goals.
Some recent research casts doubt on the ability of Medicaid managed care to produce savings. To the extent that managed care programs can achieve other policy objectives and, in concert with other reforms, improve access and quality while controlling costs, it should be incorporated into the waiver. Invoking ‘managed care’ as a panacea for Medicaid’s challenges should not become a shortcut around the hard work of genuinely confronting those challenges.  Integration of services through the U of I health system has great promise, but the proposal in the 1115 waiver application was disappointing. We hope it can be strengthened during negotiation and implementation.

Access Assurance Program will shift to payments based on uncompensated care costs (page 22)

The original waiver draft stated on page 18 that the Access Assurance Program, the program being proposed to replace Medicaid Upper Payment Limit (UPL) supplemental payments to hospitals, would move UPL payments to Access Assurance Program payments. The new waiver application revises that statement to say that the Access Assurance Pool will initially replicate the methodology for UPL payments in the State Medicaid plan but that it will transition to a payment methodology based on uncompensated care costs. In a letter to HMA, Health and Medicine suggested that a minimum amount charity care, the best measure of uncompensated care, should be a prerequisite to qualifying for Access Assurance Program payments. Advocates will need to continue engaging with the State and CMS as new payment methodologies for this program are negotiated to ensure access to care for un- and under-insured people.

Definition of “Distressed Hospital” for Health System Integration and Transformation Performance Program (HSITPP) and for the Loan Repayment Program (page 21-22; 28-29)

The 1115 waiver proposes a performance-based incentive pool, the HSITPP, to encourage hospitals to invest in quality improvements. The original waiver draft divided the HSITPP into two pools—one for “distressed” hospitals and one for all others—but did not define “distressed hospital.” The original draft waiver application also proposes to allow “distressed hospitals” to set up their own loan repayment programs without defining “distressed hospital.” The new waiver application establishes two criteria for the ‘distressed’ designation.

To sum up the new definition, a “distressed hospital” is either of the following:

1)    a Critical Access Hospital (CAH). Critical Access Hospitals are hospitals in rural areas with no more than 25 inpatient beds that are more than 35 miles from any other hospital; or,
2)    a “safety net hospital” as defined in 305 ILCS 5/5-5e.1. That section of the Public Aid Code defines “safety-net hospital” as a general acute care or pediatric hospital that is also a Disproportionate Care Hospital under the Social Security Act (in general, DSH hospitals serve largely Medicaid and low-income uninsured patients) and either:
a.    at least 40% of its inpatient days are provided to Medicaid patients AND at least 4% of its total charges are charity care charges for uninsured patients
b.    at least 50% of its inpatient days are provided to Medicaid patients

Advocates should note the provenance of this statute. The State of Illinois defined ‘safety-net hospitals’ in 2012 to exempt those hospitals from cuts to Medicaid rates. It is worth considering whether a new definition of ‘safety net hospital,’ designed to meet the policy goals of the waiver, is necessary. Some questions on this matter:

  • Should the incentive pool be available to rehabilitation hospitals, which are excluded in the existing definition?
  • Charity care is defined as “charity charges for services provided to individuals without health insurance or another source of third party coverage.”  Does this neglect the need for and impact of financial assistance for insured individuals who are unable to pay deductibles and co-payment or co-insurance?  Would including charity charges to cover health insurance cost sharing requirements water down the charity care standard in the safety net decision, or would it strengthen it by taking into account the difficulties facing the under-insured and the hospitals that serve them?
  • Do the criteria target the right hospitals for special consideration under the Health System Integration and Transformation Performance Program? Are there hospitals that would be considered ‘distressed’ under this definition that in fact have ample alternatives to affordably finance investments in quality and integration? Are there other hospitals that need more support to meet the waiver’s delivery system transformation goals that will be left out of the distressed pool?

Regional Pubic Health Hubs (page 24-25)

Another portion of the waiver that is worth advocates’ attention is the provision related to the Regional Public Health Hubs, found in the Population Health pathway, on page 24 of the waiver application.  This provision proposes to ”…incentivize integration of public health and traditional health care delivery toward achieving better overall population health outcomes, Illinois will create a bonus pool, funded at $10 million annually, for health plans that agree to use the funds to develop population health interventions in conjunction with public health entities, including newly created Regional Public Health Hubs.”  This section goes on to say that the hubs “will serve as a ‘nexus’ between the Illinois Department of Public Health (IDPH), local health departments (LHDs), communities, and the health plans and providers serving the region.”

Health and Medicine is supportive of funding for population health efforts.  We as well as others who commented on the draft of the waiver raised concern that this funding may move control and leadership for community health planning and program development away from health departments to managed care organizations who will be receiving such funds.  In the proposal LHDs and IDPH will be dedicating their limited resources – including staff time and their rich data, experience, and expertise in community health assessment and planning – to making the efforts of the Regional Public Health Hubs successful at improving population health.  Health and Medicine supports efforts for increased collaboration on this front; however, using the entirety of the $10 million for population health for payments to managed care organizations, whose missions are not focused on population health, does not align with the fourth goal: “Enhance the ability of the health care system to engage in population management, by leveraging public health resources and encouraging linkages between public health and health care delivery systems.”  Leveraging public health resources precludes privatizing control and leadership of those resources; the waiver funds ought to support entities with population health management expertise (that is, local and state health departments).

Managed care organizations lack the depth of community health needs assessment and planning knowledge and skills that local and state health departments and public health practitioners have built over decades of work and which they will contribute to the Regional Public Health Hubs.  Within their missions, health departments are dedicated to improved community and population health and they have carried out their duties with very limited resources.  Alternatively, privately-run managed care organizations are dedicated to population health only approximately as far as it impacts the patients that are enrolled through their plans.  The State already supports such entities by awarding them Medicaid contracts that already include quality metrics and incentive payments, so no further support is needed. 

The waiver is an opportunity to expand on the local and state health departments’ capacities to do the valuable work of supporting population health. Rather than giving additional payments to managed care organizations, the state should require that managed care organizations that receive Medicaid contracts participate in the Regional Public Health Hubs’ population health efforts as a prerequisite of receiving publicly-funded Medicaid contracts.  The $10 million in annual support for population health should go to support the local and state health departments whose very missions are focused on improving the health of the public and are in need of support to carry out that mission.  Privatizing the public’s funds and the expertise and data of health departments is unlikely to lead to the population health improvements that the State seeks as part of the Triple Aim.

Cost Sharing (page 46-47):

In an alarming shift, the new 1115 waiver application contains requests for waivers of federal requirements related to Medicaid cost sharing. The original draft stated simply, “Illinois is not requesting cost sharing as part of this demonstration.”  The new waiver application states that Illinois will maximize cost sharing and requests waivers of federal law requiring income tracking and patient/provider notification to ensure that cost sharing does not exceed 5% of the family’s income.  In addition, the new waiver application asks for a waiver of requirements that restrict collection of co-payments for non-emergency services furnished in an emergency department. Those requirements include informing patients of the cost sharing obligation and identifying an alternative non-emergency provider that can provider services in a timely manner.

Requesting waivers of these consumer protections while the state upgrades its MMIS system improperly    shifts a financial burden to Medicaid beneficiaries without meeting any clear policy objective.  The 1115 waiver application states strongly that Illinois will shift its Medicaid system to address the social determinants of health. The efficacy of cost sharing in Medicaid is contested to begin with, and implementing cost-sharing without solid consumer protections is contrary to the health equity goals described in the waiver application. As poverty is a key social determinant of health status, placing additional financial burdens on Medicaid enrollees is contrary to the “emphasis on the social determinants of health throughout all of our programs, services, policies and reform initiatives” stated on page 4 of the waiver application.

Feb 13, 2014 Written By: Health & Medicine Policy Research Group (HMPRG)

Recent Health Reform-Related Comments From Health and Medicine

An important part of health and healthcare advocacy is providing relevant testimony and commentary for different legislative, regulatory, and other reform efforts.  

Health and Medicine knows this well, both as longtime advocates and in our recent efforts to engage stakeholders in the 1115 Medicaid waiver process.  In addition to the role of organizing public stakeholder meetings and collecting and summarizing comments from stakeholders, we provided our own analysis and commentary on the 1115 waiver.  (If you’re interested in highlights regarding the hundreds of comments we summarized and categorized, check out this recent blog post.)

Relatedly, as the ACA required Illinois to provide an Alternative Benefit Plan that defines the coverage for those covered by the Medicaid expansion, HFS provided an opportunity for individuals and organizations to submit comments.  

We’re happy to share Health and Medicine’s input on these important healthcare reform efforts with others working to improve the health and healthcare of all Illinoisans.

Comments for Illinois’ Medicaid Alternative Benefit Plan:

Health and Medicine’s Comments regarding Illinois’ Alternative Benefit Plan

Commentary for Illinois’ Medicaid 1115 Waiver:

Health and Medicine submitted comments in reaction to the draft of the Illinois Medicaid 1115 Waiver application and also sent a letter to Health Management Associates regarding the issue of charity care being listed as a requirement for participating in the Access Assurance Pool, as outlined in the Delivery System Transformation section of the waiver application.  The Access Assurance Pool can provide a significant lever for increasing access to care for those who remain un- and under-insured, a major area of interest for Health and Medicine and other advocates in the State.

Health and Medicine’s Comments on the 1115 Draft Application

Letter to Health Management Associates Regarding Charity Care and the Access Assurance Pool in Illinois’ Medicaid 1115 Waiver

What’s next?

An updated 1115 Medicaid Waiver application that will be sent to the Federal Center for Medicare and Medicaid Services (CMS) on March 11th has been made available for review here.  Health and Medicine is working with the State on holding hearings on February 14, 2014 in Springfield and on February 20, 2014 in Chicago (register here).  Individuals can provide written or oral testimony at either of these hearings and the State will be accepting comments until February 20, 2014.  See the State’s 1115 Waiver page for more details on how to submit comments.

Health and Medicine is continuing to analyze the 1115 waiver application and the comments that advocates submitted.  Check back here often as we will be sharing additional analysis in the coming weeks and months.  

Feb 11, 2014 Written By: Health & Medicine Policy Research Group (HMPRG)

Illinois' Medicaid 1115 Waiver Stakeholder Update

Health and Medicine has been responsible for reviewing and summarizing the public comments on the draft of Illinois’ 1115 waiver application. The stakeholder engagement process was extraordinary in the State’s history, with over 450 individuals and organizations registering to attend stakeholder meetings.  Both Health Management Associates and the State used the summaries of input from stakeholders to craft the new waiver application, which is available here.
 
As stakeholders across Illinois prepare for the next steps in the 1115 waiver process, here are some highlights from the public comments on the draft waiver application:
  • Eighty-five organizations submitted 949 comments or recommendations
  • Disability rights advocates and service providers submitted the most comments at 209, followed by health policy advocates with 99, housing organizations with 87, and aging advocates and providers with 81.
  • Of the four pathways in the draft 1115 waiver application, Home and Community-based Services was the pathway with the most comments.
  • Health and Medicine used 50 broad categories to organize the comments. The top 5 categories of comments were:
    • Governance and Financing of the Waiver
    • Care Coordination
    • Waiver Process
    • Housing
    • Specific Reimbursement Recommendations
Overall, stakeholder comments offered suggestions for improving the waiver application so that it matches ongoing health reforms that the State has been working to implement, ensuring that it takes into account the care and support happening in clinics, community organizations, and within communities, and also asking for further assurance of protections for the different consumers and constituencies who advocates and providers serve.  Many comments expressed general support for the waiver and requested that stakeholders continue to be engaged beyond the application process for both the negotiation and implementation phases of the waiver.

Many stakeholders commenting on care coordination highlighted how their current activities could contribute to the overall waiver goal of coordinated health care and social services. Of course many also included recommendations for reimbursing for those activities, and still more requested more detail about how the waiver contemplates changes to existing delivery and payment systems.

The ambitious changes the waiver proposes for Illinois’ long-term services and supports system stimulated intense commentary. The 1115 waiver would consolidate nine 1915(c) waivers that Illinois currently uses to provide home and community-based services under a single streamlined assessment, service planning and rate setting system. Amidst the understandable anxiety from advocates and providers alike, stakeholders offered suggestions for common service definitions, consumer protections, training for LTSS workers, and expanding community services for people with serious mental illness and people with substance use disorders, to name just a few topics.

The possibility of new funding pools for hospitals to expand services and implement delivery system reforms piqued stakeholders’ interest as well. Several offered recommendations for performance metrics and visions for integrated delivery models the incentive pools could support. Others expressed unease about interfering with existing hospital financing mechanisms and concern about the exclusion of some providers, especially downstate and rural hospitals. Some comments also expressed concerns with the Universal Assessment Tool’s (UAT) development and implementation, the desire for more details, and requests for assurance that stakeholders will be deeply involved in producing, testing, and modifying the UAT.

The public comments also reflected a passionate interest in the 1115 waiver’s housing proposal. Several stakeholders offered thoughtful arguments on the relationship between housing and health outcomes, and many also recommended additions and improvements to the draft waiver application’s plan for incentivizing housing supports through Medicaid, including calls for funding wraparound services and integrated housing for people with disabilities.

Emphasizing the connection between the health care workforce and the overall goals of the waiver, many comments suggested specific additions to the loan repayment and GME proposals while also highlighting the need for a linguistically and culturally competent workforce that includes people with disabilities and people who have been justice-involved and further, that all workers are paid a living wage.

There were hundreds of comments on many, many diverse topics, reflecting the wide interest and varied expertise of Illinois’ health care providers, consumers, and advocates. Be sure to take a look at the new waiver application to see what’s changed and please stay involved as Illinois negotiates with the Center for Medicare and Medicaid Services and moves toward implementation.

Many of the comments have not been included by HMA and the State in the final draft of the Waiver Application, whether because they are not matters that need to be waived by the CMS, are implementation issues, or if for some other reason, they did not fit into the application; however, these comments will be helpful to advocates and the state as negotiations with CMS proceed and as the state moves to implement the final agreement between the State and CMS. It is a rare and valuable opportunity to have a large portion of the State’s many committed health advocates and constituencies provide such engaged input for improving a large program, such as Medicaid.  Health and Medicine is committed to ensuring that the comments that were generated through the stakeholder engagement process are further analyzed and those that may have not been included in the waiver are taken into consideration for further improving Medicaid at the State level. 

The 1115 waiver has been described as a request to the Federal Government to waive certain requirements and provide financial flexibility to improve Medicaid in Illinois.  The necessary counterpart to the waiver application is continued stakeholder engagement within the State, both to implement the waiver itself and to make reforms to further ensure access to care, increase care quality, and improve the health of Illinoisans. Health and Medicine plans to share more details of the comments moving forward so that all of us can learn from other organizations’ priorities and develop more robust planning, programming, and advocacy agendas. We thank the advocates and constituents who have been involved thus far and are excited to continue to engage people regarding improving Medicaid in Illinois.
Jan 09, 2014 Written By: Health & Medicine Policy Research Group (HMPRG)

Check out this helpful document that explains the many different acronyms related to Coordinated Care in Illinois.

When we say that the unofficial tagline of healthcare policy work is “Drowning In Acronyms”, we’re only partly kidding. There are so many abbreviations that our new Center for Long-Term Care Reform Director Sharon Post made a very helpful Illinois Coordinated Care Legend to help our staff keep the  differences between ACEs, ACOs, CCEs, MMAIs, etc straight. We’ve decided to share it in case it is helpful to you as well. Click here to view it!
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