Delivery of Care

When the conversations about health, health care delivery, do not converge

Four separate narratives took place on Nov. 12, all important and compelling in their own view, but they occurred mostly in silos

Photo by Richard Asinof

Wendy Claiborne, left, and her daughter, Traecina Claiborne, right, with David Jacobs, center, three of the people honored at the Childhood Lead Action Project 23rd annual celebration. Jacobs, who is research director of the National Center for Healthy Housing, praised the Childhood Lead Action Project as being one of the best grassroots community groups battling lead poisoning in the nation. The mother-and-daughter team won a successful civil legal action against a landlord, whom the jury found negligent and liable for damages caused from the lead poisoning in August of 2015.

Courtesy of the Mayo Clinic

Two panels of a patient engagement tool brochure prepared by the Mayo Clinic, comparing the weight change and cost attributes of anti-depressant medications, reflecting the the best available research studies, without any funding from makers of depression medicines.

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By Richard Asinof
Posted 11/16/15
There are numerous, ongoing conversations and dialogue around the delivery of health care occurring in Rhode Island, but, for the most part, they are still being conducted in silos, without much in the way of convergence or connection. Last week, four such conversations occurred on the same day; in response, ConvergenceRI created the beginnings of a guide for the perplexed, where the story lines converged.
What will Brown University President Christina Paxson say in her talk, “Unpacking Racial Health Disparities,” on Nov. 16, and how will it connect to ongoing efforts to develop health equity zones in Rhode Island? Would Brown University’s Medical School or its School of Public Health be willing to underwrite a pilot program to integrate the Prevention Institute’s health equity metrics as well as the 37 evidence-based community health indicators being developed by Providence into an evidence-based approach, in order to integrate the social determinants of health into the population health analytics management at a series of community health centers in Rhode Island’s urban core cities? How can the ongoing conversation about reducing toxic stress in Rhode Island become part of the equation with the Care Transformation Collaborative and PCMH-Kids?
The popularity of period tracker apps, as detailed in a story in The New York Times on Nov. 12, entitled, “How Period Trackers Have Changed Girl Culture,” could have been subtitled, how patients and consumers using digital media are changing the conversation around their own health care. There are more than 200 period tracker apps to choose from, and consumers have downloaded Period Tracker and Period Calendar/Tracker more than 10 million times from the Android store alone, according to the IMS Institute for Healthcare Informatics.
Period tracker apps, as the article reported, can track a range of issues related to the menstrual cycle, including emotions, cramps, weight, sleep, energy, food cravings and more. They can also record when you had sex or remind you to pack tampons, take your birth control pill or do a breast exam – “all information women say is both empowering and liberating,” according to the article.
Unlike with most hospital IT systems and even patient-engagement programs, such as the one described by the Mayo Clinic, the woman becomes the arbiter of the information, and how it shared – not the health care delivery system. The information is not directly tied or stored by a state or federal or health care entity database; it is not driven by a wearable, medtech device. It is patient-driven, consumer-driven health.

PROVIDENCE – There were at least four competing narratives in play on Thursday, Nov. 12, each with its own stream of conversations occurring, each with its own distinctive perspective on the delivery of services within the health care ecosystem of Rhode Island.

The narratives did not seem to converge or connect, perhaps serving as a proof of Euclid’s parallel postulate: that two separate lines will continue in space and never intersect, as if the world was flat.

Even more perplexing, from ConvergenceRI’s point of view, was how to connect the conversations into one coherent, cogent story.

The first image, however trite, that came to mind was the adage about nine blind men and women describing an elephant, each with its own specific – and accurate – view of the animal – the tusk, the trunk, the tail, and the foot – but missing the whole story.

The elephant in the room, of course, is the patient.

In writing this story, ConvergenceRI decided to invoke the optimism of Buckminster Fuller, and his definition of synergy, that the creation of a whole is greater than the simple sum of its parts.

The first thread was the 2015 R.I. Care Transformation Collaborative Annual Learning Collaborative, held at the Renaissance Hotel, attended by more than 200 primary care team members, practice leaders, nurse care managers, medical assistants and stakeholders, entitled: “Primary Care Plus – Paving the Way.” The guest speakers were to focus on the primary care team’s role in partnering with patients [emphasis added] as well as the management of high-risk patients.

Continuing education credits were offered for nurses, social workers and physicians attending.

For the uninitiated, the Care Transformation Collaborative, formerly known as the R.I. Chronic Care Sustainability Initiative, or CSI-RI, is an all-payer, patient-centered medical home approach that now delivers primary care to about one-third of Rhode Island’s population, more than 300,000 Rhode Islanders – even if the patients themselves may be unaware that that they are participants in a PCMH.

The Care Transformation Collaborative serves, in many ways, as the playing and practice fields for health care reform in Rhode Island, directed at changing the way primary care is delivered. It is where the holy grail of health care reform – the triple aim – gets frequently invoked: to improve the quality and access to care, to improve outcomes and lower costs, and to improve patient satisfaction.

The problem, according to Dr. Kathleen Hittner, the R.I. Health Insurance Commissioner, who addressed the gathering mid-morning, was this: “We haven’t demonstrated cost savings yet.”

The second thread was the application process for the “Accountable Entity Coordinated Care Pilot Program,” with applications due on Friday, Nov. 13, the fast-tracking of efforts begun under the Reinventing Medicaid working group, now enshrined in law as part of the Reinventing Medicaid Act of 2015.

This has been kind of a stealth conversation, well below the radar screen. Some folks in leadership positions who attended the “Primary Care Plus – Paving the Way” conference were well aware of the program and the application deadline; they told ConvergenceRI during breaks in the proceedings that they were still pondering how the proposed pilot program would work, but were preparing applications anyway.

When asked by ConvergenceRI, a spokesman for the R.I. Executive Office of Health and Human Services declined to offer any comment. The pilot program is one of those “hot potatoes” that has been handed to Anya Rader Wallack, the new director of Medicaid. [See link to ConvergenceRI story below.]

The proposed standards for what a “certified accountable entity” will not be issued until February of 2016, but the pilot program, with less rigorous standards, is scheduled to be on Jan. 1, 2016, covering some 25,000 Medicaid members.

The fast-tracking is tied to the overarching goals to have 50 percent of all Medicaid payments made through alternative payment models such as accountable entities by 2018, and to have 25 percent of all Medicaid members enrolled in an accountable, integrated provider network by 2018.

Once again, the promise is that the transformation of the Medicaid managed care system will reduce costs by improving coordination of care and by introducing harmonized quality metrics. And, as with the Care Transformation Collaborative, the actual reduction in costs is still theoretical, a work in progress.

Translated, the current cost-effective, high-quality outcome, managed Medicaid program delivered by federally qualified community health centers is about to be disrupted, big time, allowing larger hospital systems, such as Prospect Medical, the for-profit parent of CharterCARE, to become players and capture a share of the Medicaid market.

The third thread was an ongoing dialogue, part of the continuing conversation that emerged following the event, “Building a Collaborative Strategy To Help Reduce Toxic Stress in Rhode Island: A Conversation/Convergence,” held on Oct. 28 at Rhode Island College, about how the concepts of health and health equity, differentiated from health equality, could become part of the metrics of measuring quality outcomes in the new accountable care world. ConvergenceRI met with a key player in the state's health care ecosystem to discuss strategies about how to integrate health equity into the existing work on harmonizing quality metrics now underway.

The Prevention Institute, in partnership with the Robert Wood Johnson Foundation, has developed a comprehensive new approach to the metrics of health equity. Called “Measuring What Works To Achieve Health Equity: Metrics for the Determinants of Health,” the recently published work provides a tool for the way that health equity can become part of the metrics measuring the delivery of health, and not just health care.

In Providence, one of four cities selected to be part of a pilot project, the Healthy Communities Transformation Initiative, two evidence-based tools are being developed: a healthy communities index and a healthy communities assessment tool. With the index, communities can identify baseline conditions, prioritize investments and evaluate profess in achieving goals, focused on educational opportunities, economic health, employment opportunities, environment hazards, health systems, public safety, housing, neighborhood characteristics, transportation, and social cohesion. Those domains have been translated into 37 evidence-based community health indicators.

Under the direction of Peter Asen, the director of Providence’s Healthy Communities office, a website has been created to input the data, by city neighborhood, into indicator categories.

The question is: how can the 37 evidenced-based community health indicators be plugged into an existing health population management analytics database, using the Prevention Institute’s metrics, to develop benchmarks for health equity?

To date, however, the State Improvement Model plans and the Reinventing Medicaid plans have not chosen to pursue this kind of pilot program, focused on integrating the social determinants of health in the metrics of health care delivery. Why not?

The fourth thread was the celebration held by the Childhood Lead Action Project in the Rotunda at the Citizens Building. Two of the recipients of the annual awards presented by the grassroots community group fighting lead poisoning in children were a mother and daughter, Wendy and Traecina Claiborne, who some 20 years after being poisoned by lead in an apartment in Pawtucket, went to court and prevailed in a civil lawsuit that held the landlord negligent and liable.

The celebration occurred at the same time that the larger-scale Publick Occurences event about racism was being held, sponsored by The Providence Journal as part of its yearlong series on racism in Rhode Island. The story of the mother and daughter, and the legacy of lead poisoning, which connected not only to the inequality and lack of health equity in Rhode Island but to disparities in education outcomes and economic attainment, seemed more on point to ConvergenceRI.

In 2014, nearly 1,000 children were newly diagnosed as having been poisoned by lead for the first time. Preventing lead poisoning from occurring becomes the solution that will improve all the educational and health care metrics, reducing medical costs and improving the quality of life. The return on investment in lead removal is $221-to-$1 invested. And yet, for all the tens of thousands of words in the stories written about racism in The Providence Journal, lead poisoning was missing from the conversation so far.

Dancing as fast as we can
The apocryphal punch line, “I’m dancing as fast as I can,” which became the title of a book by Barbara Gordon and then a movie, originates from a joke attributed to a conversation overheard at a hotel in the Catskills in New York.

The man tells the woman that he’s dancing with: I’m only going to be here for two weeks. The woman responds: I’m dancing as fast as I can.

The message delivered by Dr. Gus Manocchia, senior vice president and chief medical officer at Blue Cross & Blue Shield of Rhode Island, in the opening remarks at the R.I. Care Transformation Learning Collaborative “Learning Collaborative” session on Nov. 12 was similar: primary care practices needed to “dance faster” when it came to reducing costs.

“This is very hard work,” Manocchia began. “This kind of transformation takes time and a tremendous amount of work.”

Before the Affordability Standards were put in place by the R.I. Office of the Health Insurance Commissioner, only five cents on the dollar was going toward primary care; today 10 cents on the dollar was going to primary care, Manocchia said.

“Doctors haven’t seen that money every week in their wallets or pocketbooks,” Manocchia said. Instead, the money has gone into building the health care delivery infrastructure. The bottom line: a lot has happened, according to Manocchia.

But, he continued, “The great work that has been done so far has to go faster. Reducing costs has to go faster,” citing the Rhode Island Business Group on Health’s recent gathering and the fact that insurance premiums for small businesses in Rhode Island keep increasing by 5, 10 and 15 percent a year.

Do the needs of the patient come first?
Nilay Shah, Ph.D., a consultant with the Division of Health Care, Policy and Research at the Mayo Clinic, gave the first keynote at the CTC Learning Collaborative, entitled “Evidence in Action: Role of Shared Decision Making in a Learning Health Care System.”

Surprisingly, much of the work described by Shah focused on medication adherence for diabetes, statins for heart attack and stroke risks, anti-depressants for mental health, and the effectiveness of consumer guides presented to patients on cost, risk, and side effects. Other medication regiments targeted in decision-making aids were for osteoporosis.

The evidence-based approach to sharing more information about medication choices developed and promoted by the Mayo Clinic appeared to show that involving patients in the decision-making increased their buy-in.

However, the larger issues – such as the over-reliance on prescription drugs to treat chronic disease conditions including depression in a primary care setting, or the ongoing debate about the risk analysis over the use of statins – were not addressed, and appeared to be missing from the approach. Nor were any of the social or economic determinants of health, major factors in chronic disease management, addressed.

Shah said that there was no consistent evidence of achieving better medication adherence, health outcomes or cost reductions as a result of the efforts.

How’s your health?
In the first breakout session, focused on “partnering with patients,” Dr. Lynn Ho described the simple survey and data tool that she has used to gather the patients’ voices to access and improve the practice.

In somewhat rapid-fire delivery, Ho, a solo practitioner, described the way that she was able to work with the patients to gain their input, through the use of the survey tool, HowsYourHealth.org, which begins with a series of questions regarding health confidence: “How confident are you that you can control and manage most of your health problems?” And, if your rating was less than a 7 in a scale from zero to 10, learning what it would take to increase your score.

Ho talked about the way that she has found the tool invaluable in developing relationships with patients, enabling her to build a database that can provide insight into a patient’s changing conditions.

As the world turns
Coffee and tea at the Renaissance Hotel were provided using Starbucks brands; for the record, only white cups, no red cups, were used.

The same day as the conference, hotel workers at the Providence Renaissance Hotel voted in favor of joining UNITE HERE Local 217, by a total of 23 workers in favor and 17 works opposed to joining the union. Most of the participants at the conference appeared to be oblivious that a major union election was being held.

The scheduled date for the launch of PCMH-Kids is Jan. 1, 2016

Details, details, details on the fast track
The grist for discussion about the efforts to transform the delivery of Medicaid manage care providers into accountable care entities can be found in the appendix of the Accountable Entity Coordinated Care application, issued on Oct. 30.

The appendix describes in detail the Accountable Entity Certification Standards, which are in draft form, and will not be actually posted until Feb. 12, 2016.

In the meantime, the program has set the following dates for implementation:
Nov. 13, Round 1 pilot applications due

Nov. 27, Round 1 pilot eligible entities designated

Jan. 1, 2016, effective date when Round 1 pilot programs begin

Jan. 6, 2016, Round 2 pilot applications due

Jan. 27, 2016, Round 2 pilot eligible entities designated

April 1, 2016, Round 2, Round 2 pilot programs begin

The draft timeline for full Accountable Entity certification runs as follows:
Dec. 15, comments due on draft Accountable Entity certification standards to R.I. EOHHS

Feb. 12, 2016, final Accountable Entity application and certification standards posted

April 1, 2016, Accountable Entity applications due

June 24, 2016, Accountable Entities certified by R.I. EOHHS.

On Thursday, Nov. 12, ConvergenceRI had reached out to Michael Raia, the communications spokesman at R.I. EOHHS, to try and get a statement regarding the pilot programs for the Medicaid accountable care entities.

No response was provided.

In addition, ConvergenceRI asked: how many pilots do you anticipate will be chosen, and what will be the criteria for deciding who gets chosen? No answers were provided.

Stay tuned for a deeper give in upcoming future issues of ConvergenceRI.

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