Published in NJ Spotlight
By Andrew Kitchenman

Regulation moves Medicaid closer to insurance coverage available through federal marketplace

Jeff Brown directs the New Jersey Health Care Quality Institute’s QI Collaborative, a group that focused on redesigning the healthcare delivery system.

Efforts by advocates to increase access to healthcare may have received a major boost from the federal government this week in the form of the largest overhaul of rules relating to insurers and Medicaid and the Children’s Health Insurance Program in 13 years.

The regulatory proposal could ease the transition as Medicaid recipients move to the federal individual health insurance marketplace; change Medicaid’s definition of care coordination to include social supports outside of healthcare; and encourage the expansion of healthcare-delivery models that have proven successful in other states, according to healthcare experts.

“There’s a recognition in there that there’s a role for care coordination that goes beyond the traditional health system,” said Jeff Brown, who directs the New Jersey Health Care Quality Institute’s QI Collaborative, a group that focused on redesigning the healthcare delivery system.

Centers for Medicare and Medicaid Services (CMS) officials said they were prompted to revise the regulations due to the large number of major laws affecting managed care since the last rewrite in 2002, including the implementation of the Affordable Care Act. The rules apply to managed care, in which state Medicaid programs pay insurers (known as “managed care organizations,” or MCOs) a set amount each month, and they in turn pay providers.

The proposed regulations are capturing the attention of organizations involved in improving the health of Medicaid recipients.

Mark Humowiecki, general counsel of the Camden Coalition of Healthcare Providers, said there could be benefits from the proposal’s emphasis on making Medicaid regulations more similar to those for federal marketplace plans, as well as for those in private Medicare advantage plans.

“It make some intuitive sense — there’s certainly going to be the dynamic of some people moving in and out of Medicaid eligibility” as their income changes, Humowiecki said. He added that he hadn’t gotten a chance to review the 652 pages of regulations.

CMS officials gave this as part of the rationale for the proposal: “By aligning Medicaid managed care with other programs when possible, we believe enrollees will experience smoother transitions and have fewer disruptions to care when they transition among sources of health care coverage.”

One proposal that’s gained the attention of insurers nationally would allow states to require the MCOs to spend at least 85 percent of the Medicaid payments on patient’s health claims, which would limit all of their operating expenses — as well as their profits — to no more than 15 percent. While this brings Medicaid in line with ACA rules, insurers raised concerns about how this would affect their operations.

It’s not clear how this rule change will affect New Jersey MCOs, since the state already applies similar minimums spending amounts — known as medical-loss ratios — on managed care, with the percentages varying between 80 percent and 90 percent depending on the patients they serve.

Brown said he was most encouraged by the potential change in the regulatory definition of care coordination. For the first time, the Medicaid rules are considering adding social supports, including legal services for patients — in the definition of care coordination, a term that traditionally referred to insurers and various healthcare providers working closely together, but is increasingly including housing and other types of services.

“A key part of care coordination (is) helping with the transition with care in the health system and social services outside the health system,” Brown said, noting that residents without stable housing are more frequent visitors to hospitals.

Brown also noted that the regulations could require MCOs to list their providers in “machine readable” lists. He said that’s significant because such lists can be used by nonprofits and others developing consumer tools to make it easier for patients to search for providers that will best meet their needs. Currently, some insurers limit searches to a specific geographic area or medical specialty, instead of allowing outside groups to access the entire list of providers.

“It will allow us to see some consumer-focused innovations,” Brown said.

Humowiecki also said that it’s important for Medicaid to consider more than just healthcare in defining care coordination.

“That’s the core of our coordination intervention — if you stop at the medical intervention … you’re not going to get into” the social factors that determine residents’ health, he said.

Brown also said that he will keeping an eye on whether the regulations are used by the federal government to encourage the expansion of new state models for delivering Medicaid services. He noted that New York and Minnesota have made improvements that could benefit New Jersey and other states.

“If CMS can take some of the best practices that are really flourishing in places like that, it can benefit (patients) on a national basis,” Brown said. The program Brown leads is working with healthcare organizations on payment and delivery-system changes, with a goal of improving healthcare quality.

Read it in NJ Spotlight here.

CarePlus NJ

CarePlus NJ

Published in NJBIZ
By Beth Fitzgerald

CarePlus NJ in Paramus announced Wednesday that it is the first state-certified agency in Bergen County to establish a “behavioral health home, a new model of integrated primary care for individuals with severe mental illnesses.”

CarePlus Chief Executive Joe Masciandaro said the CarePlus behavioral health home model will be more affordable and will enable individuals with severe mental illnesses to access primary health care services more easily.

New Jersey recently authorized behavioral health home services under a provision of the Affordable Care Act to help fund this new care model. CarePlus said the ACA will benefit certified behavioral health agencies and the individuals who might not otherwise be able to afford primary care, and will also benefit the state and federal governments by decreasing the frequency and cost of inpatient hospitalizations.

CarePlus has been developing an integrated mind and body approach to wellness since 2010 when it received a grant from the federal Substance Abuse and Mental Health Services Administration. With that funding, CarePlus was able to develop integrated treatment care regimens with such outcomes as  normal blood pressure, reduction of emergency room visits, participation in wellness programs and a positive perception of care. CarePlus was also selected for a new grant to encourage patient engagement through the use of mobile technology.

Masciandaro said moving forward, CarePlus is working to provide comprehensive physical and behavioral care management and transitional care following any inpatient hospitalization. These care coordination services include a professional team of medical and behavioral health experts

CarePlus NJ is a northern New Jersey provider of recovery-focused mental health, primary care, substance abuse, and family services. It operates out of 23 sites, including outpatient centers, residential facilities and community offices.

Read the story on NJBIZ here.

Published in NJBIZ
By Beth Fitzgerald

Barnabas Health, New Jersey’s largest hospital system, and the Visiting Nurse Association Health Group have decided to partner on their journey toward a major health care reform destination: keeping patients healthy at home so they’ll spend less time in hospitals and other health care facilities.

Barnabas Health Home Care and Hospice and the VNA Health Group said the goal of their partnership is “improving the quality and efficiency of post‐acute care, home care and hospice in the communities they serve.”

Barry H. Ostrowsky, chief executive of Barnabas Health, said, “Hospitals and home care providers must find new ways to collaborate and coordinate care to provide a more seamless patient experience, reduce unnecessary rehospitalizations, and improve health outcomes for the patients and populations we serve. This partnership will position our organizations to meet these emerging challenges, while maintaining focus on delivering the highest quality post‐acute services.”

Dr. Steven H. Landers, chief executive of VNA Health Group, said the partnership with Barnabas, which he expects to become final in six to 12 months, will be similar to VNA’s existing hospital joint ventures with Robert Wood Johnson University Hospital, Englewood Hospital and Medical Center and Cape Regional Medical Center.

“This partnership with Barnabas Health is an opportunity to grow as an independent community agency while closely collaborating with a leading health system,” Landers said.

Keith L. Boroch, chief executive of Barnabas Health Home Care and Hospice.

Keith L. Boroch, chief executive of Barnabas Health Home Care and Hospice. – (BARNABAS HEALTH)

Keith L. Boroch, chief executive of Barnabas Health Home Care and Hospice, said Barnabas had been exploring various strategies for expanding its home care services. He said Medicare and commercial health plans want hospitals to “move toward providing much more of a link to home and community-based care models, to reduce (hospital) readmissions and to improve quality of care.”

One strategy could have been for Barnabas to grow its home care operations, in part via acquisitions, Boroch said.

“But as we started looking at this, we looked at the potential for partnering with a high-quality organization that had a great reputation and that shared the value system of Barnabas Health — and the VNA fit that model.”

He said partnering with VNA will help Barnabas provide patients the care they need to transition back home following acute and post-acute care. And it also positions Barnabas for a future in which the focus is on population health management, with health care systems taking responsibility for keeping people healthy. And this involves “helping people to be able to stay in their homes as they are either recovering from or are dealing with chronic illnesses, to be able to serve them in a much more focused, cost-effective manner in the comfort of their own homes — which is where people prefer to be.”

Boroch said Barnabas Health currently has about 600 employees in its home care and hospice unit, provides home care to an average of 1,700 people daily and provides hospice care to about 400 people.

Landers said VNA will continue to provide home care services on its own, as well as co-managing home care services with its joint venture partners.

VNA Health Group provides home care to about 7,000 patients daily, and provides palliative and hospice care to more than 1,500 patients.

Landers said, “We’re in an era where home and community care is growing in importance and where hospitals and physicians are more and more responsible for outcomes outside of the hospital.”

He said the partnership with Barnabas “is an exciting development to position our organizations to succeed and to make a difference in that new reality.”

Boroch said, “If you look at patients that are discharged (from hospitals) and the readmission rates of those patients, home care has better outcomes in reducing readmissions than other services.”

Right now, the two organizations have strengths in certain areas of the state; through the partnership “the patchwork that currently exists will be much more unified,” Landers said.

Barnabas provides home health and hospice services in Essex, Monmouth, and Ocean counties, while VNA Health Group independently provides home care and hospice services through the Visiting Nurse Association of Central Jersey in Monmouth, Middlesex, Essex, Hudson and Burlington counties. The partnership will align the two organizations’ services in these areas.

They will operate together but continue to use their current names: Barnabas Health Home Care and Hospice in northern New Jersey, primarily Essex and Hudson counties, and VNA of Central Jersey from Middlesex to the southern region of the state.

Read on NJBIZ here.

Published by the Trenton Health Team

(TRENTON, NJ) – Mayor Eric Jackson joined the Trenton Health Team today in presenting grants to seven churches and faith-based organizations to implement activities and educational programming to promote healthy eating and physical activity.  The awards represent the first round of funding by THT made possible through its ‘Faith in Prevention’ grant from the New Jersey Department of Health.

“Health is a priority for planning and policy within my administration,” said Mayor Jackson, who is working to implement a “health in all policies” approach for the City, having included health as a focus within the Trenton250 Master Plan.  “We count the faith community as true partners in our efforts to improve health outcomes for Trenton, helping to increase knowledge, access, and hope for our citizens.

In a city where 39 percent of the residents are deemed obese and 16 percent suffer from diabetes, the focus is on getting and staying healthy by creating a partnership between the city’s healthcare collaborative and the faith community.

“Through this program, we are encouraging community residents to take ownership of their health and well-being,” said James Brownlee, director of the Department of Health and Human Services and Health Officer for the City of Trenton, who also serves as THT’s president.  Mr. Brownlee plays a leadership role in implementing THT’s Community Health Improvement Plan, which was developed and adopted through a city-wide partnership of healthcare, governmental, behavioral and social service agencies plus the faith community.

“Faith-based organizations play a vital role in caring for the sick and vulnerable,” said Gregory Paulson, deputy director of THT.  “Through this program, their role is being recognized and supported in a way that amplifies our efforts to address priority health concerns for the city, including health literacy, obesity and healthy lifestyles, and chronic disease.”

THT is currently working with 10 faith-based organizations to implement the education and prevention program funded by the State.  Churches are deploying the evidence-based “Faithful Families Eating Smart and Moving More” curriculum.  Seven churches completed the application process and are receiving grants ranging from $3,500 to $8,500.  They are:

  • Cadwalader Asbury United Methodist Church
  • The Church of the Blessed Sacrament – Our Lady of the Divine Shepherd
  • El Centro of Catholic Charities, Diocese of Trenton
  • St. Vladimir Orthodox Christian Church
  • Shiloh Baptist Church
  • Trinity Episcopal Cathedral
  • Westminster Presbyterian Church

As additional churches begin the program, THT expects to make another round of grants for a cumulative total of $62,000 to support their participation.

Grant funds are used to underwrite programs encouraging people to eat healthy foods and increase physical activity, including exercise classes and the establishment of church gardens.  Groups involved in the program start with a self-assessment to determine the needs and interests of their congregation and community.

“These faith-based programs will help us expand on our community connections, building awareness and participation in nutrition and active lifestyle programs that will be delivered through the infrastructure of a trusted and established resource:  the community’s churches and faith-based organizations,” said Paulson.  “We look forward to an ongoing partnership with the city’s churches and congregations that will advance our shared mission of healing and health for the community.”

Published in NJBIZ
By Beth Fitzgerald

CarePlus NJ in Paramus announced Wednesday that it is the first state-certified agency in Bergen County to establish a “behavioral health home, a new model of integrated primary care for individuals with severe mental illnesses.”

CarePlus Chief Executive Joe Masciandaro said the CarePlus behavioral health home model will be more affordable and will enable individuals with severe mental illnesses to access primary health care services more easily.

New Jersey recently authorized behavioral health home services under a provision of the Affordable Care Act to help fund this new care model. CarePlus said the ACA will benefit certified behavioral health agencies and the individuals who might not otherwise be able to afford primary care, and will also benefit the state and federal governments by decreasing the frequency and cost of inpatient hospitalizations.

CarePlus has been developing an integrated mind and body approach to wellness since 2010 when it received a grant from the federal Substance Abuse and Mental Health Services Administration. With that funding, CarePlus was able to develop integrated treatment care regimens with such outcomes as  normal blood pressure, reduction of emergency room visits, participation in wellness programs and a positive perception of care. CarePlus was also selected for a new grant to encourage patient engagement through the use of mobile technology.

Masciandaro said moving forward, CarePlus is working to provide comprehensive physical and behavioral care management and transitional care following any inpatient hospitalization. These care coordination services include a professional team of medical and behavioral health experts

CarePlus NJ is a northern New Jersey provider of recovery-focused mental health, primary care, substance abuse, and family services. It operates out of 23 sites, including outpatient centers, residential facilities and community offices.

Published in NJ.com
By Susan Livio

Same-day surgery centers contributed $3.75 billion to New Jersey’s economy last year, employing 9,100 people and generating $73 million in tax dollars, according to the industry’s latest annual report that was released on Tuesday.

The second annual report by the New Jersey Association of Ambulatory Surgery Centers coincides with the introduction earlier this month of controversial legislation aimed atcurbing the astronomical billing practices of some out-of-network physicians and hospitals. The association opposes the bill, which would limit what out-of-network medical professionals could charge for services.

“We always talk to legislators, and there are things on the horizon,” said Larry Trenk, the association’s president, explaining what impact he hoped the report would have in Trenton. The goal of the report is to “solidify our place” in the market “and make them appreciate our role.”

“The report paints an impressive picture of how we impact the state economically. We’re not a mom and pop (type of) industry,” he added.

New Jersey’s 72 hospitals contributed $21 billion to the state’s economy in 2013, according to a report by the New Jersey Hospital Association in December.

There are 364 same-day surgery centers in New Jersey, each running, on average, a $4.3 million operation, according to the report. After dramatic growth in the industry in the 1990s, the state imposed a moratorium on the creation of new centers in 2009. But growth is expected, with the Affordable Care Act and Medicare both discouraging costlier in-patient hospital care whenever possible, Trenk said. More hospitals are forming partnerships with surgeons and surgery centers, he added.

“The industry has grown, there are more people employed, and the centers are busier. You are seeing more cases shift out of hospitals” such as spinal surgeries and hip and knee joint replacements, Trenk said.

Surgery centers are not legally mandated to accept uninsured “charity care” patients, which have made them the target of criticism by hospitals which must accept patients in need of emergency care regardless of their ability to pay. Trenk said the criticism overlooks the fact that each surgery center has paid a state tax based on profits. The tax was a maximum of $150,000 a year when it was instituted in 2004. This year, the most lucrative centers pay $350,000, he said.

The surgery center association’s attorney, Mark Manigan of Roseland, issued a statement last week urging lawmakers who sponsored the so-called “out-of-network” bill to eliminate the requirement that centers monitor the billing practices of their physicians, and disclose the cost of each procedure, among other concerns. Lawmakers who sponsored the bill met with the association last week as well as dozens of out insurance and health care representatives to craft a compromise.

Information about how to obtain licensing, accreditation and inspection reports for specific same-day surgery centers, may be found here. The health department began posting inspection reports in 2012 at the urging of the New Jersey Health Care Quality Institute, a consumer advocacy organization and think tank, which had obtained the records and shared them with The Star-Ledger.

Read it on NJ.com here.

Patricia Kelmar, Senior Policy Advisor for the Quality Institute, recently attended ERCI’s 22nd Annual Conference, which focused on key issues in cancer care delivery.

1. What are some of the most critical policy issues today in cancer care delivery?
One of the significant challenges now is the cost of emerging and often extremely expensive treatments. As payment systems move toward value-based payments, the challenge will be finding the most cost-effective way to deliver the care people need.

2. So how are physicians and payers going to determine which treatments will truly help patients and which ones are inappropriate?With greater sources of data we are able to better track patient health profiles and the success of their treatments. We have cancer registries, public health data, electronic health records and other sources of data about people’s health and lifestyles.

3. Much of this data has been available for years. What’s really new?
The way we are using the data is changing. We’re beginning to use the tools of Big Data to better collect and analyze data to provide life-saving information. Equally important, we are developing new sources of data. New discoveries will be made possible through data sets such as those generated through the Precision Medicine Initiative’s national research cohort, which will enroll 1 million or more volunteers who agree to share their EHRs and genomic information.

4. Who is going to pay to obtain genomic data? That’s expensive.
Genomic data is helping providers identify the most effective treatments for certain sub-,types of cancer. Gene sequencing is a powerful although expensive tool. Yet some plans are covering the cost. Intermountain Healthcare, for instance, determined that it is more cost effective to identify specific genes to ensure that a patient gets the most appropriate treatment right away. The investment of genomic sequencing will allow doctors to learn what specific chemotherapy or treatment is exactly right for an exact type of patient. Payers will not pay for ineffective treatments and, more important, patients will not endure them.

5. How does this relate to our Winter Conference on Dec. 3?
Dr. Andrew Pecora is at the forefront of using Big Data to better understand which cancer treatments truly can make a difference. He is the founder of COTA, a company that is developing national evidence-based benchmarks of patient outcomes and costs. He will be our keynote speaker. I expect his presentation to generate a lively discussion touching on topics such as: How can we bring this type of innovation to New Jersey? Who should pay for collecting and analyzing data? What policy and moral questions are raised?

 

 

Quality Institute Founders honored: Andrea Aughenbaugh, Louis Marturana, George Laufenberg, David Knowlton, Suzanne Miller, Judith Persichilli (missing from photo: Governor James Florio, Leonard Leto, Jim Morford, Michael Sedrish)

At the beginning of the Quality Institute’s 2015 spring conference, State Senator Joseph F. Vitale, Chairman of the Senate Health, Human Services and Senior Citizens Committee, stepped to the podium to unveil a Joint Legislative Resolution honoring David Knowlton, President & CEO, and all the founders of the of the New Jersey Health Care Quality Institute: Andrea Aughenbaugh, Governor James Florio, David Knowlton, George Laufenberg, Leonard Leto, Louis Marturana, Suzanne Miller, Jim Morford, Judith Persichilli, and Michael Sedrish. The joint resolution was signed by Senator Vitale and Assemblymen John S. Wisniewski and Craig J. Coughlin.

Senator Vitale thanked the founders for helping to improve health care for people in New Jersey and the nation, and noted that with Knowlton’s planned retirement this would be his last all-council conference as President and CEO. Then he spoke directly to Knowlton.

“The resolution highlights all the great things you have accomplished Dave … Well, not all. We don’t have enough room,” he said. “I know you are not going anywhere yet … And we know the Quality Institute will be in good hands with the succession you have in place with Linda Schwimmer.” (Schwimmer is currently Vice President, New Jersey Health Care Quality Institute.)

Read the Joint Legislative Resolution here.

Published in NJ Spotlight
By Andrew Kitchenman

As patients take on responsibility of choosing their insurers, doctors and medical procedures, new risks and opportunities arise

Tom Baker, insurance expert and health-law professor at the University of Pennsylvania, speaks during a conference addressing consumer choices in healthcare.

Being a patient doesn’t make you a healthcare expert.

But, more and more, people are having to make complex decisions about their health insurance and their medical care.

That’s why New Jersey healthcare analysts and policymakers are looking to create online tools that will help medical consumers get the maximum possible benefit for a given price or specific need.

Tom Baker, a health law professor and insurance expert with the University of Pennsylvania, helped a broad swath of state health policy experts think through the major issues facing New Jersey patients at a recent conference, “Powerful or Powerless, Consumer Choice in Healthcare,” held by the New Jersey Health Care Quality Institute.

Baker said society has shifted from a model in which patients’ healthcare was in their doctors’ hands to one in which there’s broad agreement that patients should be making these choices.

This is reflected in broader changes across the country and in different industries, , such as the move in retirement benefits away from pensions, which gave workers guaranteed future payments, to employer-sponsored savings accounts, in which the onus was on workers to save.

“We’re going to place responsibility on individuals so that they can manage their own safety net,” Baker said, describing the philosophy behind these changes.

In healthcare, a key example of individual choice is the insurance marketplaces, also known as “exchanges,” in which consumers pick from one of several plans.

While some employers have used private exchanges for several years, the most prominent example in New Jersey is now the federally operated insurance marketplace, healthcare.gov, which was launched under the Affordable Care Act to cover individuals and families.

Baker said insurance exchanges are intended to foster competition among health plans, leading to higher quality coverage at lower prices, and to match individuals with plans that best meet their needs. There are similar choices when selecting doctors or treatments, he said.

But Baker and other experts question whether consumers are given the right information to make these choices. For example, there can be so many options and data sources available that consumers suffer from “information overload,” leaving them unable to make choices with any confidence.

What’s more, the information that is available (or is marketed to consumers) may not be what will best serve them.

Baker pointed to the example of a hospital that advertised the view from its windows.

“We have a responsibility to set things up so that people make the right choices,” he said.

An emerging issue on the federal marketplace and other exchanges is the growing reliance on riskier plans that offer low monthly premiums but high out-of-pocket costs. Later, when patients are faced with costs they can’t afford, some forgo needed medications or doctor visits, Baker said.

Baker is working to develop software tools that patients can consult when they have to choose between health plans.

But he also pointed to a very traditional source that’s been serving patients well – insurance brokers, who he called the “silent heroes” in implementing the ACA.

Baker said health policy experts should also work to ensure that those brokers have good tools available to them, with up-to-date and pertinent data enabling them to distinguish one plan from another.

Katherine Hempstead, director of health insurance coverage for the Plainsboro-based Robert Wood Johnson Foundation, noted that researchers are still trying to determine basic facts about how insurance exchanges can best serve patients, such as how many plans should be available to choose from.

This can be even more complicated for people who want to find a healthcare provider, since much of the information that’s available online or from insurers is inadequate or outdated. The foundation has funded efforts to improve the information available to consumers about insurers’ networks of healthcare providers.

Baker noted that government-sponsored exchanges can shy away from giving certain information that would allow consumers to rank their coverage options, since insurers object to the possibility of receiving low rankings.

Suzanne M. Miller, a psychologist with Fox Chase Cancer Center in Philadelphia, cited other obstacles to helping patients make informed choices.

Patients are “often asked to make healthcare decisions under circumstances in which they feel most vulnerable, where they’re most confused, where they’re facing the most unfamiliar situations, where everything is uncertain,” she said.

Miller suggested that as healthcare systems moves toward “personalized medicine” tailored to each patient’s genetic risks, they also take into account each individual’s personality and decision-making style.

She said some patients scrutinize every detail of their health and the services they receive, while others tune out all but the most essential information. Providers should help the first group, described by Miller as “monitors,” to focus on what’s important to their health.

Miller added that providers have had success in helping patients decide what treatments to pursue by asking them to “pre-live” different scenarios, imagining different possible outcomes.

She also noted that the online tools that patients say they want can differ from what patients would actually use.

Miller cautioned everyone who’s looking at data tools to keep in mind that patients make their healthcare decisions in the context of their relationship with their doctors.

The nature of that relationship is crucial in determining whether patients understand the decision-making tools available to them, she said.

“We really need to understand what it is that patients really want and how they themselves interact with these tools,” Miller said. “We build them, but they don’t necessarily come, they don’t necessarily use them the way we think they are using them.”

Some audience members offered their personal perspective on the challenges facing patients when they make healthcare decisions.

Mark Rucci, acting co-president of East Brunswick-based provider network Partners in Care, questioned whether social changes are driving the move to insurance exchanges. He added that employers are looking to private insurance exchanges as a way to keep their costs down.

“It really comes down to finances,” he said.

Greg Paulson, deputy director of the Trenton Health Team, pointed out that healthcare choices are more complicated for people who don’t have stable housing situations or face violence in their homes.

Read original article in NJ Spotlight here.