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Advocates Corner:
8 Principles Annotated
What is an Accountable Care Organization?
"An ACO is like a unicorn; everyone thinks they know what one is, but no one has ever seen one," Gene Lindsey, president and chief executive of Atrius Health.
What population will be cared for under the Governors Bill and EOHHS initiative?
Most healthcare providers including Atrius, do not collect data on their members with disabilities as a demographic.
Nationally, people with mental disorders comprise 25% of adult population. People with medical conditions such as diabetes comprise 58% of the adult population. 68% of adults with mental disorders have medical conditions. 29% of adults with medical conditions have mental disorders. "Mental health disorders and medical comorbidity", February 2011
More locally, according to the Massachusetts Behavioral Risk Factor Surveillance Survey, adults with a disability compared to adults without a disability report: Tobacco use and obesity, higher rates of being unable to see a doctor due to cost higher rates of sexual violence. We are more likely to report More likely to be missing six or more teeth, for times more likely to report 15 days or more of poor mental health in the past month and seven times more likely to report 15 or more days of poor physical health.
According to the Massachusetts Behavioral Risk Factor Surveillance System Blacks, (24.8%) report disability compared with Whites (21%) and Hispanics (18%). Insufficient data is available to determine the presence of disability among Asians.
· Hispanics (9.4%) report needing assistance with Activities of Daily Living (bathing, dressing, eating etc. (ADLs) compared with whites (5.2%) Insufficient data was available on Blacks and Asians to determine ADLs.
· Adults with less than a high school education report having a disability (45%) compared to adults with four or more years of college education (16%).
· Adults with a household income less than $25,000 a year report having a disability (38%) and report needing help with activities (14%) than adults with a household income of $75,000 or higher.
Whatever system is created and must provide better care than is currently provided to persons with disabilities and persons from ethnic and minority populations in the Commonwealth as a justice issue and because of the correlation between minority status and chronic conditions. The system must be rooted in respect, Patient Choice and empowerment, Patient involvement in health policy, optimal healthcare access and support at the community level and access to information to protect patients and enable patients to make informed decisions. There is a handout in the room a one-page synopsis of a seven page document.
The document, created in collaboration with disability, elder and other health advocacy groups, including the Boston Center for Independent living, Disability Law Ctr., Massachusetts Law Reform Institute and HealthCare for All. Hence the acronym DAAHR, Disability Advocates Advancing Our Healthcare Rights. It contains a set of eight detailed principles we are asking Sec. Bigby to incorporate into the new dual eligibles initiative being developed. If there is time at the end of the presentation, I will highlight several of the major points contained within the document.
Principles to guide development and implementation of the EOHHS Duals Initiative
Principle 1: Participant Enrollment
Participant enrollment must be voluntary, flexible and streamlined, and respect existing provider relationships.
· Voluntary "opt in" with no "lock-in" periods.
· services within an Integrated Care Entity (ICE) should be equal to or broader than in other delivery models.
· Continuity of care is essential, requiring coverage of services by physicians, other clinicians, practices, and community-based providers by whom the participant already receive services.
· Request EOHHS pilot voluntary ICE inclusion to the broader population of persons with disabilities between the ages of 21 and 64. Particularly important in light of Governors Bill to provide integrated care through ACOs.
Principle 2: Person Centered Care
Person-centered care must treat the whole person, and must be meaningfully directed and led by the individual.
· Must be rooted in the principles of choice and self-determination, as framed by the independent living movement, with the values, preferences, and expectations of individual enrollees serving as the guide for all care.
· Must prioritize the fundamental rights of persons with disabilities, as outlined by the Americans with Disabilities Act, the Supreme Court's Olmstead decision, and the administration's Community First initiative.
· Person centered care is driven by the participant, and requires full and meaningful participation of the participant (surrogate/guardian) and other persons of his or her choice within the care team.
· Operationalizes recovery frameworks such as those outlined in the Substance Abuse and Mental Health Services Administration's 10-point "Core Consensus Principles for Reform"[1].
· Upholds the "dignity of risk" - that is, the right of persons with disabilities to accept risks in their lives.
Principle 3: Delivery System
The delivery system must include medical homes and a broad network of providers, and ensure the full range of Medicare and Medicaid services, long term services and supports.
· Eliminate bias toward institutional care in the functional or financial eligibility criteria for long-term services and supports, and to allow consumers choice of the setting for care and the provider of care.
· Incorporate a "medical home" service philosophy, as defined and described by the Agency for Healthcare Research and Quality's (AHRQ) Patient-Centered Medical Home Resource Center[2].
· The delivery model should also be designed pursuant to the guidelines in State Medicaid Directors' Letter[3] released by the Centers for Medicare and Medicaid Services (CMS) on November 16, 2010.
· The ICE model must be quality driven and broadly defined, with incentives that encourage ICEs to develop care teams creatively and responsively. This includes the ability to provide specialized services to subpopulations.
· Formularies must include broadest array of medications with emphasis on high quality outcomes for the individual over cost-cutting. Clinician and consumer choice should supercede considerations of drug cost and rigid adherence to step therapy protocols.
· ICEs must have the capacity to provide services across the lifespan of a participant with mechanisms in place to provide geriatric support services as participants age.
· Enrollment incentives must be given to potential participants that include benefits not currently available in the fee-for-service system. Coverage by the ICE should be ensured for those incurring costs while traveling out of state.
Principle 4: Cultural Competence and Health Disparities
Integrated Care Entities must have the capacity to provide services appropriate to the complex needs of a diverse population.
· Cultural competence must include the capacity to provide services in compliance with standards set out by licensing requirements of DPH and benchmarks established by the DOJ and precedents of the 2009 agreement between Partners HealthCare and BCIL/GBLS.
· ICEs should demonstrate the capacity to address disparities in health and health care between people with disabilities and those without disabilities And address disparities in health access and health outcomes across ethnic and racial populations within the disability community as a demographic.
Principle 5: Prevention
Prevention services must be accessible to people with disabilities and target additional risk factors.
· Preventive services must be core competencies of ICEs with the capacity to prevent the development of secondary health conditions and disabilities i.e. prevention of obesity and tobacco use.
· Work in collaboration with DPH Office of Health Equity and Healthy Aging and Disability
Principle 6: Consumer Voice
The consumer voice must be incorporated into the design, implementation and monitoring of the program, and individual consumer rights must be protected.
· The right to monitor quality of services is contained within Governor Patrick's proposed payment reform bill (HO 1849); this right must be expanded because of the unique needs of the population being served by ICEs. There must be an oversight entity established independent of state government and not subject to state appropriations; it must be funded by a subscription fee paid by each ICE proportional to its participant enrollment; and it must be comprised of representatives from entities within the disability, elder, and healthcare communities.
· Participants who disagree with a decision of an ICE or whose claim for assistance from an ICE is denied or not acted on promptly should be entitled to a timely decision and opportunity for an administrative hearing that complies with due process and provides all Medicaid fair hearing protections in 42 CMR 431.200 et seq.,
· Participants are to be protected by rulings that optimize their access to health care. In the Medicaid and Medicare programs . ne set of rules and one administrative appeals process should apply.
Principle 7: Financing Mechanisms
Payments must reward increased quality of health outcomes rather than reduction in costs, and any savings must be shared in order to support enhanced services.
· The system of payments must reward high-value service provision, defined by increasing quality of health care outcomes - rather than by a payer-centered perspective - i.e., reductions in cost.
· Global payment amounts and reimbursement rates to contracted provider entities should be sufficient to assure that participants have access to a broad network of providers and should be made publicly available to encourage accountability and facilitate informed consumer choice.
· Appropriate risk adjustment (and quality measurement) must take into consideration the expectation that health outcomes cannot be solely based on "rehabilitation" for people with chronic conditions or disabilities. Risk adjustment must protect small providers through appropriate risk sharing arrangements with Medicaid along with reinsurance to protect small providers against unforeseeable risk. Furthermore, systems must be developed to prevent ICEs from shifting costs to contracted provider entities, participants, or other publicly-funded systems or programs.
· Protections and penalties must be put in place to prevent cost-cutting which results in cutting of essential services. Instead, emphasis on financial savings must focus on areas which also reflect increased quality, such as reduced high-cost hospitalizations and readmissions.
· Cost savings must be shared with the state, with savings being funneled back into funding pilot programs and public health initiatives to increase access and improve health outcomes for ICE members.
Principle 8: Quality Measurement
Consumer perspectives must be central to the assessment of services provided by the Integrated Care Entity.
· High quality healthcare requires the capturing and reporting of valid and reliable data based on population appropriate quality metrics incorporating contemporary frameworks of disability as outlined by the CDC, Institute of Medicine and World Health Organization Patient Protection and Affordable Care Act and emerging consumer defined "value" assessment tools.
· Financial incentives and penalties should be calculated according to the ICE's performance as compared with other ICEs, as well as the overall health outcomes of persons with disabilities in Massachusetts and persons without disabilities as measured by the state's Behavioral Risk Factor Surveillance System health indicators.
· Both the evaluation criteria and the results of assessments should be publicly available and accessible a number of methods, including the EEOHHS website.
For more details go to: http://www.dpcma.org/Issues/HealthCareReformII/tabid/846/Default.aspx Click on DAAHR Final Response
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Tito, is a 52-year-old African-American male living in Springfield Massachusetts. He is visually impaired as a result of complications from diabetes. He is a smoker with a history of depression and substance abuse.
· Tito does not have a PCP.
· His primary source of care is the emergency room
· Amelia is a 34-year-old white woman living in Dorchester. She has multiple sclerosis. She is a smoker subject to chronic bronchitis. Amelia also experiences episodic depressive periods and has been hospitalized four times in the past six years for depression.
· Amelia does not have a PCP
· she has a 15 year relationship with her neurologist
· She has an five year relationship with her psychiatrist
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