Julie Darnell
University of Illinois at Chicago
Collaborators:
Christina Andrews, University of South Carolina
Teri Browne, University of South Carolina
Sarah Gehlert, Washington University in St. Louis
Robyn Golden, RUSH
November 19, 2013
University of Chicago
Outline
I.
II.
III.
IV.
V.
Strengths of social work that align with the goals
of the ACA
Social workers’ role in assuring access to health
insurance coverage
Heightened focus on integration and care
coordination: Implications for social workers
Expanded coverage for behavioral health services:
Implications for social workers
Resources in Illinois
Five Health Social Work Strengths
that Align with the ACA
1. Individuals are situated within social contexts.
2. The systems perspective considers & connects
multiple intersecting spheres: health, education,
employment, and child welfare.
3. Physical & mental/behavioral health are integrated.
4. All efforts and actions are guided by a base of
evidence that is informed by research within
communities.
5. Social Work historically has targeted services to
disenfranchised groups.
Why is Help in Enrolling in
Insurance Programs Needed?
 Huge numbers of uninsured: ~50 million in 20111
 Historically modest rates of participation in Medicaid
among eligible populations2
 32%-81% in studies
 Many individuals don’t know about insurance coverage3-4
 Unaware or skeptical they would qualify or would find
affordable coverage
 48% have heard “nothing” and 28% “only a little” about
exchange
 78% have “not heard enough to say” whether state will
expand Medicaid
Sources: 1U.S. Census. (2012). Income, Poverty, and Health Insurance Coverage in the United States: 2011.; 2Sommers, B. et al. (2012).
Understanding Participation Rates in Medicaid: Implications for the Affordable Care Act. U.S. Department of Health and Human Services;
3Perry, M. et al. (2012). Faces of the Medicaid Expansion: Experiences of Uninsured Adults Who Could Gain Coverage. Kaiser Commission
on Medicaid and the Uninsured; 4Kaiser Family Foundation. Kaiser Health Tracking Poll: March 2013.
Types of Consumer Assistance
 Consumer assistance programs
 Navigators
 In-Person Assisters
 Certified Application Counselors
 Exchange/Marketplace
 Medicaid
 Champion for Coverage
Status of State Exchanges
Declared
state-based
exchange
Planning for
partnership
exchange
Default to
federal
exchange
Consumer Assistance
State-Based
Exchange
Partnership
Exchange
FederallyFacilitated
Exchange
Statewide Consumer
Assistance Programs (CAPs)
OPTIONAL
OPTIONAL
OPTIONAL
Navigator
REQUIRED
REQUIRED
REQUIRED
In-Person Assister (IPAs)
OPTIONAL
REQUIRED
NONE
Certified Application
Counselor (CAC)-Medicaid
OPTIONAL
OPTIONAL
OPTIONAL
Certified Application
Counselor (CAC)-Exchange
REQUIRED
REQUIRED
REQUIRED
Program
Sources: Enroll America. (March 2013). How can Consumers Get Help Enrolling in Health Coverage; Kaiser Family Foundation. (April
2013). Consumer Assistance in Health Reform. Darnell, J.S. (2013). “Navigators and Assisters: Two Case Management Roles for Social
Workers in the Affordable Care Act.” Health and Social Work; Robert Wood Johnson Foundation. (March 2013). Navigators and In-Person
Assistors: State Policy and Program Design Considerations; Brooks, T. In-Person Assistors May Look a Lot Like Navigators. Retrieved
from http://ccf.georgetown.edu/all/in-person-assistors-may-look-a-lot-like-navigators/.
Duties of Navigators & Assisters
Consumer
Assistance
Programs
Navigator
In-Person
Counselor/
Assister
Education/Outreach


Enrollment in QHPs

Duty
Certified Application
Counselors
Medicaid
Exchange
State option




State option

State option
or Refer
State option
or Refer
State option
or Refer

State
option
Mid-year changes


State option


Culturally/linguistically appropriate





Grievances and
complaints

State option
or Refer



Data collection and
reporting

State option
State option
State option
To be
determined
Enrollment in
Medicaid
Sources: Kaiser Family Foundation. (April 2013). Consumer Assistance in Health Reform; Robert Wood Johnson
Foundation. (March 2013). Navigators and In-Person Assistors: State Policy and Program Design Considerations.
 = Yes;  = No
IL: In-Person Counselor
 $27 million distributed to 44 organizations in Illinois
 http://www2.illinois.gov/gov/healthcarereform/Documents/Health%20Benefits%20Exc
hange/FINAL%20IPC%20Grant%20list%20071713.pdf
Navigators
http://www.cms.gov/CCIIO/Programs-and-Initiatives/HealthInsurance-Marketplaces/Downloads/navigator-list-8-15-2013.pdf
Challenges and Opportunities
 Opportunity: Consumer assistance roles align closely
with social work case management functions
 Consumer assistance programs (CAPs)
 Navigators
 In-person assisters (IPAs)
 Certified application counselors (CACs)
 Challenge: Social work is swimming against the tide as
other health professionals (nurses) and nonprofessionals (lay individuals) have assumed these roles
Additional
Challenges
Additional Challenges:
30 million uninsured in 2019
60
55
50
44
40
Uninsured
(millions) 30
37
31
30
30
30
30
31
31
20
10
0
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
Who are they?
The
How many?
Uninsured
Unauthorized/Undocumented
11 million
Medicaid eligible but not enrolled
Next largest
Unaffordable coverage
*3 million (net): Not eligible
for Medicaid -Supreme Court
*Some of the 18-19 million+
who are exempt from penalty
*6 million not exempt from
penalty, of whom:
 .6 million < 100% FPL
 2.4 million 100-300% FPL
In between coverage
?
Source: Congressional Budget Office.
(2012). Payments of Penalties for Being
Uninsured under the Affordable Care Act.
Free Clinic Patient
Free Clinic Patient
How to Get More Involved:
Eligibility & Enrollment
 Advocate for Medicaid
 For coverage expansion
 Against cuts in benefits
 Advocate for immigration reform, coverage of
unauthorized and newly-arrived immigrants
 Advocate for continuous coverage
 Join (or form) oversight bodies (e.g., boards, advisory
groups) that oversee exchanges
 Become certified/trained as:
 Navigators, Ombudsman, Assisters, Application counselors
How to Get More Involved:
Eligibility & Enrollment
 Advocate for Medicaid
 For coverage expansion
 Against cuts in benefits
 Advocate for immigration reform, coverage of
unauthorized and newly-arrived immigrants
 Advocate for continuous coverage
 Join (or form) oversight bodies (e.g., boards, advisory
groups) that oversee exchanges
 Become certified/trained as:
 Navigators, Ombudsman, Assisters, Application counselors
ACA, Social Work, and
Care Coordination
 ACA creates opportunity for new social work roles
 Avenues to sustainable care coordination by social workers
increasingly available
 Provisions include
 Changing incentives
 Changing payment structures
 Move away from fee-for-service
 ACA provisions of note:
 Penalties for hospital readmissions
 Value-based purchasing
 Bundled payments
 Patient-centered medical homes
 Accountable care organizations
Second Curve
First Curve
Second Curve
Direct
Contracts with
Employers
Traditional Fee-for-Service
Payment System
Option on
the Health
Exchange
Medicare
Advantage Plan
Readmission
Rate
Penalties
Accountable Care
Organizations
Population Health Per
Capita Payment System
Bundled
Payment
Pilots
Adapted from Ian Morrison
Patient Protection and Affordable
Care Act of 2010
Reform component
What it means
What we need to
work on
Readmissions
Financial penalties for Quality and patient
excess readmissions
safety
Value Based
Purchasing
Payment based on
performance on core
measures
Hospital Acquired
Conditions
1% reduction in
payment if in top
quartile
Care coordination
Evidence-based care
maps
Clinical
documentation
Patient Protection and
Affordable Care Act of 2010
Reform component
What it means
What we need to
work on
Coverage expansion
More patients with
insurance
Manage access
Bundled payments
Lump sum payments to
multiple providers for
designated conditions
Alignment and
partnerships
Accountable Care
Organizations
Patient-centered medical
home
Manage quality and cost
Manage care of specified
beneficiaries;
Manage populations
quality/cost; share of cost
savings
Care coordination
Services, structures and
Informatics
access for continuous &
comprehensive care
Avoidable Readmissions Penalty
 Incentive to improve care transitions and reduce
avoidable readmissions
 Lost reimbursement to drive performance
improvement
 Penalty for each hospital based on risk adjusted actual
30-day readmission rate compared to expected
readmission rate
 Reduced Medicare DRG payments by 1%, rising to 3% in
2015
 3 target conditions starting in FY 2012, expanding to 7 in
FY 2015
 Hospital-specific readmission rates posted on Hospital
Compare website for public viewing
 Expand to skilled nursing homes and HH agencies
Community Based Care
Transitions Program (3026)
 Provides funding to hospitals and community-based
entities that furnish evidence-based transition services
to Medicare beneficiaries at high risk for readmission
 Preference for medically underserved areas, small
communities, rural areas and AoA programs
 Services must include at least one of 5 interventions
 Arranging post-discharge services
 Providing self-management support (or caregivers
support)
 Conducting medication management review
 Funding up to $500 million over 5 years started in 2011
Bundled Payments
 Bundled payment pilot began January 31, 2013
 Single Medicare payment to cover all services for an
episode of care to be distributed among care
providers:




Acute hospital services
Physicians’ services
Care coordination and transitional care services
Post-acute services



Home health care
Skilled nursing facility services
Inpatient rehabilitation services
 Pilot testing four variations on bundling model over
3 years to assess efficacy
Medical Homes
 Change in outpatient care delivery toward
coordinated, chronic care, including the following
supportive services:
 Care coordination
 Case management
 Health promotion
 Transitional care
 Patient and family support
 Referral to community services
 Additional funding available for coordination
through greater reimbursement
Accountable Care Organizations
 Medicare Shared Savings Program (3022) creates
incentive for the establishment of Accountable Care
Organizations (ACOs)
 Networks of physicians and other providers
 Integrated, cooperative services designed to foster
collective accountability
 Share savings resulting from the ACO’s coordinated care


Reduced Medicare expenditures
Improved beneficiary health outcomes
 No consensus on vital components of an ACO
 Will have to address social issues to see true cost savings
 Opportunity for social work to achieve savings and
quality improvement
The CMS Innovation Center
 Test innovative payment and service delivery models
 To reduce program expenditures
 To preserve or enhance the quality of care furnished to
Medicare and Medicaid beneficiaries
 Preference given to models that improve health care
coordination, quality, and efficiency
 Authority to expand any model
 Funding of $1 billion per year for 10 years
 Released through ongoing Funding Opportunity
Announcements
 Targeted distribution within priority areas
 Budget neutrality requirement waived during testing
PCORI
 Patient-Centered Outcomes Research Institute governed
by 21-member Board of Governors
 “Patient-Centered Outcomes Research (PCOR) helps
people and their caregivers communicate and make
informed healthcare decisions, allowing their voices to be
heard in assessing the value of healthcare options.”
 Research priorities:
 Assessment of prevention, diagnosis and treatment options
 Improving healthcare systems
 Communication and dissemination research
 Addressing disparities
 Accelerating PCOR and methodological research
Thrive Under Reform
 Key elements to making the ACA successful
 Engaging patients
 Prevention and wellness
 Not transactions but a journey
 Transparency of performance
 Focus on burden of treatment, not illness
 Cost and quality in the same breath
 Where does social work fit?
Getting to the Table
 What can social workers do to get to the table?
 Find cross-institutional ways to collaborate
 Learn to communicate and market social work
 Frame social work from other perspectives

Speak the language of other professions
 Vary the message to fit the mission of the team
 Find ways to partner with other disciplines

Example: Delegating tasks to community health workers so
social worker can focus on skilled activities
 Share evidence about effective social work interventions
Focus on Social Needs of Patients:
A Look at the Evidence
Shier et al. March 2013.
Health Aff vol. 32 no. 3
Enhanced Discharge Planning
Intervention for Older Adults
Outcome
Odds ratio
95% CI lower
95% CI upper
Patient stress
0.85
0.61
1.19
Caregiver stress
1.02
0.73
1.42
Physician
appointment
made*
2.70
1.64
4.45
Physician
appointment
kept*
2.09
1.51
2.89
General health
rating
(excellent/very
good vs
good/fair/poor)
1.27
0.85
1.88
30-day mortality
(N = 906)
1.54
0.76
3.10
Readmission
within 30 days
1.11
0.76
1.62
Altfeld, Susan J., et al. "Effects of an Enhanced Discharge Planning Intervention for
Hospitalized Older Adults: A Randomized Trial." The Gerontologist 53.3 (2013): 430-440.
Older Patients with
Advanced Illness
Challenge: “Hospital social work departments, which
traditionally had the primary responsibility for addressing
problems affecting a patient’s life in the community after
discharge, have been deprofessionalized, shrunk, or
eliminated altogether in the last generation.”
Opportunity: “Hospitals and health plans wishing to
practice dignity-driven decision making have invested
additional resources in social workers to manage the task of
working effectively with the home and community-based
service network.”
Bruce Vladeck
Erin Westphal
“Dignity-Driven Decision Making: A Compelling Strategy For Improving Care
For People With Advanced Illness,” Health Affairs. June 2012
Complex Discharge Panel May
Heave Influenced Decline in LOS
Percentage Of Discharges With Long Length-Of-Stay Among Adult Patients At Denver Health
Medical Center, January 2007–August 2011.
MacKenzie T D et al. Health Aff 2012;31:1786-1795
©2012 by Project HOPE - The People-to-People Health Foundation, Inc.
Impact on Behavioral Health
 Insurance coverage for behavioral health will expand
significantly under the ACA through two key
provisions:
 Medicaid expansion
 Creation of the marketplace
Impact on Behavioral Health
 The ACA requires that behavioral health be included
in “essential benefits” offered by all private insurers
 All state Medicaid programs will also be required to
provide behavioral health coverage
 However, public and private insurers will have some
discretion in the types and volume of behavioral
health services covered
Impact on Behavioral Health
 The ACA also aims to enhance the quality of coverage
by extending the reach of the Mental Health Parity
and Addiction Equity Act (MHPAEA) of 2008
 Medicaid and newly-established HIEs will be required
to offer behavioral health benefits that are no more
restrictive than benefits for medical services
Behavioral Health Workforce
 Increase in coverage for behavioral health services is
expected to lead to increased demand for behavioral
health services
 Demand for Medicaid-covered behavioral health
services is expected to increase most, as a higher
proportion of low-income individuals have untreated
behavioral health disorders
Behavioral Health Workforce
 ACA also emphasizes integration of physical and
behavioral health through ACOs and PCMHs
 Great overlap among behavioral health disorders and
chronic and acute medical conditions
 Many ACOs and PCMHs are emphasizing
identification and treatment of these “high risk”
populations
Behavioral Health Workforce
 Bureau of Labor Statistics estimates significant
increase in demand for behavioral health services
providers
 Increase in demand of 34% for healthcare social
workers and 31% increase for behavioral health social
workers between 2010 and 2020 (16% for other SWs)
Implementation Challenges
 Service systems may not be ready to address rapid
growth in demand for behavioral health services
 At present, only 50% of substance abuse treatment
providers accept Medicaid
 Immediate access to truly integrated services may be
limited to health care “innovators” engaged in early
ACO/PCMH efforts
Implementation Challenges
 Case of Massachusetts: Enrollment difficulties; co-pays
as deterrents to help seeking; loss of presumptive
eligibility clause (Capoccia et al., 2012)
 Some left out of ACA coverage expansions, including
undocumented residents
 Among those with coverage, great variation across
states in the generosity and scope of coverage for
behavioral health services
Opportunities for Social Workers
 Assume leadership roles in systems expansions of
behavioral health services
 Demonstrate capacity to contribute to integrated care
models by assisting patients with co-occurring
behavioral health conditions
Patient Navigation: A Lit Review
Study
Year
Patients
Design
Disease
Social Worker Role
Results
Peacher,
Palomino, Lo
& Woodruff
2013
100 mostly Latinorural CA
Observational
Cancer
Convert uninsured or
inadequately insured to adequate
insurance
--Improved insurance status for
all but 2 patients
Tejeda,
Darnell, et al.
2013
250 mostly AA,
Latina uninsured,
public ins.-Chicago
Quasiexperimental
with controls
Cancerbreast/cervical
Supervisor & navigator
Identified and resolved barriers
--Intrapersonal barriers are the
most frequently identified
barrier
--System barriers persist beyond
first encounter with navigator
Markossian,
Darnell, and
Calhoun
2012
897 mostly AA,
Latina uninsured,
public ins.-Chicago
Quasiexperimental
with controls
Cancerbreast/cervical
Supervisor & navigator
Identified and resolved barriers
--Intervention subjects had
shorter time to resolution than
controls
Ell, Lee & Xie
2010
3 pooled
analyses
Depression,
Cancer,
Diabetes
Communication/system
navigation, referral to community
resources
--Patients perceived navigation
services as helpful
--Physicians viewed navigation
tasks as new
Ferrante,
Cohen and
Crosson
2010
75 mostly female,
elderly, white,
insured
Qualitative
Unknown
Choosing, understanding and
using health coverage, providers,
and services
Making decisions about
treatment
Managing conditions & care
received by multiple providers
--Navigators helped patients
obtain ancillary & social services
--Navigators arranged
appointments
--Navigators provided emotional
support
DwightJohnson, Ell
and Lee
2005
55 Latio
Randomized to
collaborative,
usual care
Cancerbreast/cervical
Problem solving therapy
Rx adherence
System navigation
--Improvements in depression
and emotional well-being
Tingen,
Weirich,
Heydt et al.
1998
1,522 mostly AA
Correlational
Cancer-prostate
Navigate health system
--Perceived benefits predicted
participation in screening
--Demographic factors predict
screening
Illinois Health Matters
Illinois.gov
Getcoveredillinois.gov
Consumer Assistance
A Cautionary Tale?