[PDF]Health and Human Services Special Report - Rackcdn.comhttps://afd34ee8b0806295b5a7-9fbee7de8d51db511b5de86d75069107.ssl.cf1.rackc...
0 downloads
171 Views
6MB Size
Health+Human Services Special Report
2015
A R E S E A R C H R E P O RT F R O M T H E G O V E R N I N G I N S T I T U T E A N D C E N T E R F O R D I G I TA L G O V E R N M E N T
Realizing Better Outcomes at a Cost Governments Can Afford
DR. WILLIAM GOLDEN, MEDICAL DIRECTOR, ARKANSAS MEDICAID
A SUPPLEMENT TO GOVERNMENT TECHNOLOGY/GOVERNING
Association of Administrators of the Interstate Compact on the Placement of Children Annual Meeting
INFLUENCE BUILD CONNECT 2015
Establishing Uniform Legal and Administrative Procedures Governing the Interstate Placement of Children
American Association of Public Welfare Attorneys Annual Training and Education Conference Attorneys Sharing Knowledge and Promoting Innovation
American Association of SNAP Directors Annual Education Conference Strengthening Long Term Family Health and Well-Being
IT Solutions Management for Human Services Annual Conference Sharing Innovative Solutions, Connecting IT Professionals, Collaborating with Private Sector Partners
National Association of Public Child Welfare Administrators Annual Meeting Developing Public Child Welfare Agencies to Improve Performance and Consumer Outcomes
National Association for Program Information and Performance Measurement Annual Education Conference Enhancing the Integrity and Outcomes of Human Service Programs
National Association of State Child Care Administration Focusing on the State, Affordable, High-quality Care of Children
National Association of State TANF Administrators Providing Expert Support and Consultation on TANF and Human Service Program Issues
National Staff Development and Training Association Annual Conference Sharing Ideas and Resources on Organizational Development, Staff Development and Training
Creating Strategic Directions in the Transformation of Health and Human Services @APHSA1 www.APHSA.org
CONTENTS 18 Smarter Policies and Programs for Better Results •• ••
KES PHOTO | KAREN E. SEGRAVE
••
Looking at Individuals and Families Holistically Prevention Pays Off Coordinating Programs and Funding Efforts
22 Technology as a Cure to HHS Ills
11
•• •• •• •• ••
4 Seeking Stable Ground in a Shifting Landscape
•• ••
5 The Race to Improve Care and Control Costs: Challenges and Trends in Health Care •• •• •• •• ••
Data and Analytics Improving Data Management Reducing Waste and Identifying Fraud Integrated Eligibility Systems Document and Case Management Systems Websites, Mobile Devices and Apps Telemedicine
28 Exceptional Care and Improved Services at an Affordable Price
Medicaid: To Expand or Not to Expand? Managed Care: Not New, But Better? Paying for Value Instead of Volume The Medicaid Doctor Drought MMISs and Moving Away From the Big-Bang Approach
12 The Struggle to Help People in Need: Challenges and Trends in Human Services Poverty, Hunger and Homelessness: Pervasive Ills
15 Health and Human Services: Interdependent and Inseparable •• ••
When Poverty Means Poor Health — and Poor Health Means Poverty The Role of Mental Illness and Substance Abuse in Health Care
12
DAVID KIDD
••
COVER PHOTO BY KES PHOTO | KAREN E. SEGRAVE © 2015 e.REPUBLIC. ALL RIGHTS RESERVED 100 BLUE RAVINE ROAD, FOLSOM, CA 95630 916.932.1300 PHONE | 916.932.1470 FAX
He a l t h +Hu ma n S e r vi c e s | SPECI A L R E P OR T
3
INTRODUCTION
Seeking Stable Ground in a
Shifting Landscape
they are seeking — and sometimes finding — more stable ground five years later. However, leaders must still find answers to tough questions, including the biggest one: How do we provide effective, comprehensive care and services in a way that is fiscally sustainable? Meanwhile, legislatures are still debating if their states should expand Medicaid and, if so, to what degree. State officials are contemplating approaches such as managed care, integrated eligibility and paying for performance to reduce unnecessary costs and improve outcomes. CIOs are undertaking efforts to implement robust network
AP IMAGES
services for telemedicine solutions to improve access — particularly in rural areas. They’re also implementing Even after states’ health insurance exchanges were functional, questions remained, particularly as Supreme Court cases threatened to alter or fully derail the ACA.
technologies to glean greater insights from data and analytics to support preventive care, improve services and
I
t has been a rocky road for health and
to individuals who buy health plans
human services (HHS) leaders as they
through a federally managed exchange
Importantly, at the center of this is
have grappled with sweeping changes
reduce fraud, among other things.
(as opposed to a state-based exchange).
people — individuals and families who
that came with the Affordable Care Act
At the time of the court case, 34 states
may be struggling with a plethora of
(ACA). While some states successfully
relied on a federal exchange with
physical, mental, social and financial
rolled out ACA components such as
millions of Americans enrolled.2
challenges, which are often intercon-
In both cases, the Supreme Court
health insurance exchanges (HIXs) —
nected in a web of complexity. State
albeit with a few minor hiccups — others
sided with the Obama Administration,
and local governments are increas-
faced serious hurdles and setbacks.
but challenges to the law are likely to
ingly aware of the linkages between
result in continued volatility for HHS
health and human services and the
tional, questions remained, particularly
agencies. Regardless, most states would
reality that if we are to solve the
as two cases before the Supreme Court
likely agree the chaos that reigned in the
problems of one, we need to address
threatened to dramatically alter or
early days of the ACA has passed and
the challenges of the other.
Even after states’ HIXs were func-
fully derail the ACA. The first, National Federation of Independent Business v. Sebelius, questioned the constitutionality of the individual mandate.1 The second, King v. Burwell, contended subsidies should not be issued
4
This Health and Human Services Special Report will provide updates on where states are in this ACA era, discuss the challenges state and local governments continue to encounter, and highlight leaders who are developing successful policies with the potential to scale and be replicated across the country.
He alth+ Human S erv ic es | S P ECIAL REP OR T
HEALTH CARE
The Race to Improve Care and Control Costs: Challenges and Trends in Health Care
F
or the first time, the Centers for
Since the passage of the ACA (and
expansion will save the federal govern-
Medicare and Medicaid Services
at the time of this writing), 31 states
ment and state governments money
(CMS) project health care will hit
(including the District of Columbia) have
in the long term — as well as provide
a cost of $10,000 per person, for a total
expanded Medicaid, 1 state is discuss-
insurance to millions more individuals
of $3.207 trillion, in 2015. But despite
ing expansion and 19 states have not
who are currently uninsured. Critics
the fact the United States spends more
expanded. Proponents say Medicaid
argue states cannot afford the ultimate
per capita on health care than any other industrialized nation, it consistently ranks last or near last in terms of outcomes when compared to health systems in European and Scandinavian countries.3 This exorbitant expense — and lack of positive results — is troubling for state and local governments that
In June 2015, the Governing Institute and the Center for Digital Government conducted a nationwide survey of 285 state and local government leaders about the status of health and human services in their jurisdictions, the challenges they face and how they are working to overcome them. Unless otherwise noted, the research in this report is a result of this survey.
What are the most effective ways to reduce costs and improve outcomes in health care? Preventive care
77%
help shoulder the costs of Medicaid and the Children’s Health Insurance Program (CHIP). Most of what we
Improve diagnosis and care for mental health
45%
see happening in HHS agencies — and many of the trends we will discuss in this report — are a result of the need to
Improve collaboration among health and human services agencies
44%
reduce costs and improve outcomes. Reduce health insurance costs
Medicaid: To Expand or Not to Expand? One bone of contention with the
38% Data and analytics
27%
ACA — usually split along political party lines — has been Medicaid expansion. While the ACA extended Medicaid to all
Incorporate greater business efficiencies with increased use of IT and automation
26%
Americans under age 65 whose family income is at or below 133 percent of federal poverty guidelines, the Supreme
Cap malpractice suits
21%
Court ruled a state’s existing federal Medicaid funding was not contingent on its decision to expand — essentially rendering Medicaid expansion a voluntary act.
Telemedicine
16% Source: Governing Institute HHS Survey, 2015
He a l t h +Hu ma n S e r vi c e s | SPECI A L R E P OR T
5
expense of adding to Medicaid rolls.
do not qualify for Medicaid (they
Iowa, Michigan, Pennsylvania, New
While the federal government will
are too high), but they are also not
Hampshire and Indiana had received
initially pay 100 percent of the cost for
eligible for subsidies on a health care
approval to implement Medicaid
expansion, states will be responsible for
exchange (they are too low). Because
expansion in ways that do not meet
10 percent of the cost after 2020.
the ACA envisioned low-income people
federal rules, but still access federal
There have been some significant
receiving coverage through Medicaid,
matching funds for newly eligible adults.
impacts of Medicaid expansion (or lack
it does not provide financial assistance
Some of the caveats include charging
thereof ). The first is fewer uninsured
to individuals below poverty for other
premiums to enrollees, eliminating
individuals, which was the intention
coverage options. As a result, adults in
certain required benefits and using
of the provision. As of January 2015,
states without Medicaid expansion can
health behavior incentives.
11 million people had enrolled in Medic-
fall into a “coverage gap.”
5
The third effect is the trend of
aid since the ACA took effect, for a total
While state leaders contend the compromises make Medicaid more
of more than 70 million people in the
states seeking waivers from the federal
fiscally sustainable for their states, oth-
program.4 This is largely due to expan-
government to develop compromises
ers argue the changes are overly harsh
sion in 31 states.
to full Medicaid expansion. These
to economically challenged populations.
expansions essentially contain caveats,
It remains to be seen how far the federal
of the ACA’s goal — people left behind.
which the states say will help offset costs
government is willing to let states go in
States that did not expand Medicaid
and reduce wasteful spending. At the
making exceptions, but Medicaid has
have populations with incomes that
time this report was published, Arkansas,
long been a petri dish for innovation,
The second effect is the antithesis
whereby states experiment with different models. This is likely to continue.
Current Status of State Medicaid Expansion Decisions
Managed Care: Not New, But Better? The origin of managed care dates back to at least 1917 in the United States.6 It has been around for almost a century and continues to increase in popularity despite differing opinions on whether it’s a successful approach to improving outcomes. Critics say managed care simply transfers the risk to private companies rather than the government, and the long-derided feefor-service (FFS) model — in which doctors and health care providers are Adopted (31 states, including D.C.) Adoption Under Discusion (1 state) Not Adopting at This Time (19 states)
NOTES: Current status for each state is based on KCMU tracking and analysis of state executive activity. **MT has passed legislation adopting the expansion; it requires federal waiver approval. *AR, IA, IN, Ml, PA and NH have approved Section 1115 waivers. Coverage under the PA waiver went into effect 1/1/15, but it is transitioning coverage to a state plan amendment. WI covers adults up to 100% FPL in Medicaid, but did not adopt the ACA expansion. SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated July 20, 2015. http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/
6
He alth+ Human S erv ic es | S P ECIAL REP OR T
paid for each service performed — still reigns in many managed care plans. They also contend some managed care organizations (MCOs) have inadequate networks of doctors and those plans can vary drastically from state to state, among other arguments.
In your opinion, is the move to managed care working?
Ohio is revamping its managed care program. In 2012, the state initiated
It’s too early to tell
several changes. The modifications
44% 49%
included linking health plan payments to performance, integrating care delivery for Medicare-Medicaid enrollees (dual
No
eligibles) and providing more account-
15% 23%
able care for children with disabilities. The state’s changes appear to be working. According to a report
Yes
14%
22%
released in August 2015 by Gov. John Kasich’s administration, total Medicaid spending was $23.5 billion in the fiscal
Don’t know
year that ended June 30 — 7.6 percent
13% 7%
less than projected. In addition to expanded managed
We have not moved to a managed health care model
6% 6%
2015
care, those savings are attributed to add-
2014
shortening nursing home stays and
ing more home-based care for seniors, capitated reimbursement policies.10
Source: Governing Institute HHS 2014 and 2015 Surveys
Paying for Value Instead of Volume • Medical-loss ratio. CMS would set
In January 2015, the Depart-
of all Medicaid beneficiaries nationwide
an 85-percent standard, meaning
ment of Health and Human Services
receive most or all of their care from risk-
85 percent of insurers’ revenue
announced its goal of tying 30 percent
based MCOs. According to the Kaiser
must go to medical costs (versus
of traditional FFS Medicare payments
Family Foundation, 39 states, including the
administrative expenses and profits).
to quality or value through alternative
Despite these qualms, more than half
District of Columbia, have contracts with
• Network adequacy. CMS would
payment models, such as Accountable
a comprehensive Medicaid MCO, and all
require states to set standards on
Care Organizations (ACOs) or bundled
but 3 have some form of managed care.
how long patients should wait or
payment arrangements by the end of
By the end of 2015, 46 million Medicaid
travel to see a doctor.
2016, and tying 50 percent of payments
7
beneficiaries are expected to receive their health coverage through private plans.
8
• Long-term care. CMS would
to these models by the end of 2018.11
mandate for managed care to comply
The move was the latest in an
In May 2015, CMS proposed
with federal law, which requires
increasing shift away from the traditional
updates to Medicaid managed care
plans to provide care in the least
(and problematic) FFS model to a system
rules in an attempt to improve
restrictive setting possible. This
that rewards value rather than volume.
outcomes. The major changes include:
would encourage the use of at-home
FFS has long been lambasted as doing
care (as opposed to nursing homes).
nothing to reduce avoidable hospital
• Quality ratings. While Medicare has a five-star system evaluating private
• Accreditation and monitoring.
readmissions or expensive emergency
plans, there is currently no national
The CMS proposal sets out at least 14
room visits. While FFS is the dominant
standard for Medicaid managed
areas states would have to collect data
payment model for providers under
care plans.
on to provide baseline comparisons.
Medicaid — even in states where MCOs
9
He a l t h +Hu ma n S e r vi c e s | SPECI A L R E P OR T
7
are common — new, innovative models
preventive services. (For more
care delivery system. DSRIP programs
are beginning to emerge.
information on Arkansas, see
focus on measurable outcomes based on
“Arkansas Crunches Numbers
a set of metrics. States with approved
for Insight into Medicaid Patient
DSRIP projects include California,
Journey” on page 10.)
Kansas, Massachusetts, New Jersey,
State Innovation Models Initiative. Part of this innovation is stimulated by CMS’ State Innovation Models (SIM) Initiative, which is
• Maine — The state is aligning
New Mexico, New York and Texas.
benefits from its Medicaid program
port to states for the development and
with benefits from Medicare and
programs include innovative payment
testing of state-led, multi-payer health
commercial payers to lower costs
reforms, consistency in performance
care payment and service delivery
for Medicaid, Medicare and CHIP
metrics, information technology and
models. The aim is to improve health
populations while improving access
population health, and collaborative
system performance, increase quality
and quality. The model will support
learning and infrastructure.13
of care, and decrease costs for Medic-
the formation of multi-payer ACOs
aid and CHIP beneficiaries, as well as
committed to providing greater
incentivizing value over volume. The
for all residents of participating states.
value in return for performance-
state is targeting a 25 percent reduc-
based payment.
tion in avoidable hospital use over the
The SIM Initiative has already
New York’s DSRIP program is
doled out hundreds of millions of
• Colorado — The “Colorado Frame-
next 5 years. The New York program
dollars in awards to states to both
work” will provide access to inte-
is pay-for-results (moving away from
design and test innovative health care
grated primary care and behavioral
fee-for-service) and DSRIP funds will
payment and service delivery models.
health services in coordinated com-
only go to performing provider systems
During round one of the initiative,
munity systems, as well as apply
(PPSs) that successfully achieve targets
nearly $300 million was awarded to
value-based payment structures and
to measurable health outcomes. The
25 states. The states selected to test
expand IT efforts (including tele-
state’s goal at the end of the 5-year
their model included Oregon,
health). The state is also integrating
Vermont, Massachusetts, Arkansas,
physical and behavioral health care
Minnesota and Maine. Round two
in primary care practices and
recipients, announced in December
community mental health centers.
12
2014, were awarded more than While each state’s model is
$660 million. Thirty-two states were granted an award and 11 states were
unique, there are consistencies.
selected to test their model. These
Among them: coordinating care;
states included Washington, Idaho,
aligning multiple benefits programs
Colorado, Connecticut, Delaware,
to reduce redundancies; focusing on
Iowa, Michigan, New York, Rhode
population health; using technology
Island, Ohio and Tennessee.
to lower costs and improve access;
Some of the innovative plans these states are implementing include:
and integrating primary, behavioral and mental health. Delivery System Reform
• Arkansas — By 2016, a majority of
8
Key elements present in state DSRIP
providing financial and technical sup-
Arkansas residents will have access
Incentive Payments. Similar to the
to a patient-centered medical home,
SIM Initiative, Delivery System Reform
which will provide comprehensive,
Incentive Payments (DSRIP) provide
team-based care with a focus on
federal funding to states with innovative
chronic care management and
solutions to help transform the health
He alth+ Human S erv ic es | S P ECIAL REP OR T
Through its DSRIP program, New York is targeting a
25%
reduction in avoidable hospital use over the next 5 years.
The state’s goal at the end of the 5-year program is to have
90%
of all MCO Medicaid payments be value based.
DSRIP program is to have 90 percent
Association, approximately 25 percent
of all MCO Medicaid payments to
of the U.S. population lives in rural areas
providers be value based.
while only 10 percent of physicians
14
practice there.16 Doctors who practice
The Medicaid Doctor Drought As part of the ACA, doctors who
in rural areas treat more Medicaid patients compared to urban areas —
treated Medicaid patients enjoyed a
18 percent of rural Americans are
two-year increase in reimbursements.
Medicaid recipients compared with
Between Jan. 1, 2013 and Dec. 31, 2014,
15 percent of urban Americans, and
doctors were reimbursed for Medicaid
doctors in rural America receive an
at the same levels as Medicare. Previ-
average of 25 percent of their reim-
ously, doctors were only reimbursed
bursements from Medicaid compared
for Medicaid at 59 percent of Medicare
with 20 percent for non-rural doctors.17
reimbursement rates.
For more informatio n about a services-based ap proach to MMIS implementati on, download the Center for Digital Government and Governing Institute handbook, “A Bold Solution for a Broken System: A Handbook for MMIS Refor m,” at www.governing.com/ MMISHandbook.
This confluence of factors could
But the two-year increase has
create a lack of access. To bridge this
ended and a problem has emerged: At
gap, Missouri enacted a law in 2014
thousands of intricate business rules
the same time the number of people
allowing medical school graduates who
and extensive custom development.
eligible for Medicaid increases, the
have completed their licensing exams
In response, public agencies and their industry partners often con-
“
front the complexity and scale of the challenge using an approach to
Historically, the big-bang approach has resulted in systems that take longer to deploy and are more expensive than initially scoped. We’ve said we don’t want to pay for that approach anymore.”
develop these systems that can best be described as a “big bang.” These deployments take years to complete, during which time state requirements and Medicaid regulations are fre-
— Jessica Kahn, Director, Data and Systems Group, CMS
quently modified. But this is changing. “Historically, the big-bang approach
number of doctors willing to see them
but haven’t finished a residency to
has resulted in systems that take longer
may decrease. Accepting new Medicaid
practice immediately in underserved
to deploy and are more expensive than
patients may not be financially prudent
areas, so long as they join a primary care
initially scoped,” says Jessica Kahn,
as payments will fall by 47 percent
practice of a “collaborating physician”
director of the data and systems group
in 2015.
who agrees to accept responsibility for
for CMS. “We’ve said we don’t want to
an assistant physician for one month.
pay for that approach anymore.”19
MMISs and Moving Away from the Big-Bang Approach
2015, which encourage a modular or
15
States have the option of continuing
CMS proposed new rules in April
to fund the higher reimbursement rate, but 27 states have chosen not to. The doctor drought is particularly hard on rural areas, which are tradi-
incremental certification process for
Costing anywhere between
MMIS deployments with updated
tionally underserved by primary care
$50 million and $150 million,
policies for receiving enhanced federal
doctors and whose residents are statis-
Medicaid management information
matching funds as each module is cer-
tically older, poorer, sicker and more
systems (MMISs) are one of the
tified. CMS is also talking with states
overweight than those in urban areas.
largest IT investments a state makes.
that are in the process of replacing
According to the National Rural Health
They’re also notoriously complex, with
their current MMIS, discussing how
18
He a l t h +Hu ma n S e r vi c e s | SPECI A L R E P OR T
9
ARKANSAS CRUNCHES NUMBERS FOR INSIGHT INTO MEDICAID PATIENT JOURNEY to move toward a flexible, less costly MMIS model. This approach includes states contracting for services in a subscription model to eliminate large capital outlays in favor of predictable monthly operating expenses. “We have more states embarking on an MMIS redesign and re-procurement than we’ve ever had before, all at once,” Kahn says. “We’re talking to them about what it takes to have a successful RFP, we’ve talked about the administrative services model, what modules they want to start with, how to ensure interoperability and a number of other issues.”
“
Some of our better and more efficient clinicians have said, ‘Hey, for the first time in my career someone is going to pay me more for doing a better job.’” — Dr. William Golden, Medical Director, Arkansas Medicaid
Wyoming has already adopted an MMIS-as-a-service model and expects to launch a series of procurements this year for servicesbased MMIS modules to replace its 30-year-old mainframe technology. “We want to contract for services, and we don’t want all of those services to be with one vendor,” says Teri Green, Wyoming’s Medicaid director. “Standing up a new traditional MMIS is very costly and time consuming, and continuing to operate our old system doesn’t make good business sense.”20
10
He alth+ Human S erv ic es | S P ECIAL REP OR T
The state of Arkansas has emerged as a ground-breaking innovator on strategies to incentivize and enable providers to achieve better results at a lower price point. In 2011, the state embarked on the Arkansas Health Care Payment Improvement Initiative. Two important components of the initiative were creating episodes of care — which is a collection of care provided to treat a particular acute condition for a given length of time — and patientcentered medical homes, whereby patient treatment is coordinated through a primary care physician to ensure they receive the necessary care when and where they need it. The state first selected five episodes of care — hip and knee replacement, congestive heart failure, upper respiratory infection, attention deficit/ hyperactivity disorder and perinatal — and then recorded all expenditures related to the episode of care within a certain amount of time (typically 30 to 60 days). By doing this, the state could determine an average cost for each episode of care and communicate this to accountable care providers — those doctors or hospitals who would serve as the central point for episodes of care in the future. “We used our claims warehouse in an increasingly sophisticated way to manage claims data and create an accounting of all of these services. We then created report cards so the accountable provider could see the total cost of care and determine where their patients, on a risk-adjusted basis, spent dollars when compared to peers,” says Dr. William Golden, medical director of Arkansas Medicaid. “Our episodes of care and patient-centered medical homes programs have each crunched about 350 million claims to create these report cards.”
Arkansas crunched data from roughly
350 million
claims to create report cards that show average costs for certain episode s of care.
Providers who have below-average costs reap 50 percent shared savings of their average cost per case below the threshold. Providers who have high costs must share in those costs. The result is a system where providers have a baseline for where their costs should be and incentives to ensure patients recover without expensive and avoidable procedures and interventions. Arkansas also created patient-centered medical homes, which are more conducive to chronic disease management and prevention, as opposed to acute illnesses. The state has now added episodes of care and plans on establishing up to 15 in the coming years. Golden says both providers and payers have largely been on board. “Some of our better and more efficient clinicians have said, ‘Hey, for the first time in my career someone is going to pay me more for doing a better job.’” Through data, the state is providing insight into the total patient journey. Armed with this information, the accountable care provider can modify the total amount of resources it should take to deliver services. “It’s clear that timely data is essential for the episodes as it equips the providers with the roadmap for how to improve,” Golden says.21
KES PHOTO | KAREN E. SEGRAVE
Dr. William Golden, medical director of Arkansas Medicaid, helped the state use its claims warehouse data to report care costs to accountable providers.
He a l t h +Hu ma n S e r vi c e s | SPECI A L R E P OR T
11
HUMAN SERVICES
DAVID KIDD
According to a 2014 U.S. Census Bureau report, the poverty rate is down from the previous year. However, the majority of HHS leaders surveyed felt poverty and homelessness are a larger problem now than in the past.
The Struggle to Help People in Need:
Challenges and Trends in Human Services
T
he recession was tremendously
sharing of data to be more efficient and
in children living in poverty, another
difficult for human services
create better outcomes with less work.
report noted child poverty reached its
agencies. Many of them saw
They are also adopting technologies
highest rate in 20 years, increasing by
sharp increases in the number of
that allow them to increase access and
2 percentage points between 2008 and
people who needed assistance, includ-
make more informed decisions.
2012. Currently, 16 million children
ing individuals and families who had never before sought government help. At the same time, these agencies grap-
live in poverty in the U.S. — one of the
Poverty, Hunger and Homelessness: Pervasive Ills Are poverty, hunger and homeless-
pled with budget decreases and took
The U.S. Conference of Mayors surveys 25 cities every year on
a backseat as states spent time and
ness getting worse? There are differing
homelessness and hunger, as well
energy on implementing components
opinions, largely because it depends on
as their budgetary capacity to provide
of the ACA, most notably the HIXs.
which years you compare. A 2014 Cen-
services. Among their findings:
sus Bureau report noted poverty had
• The number of families experienc-
The silver lining of these issues
12
richest countries in the world.23
is human services agencies have
declined from 15 percent to 14.5 percent
ing homelessness increased across
increasingly looked to smarter policies
from the previous year.22 While the
the cities by an average of 3 percent
that encourage collaboration and the
report attributed this decline to a drop
over the last year.
He alth+ Human S erv ic es | S P ECIAL REP OR T
• Across the cities over the past
example, robust public transportation
year, an average of 22 percent of
options and strong public education
the demand for emergency shelter
systems can make significant strides in
is estimated to have gone unmet.
bolstering economic mobility for low-
Because no beds were available,
income and poverty-stricken citizens.
emergency shelters in 73 percent
Ester Fuchs, the director of the
of the cities turned away homeless
Urban and Social Policy Program
families with children.
at Columbia University’s School of
• Seventy-one percent of the cities
Across-the-board cuts to SNAP benefits beginning in late 2013 totaled
$5 billion in just 1 year, which reduced the monthly benefits for every SNAP participant in the country.
International and Public Affairs, says Other communities are being
reported an increase in requests
mayors and other local government
for emergency food assistance over
leaders in particular have a huge
proactive about identifying people
the past year.
opportunity to move the needle
in need and providing assistance
on poverty.
before an individual or family finds
• Fifty-six percent of those asking for food assistance were families.
“Mayors can create policies that
• Twenty-seven percent of the cities
themselves in crisis. Over the last two
have a long-term impact on poverty
years, the National League of Cities
said the demand for food assistance
and the ability to create economic
(NLC) Institute for Youth, Children and
was unmet.
mobility for city residents,” says
Families (YCF) has been working with
Fuchs, who was also a special adviser
five cities — Houston, Louisville, Ky.,
Recent budget cuts to the Supple-
to NYC Mayor Michael Bloomberg.
Newark, N.J., Savannah, Ga., and
mental Nutrition Assistance Program
“Mayor de Blasio’s universal pre-K
St. Petersburg, Fla. — to help low-income
(SNAP) have made addressing hunger
program is one example,” Fuchs says.
families pay their utility bills and achieve
more difficult. While SNAP funding
“Early learning for kids is extremely
financial stability. The LIFT-UP program
increased in the wake of the recession,
important and impacts their capacity to
is innovative because it uses missed
the additional funding was not perma-
learn down the road. Mayor de Blasio
utility bills as an opportunity to identify
nent, and the number of food insecure
was successful at getting the state to
individuals and families who are likely
households is now close to what it was
fund universal pre-K — $300 million
on the brink of financial crises and
in 2008 — 14.6 percent then compared
for 5 years. Low-income families
works to provide resources and social
to 14.3 percent now. Across-the-board
will be huge beneficiaries of this
services to them before their situation
cuts to SNAP benefits beginning in late
over time.”
becomes more dire.27
24
26
2013 totaled $5 billion in just 1 year, which reduced the monthly benefits for every SNAP participant in the country. While some of the funding is being redirected to programs such as the Healthy Hunger-Free Kids
HHS leaders believe poverty and homelessness are: Becoming a much larger problem than in the past
62%
Act (HHFKA), additional cuts are scheduled for this year and next.25 Confronting Poverty
As governments look for ways to help citizens in need, they should not underestimate the power of basic and traditional government services. For
Remaining relatively steady
37% Not as big of a problem as they were in the past
1% Source: Governing Institute HHS Survey, 2015
He a l t h +Hu ma n S e r vi c e s | SPECI A L R E P OR T
13
Solving Chronic Homelessness
Sixty-two percent of individuals surveyed in the Governing Institute’s HHS survey said they felt poverty and homelessness are a “much
“
If an individual or family is homeless, we want it to be a temporary situation and we want to have the systems and resources in place to move them quickly to permanent housing.” — Brenda Donald, Deputy Mayor, Health and Human Services, Washington, D.C.
larger” problem now than in the past. However, despite this, there have been recent successes in reducing
• Creating a “by-name list”
food insecurity issues at home, some
homelessness. The U.S. Interagency
of everyone experiencing
children rely on school to provide the
Council on Homelessness (USICH)
homelessness in the community
only real meal they eat each day.
works to coordinate the federal
• Assessing veterans experiencing
response to homelessness by helping federal agencies collaborate, and assists states and local communities
gram, a subset of the Child and Adult
their needs and goals
Care Food Program, addresses this by
• Implementing a “housing first”
reimbursing city agencies, schools and
in strengthening their efforts. A major
approach, which removes barriers
nonprofit organizations that provide
focus for USICH has been working
and prerequisites and prioritizes
nutritious meals at afterschool and
with the U.S. Department of Veterans
providing access to permanent
weekend programs for children and
Affairs (VA) and the Department of
housing as quickly as possible28
youth. The program was made possible by the Healthy Hunger-Free Kids Act
Housing and Urban Development In Washington, D.C., Brenda
(HUD) on interagency strategies
in December 2010 and is available in all
and initiatives for ending veteran
Donald, the deputy mayor for Health and
50 states. Afterschool programs are eli-
homelessness. For example, through
Human Services, says the district’s Inter-
gible for federal funding if they have an
the 25 Cities Initiative, agencies jointly
agency Council on Homelessness laid out
educational or enrichment component
coordinate technical assistance to
its five-year plan to end family homeless-
and are located in an area in which at
communities experiencing high
ness by 2017 and veteran homelessness
least 50 percent of the children qualify
levels of veteran homelessness. As
by the end of 2015. By the end of 2022,
for free or reduced lunch.
of August 2014, the cities involved
the goal is for homelessness to be “rare,
in this initiative had housed more
brief and non-recurring.”
than 10,000 individuals. Some of the greatest success stories
The problem is it’s not widely used. Recognizing this, NLC has, for several
“When we say ‘end homelessness,’
years, awarded grants to various cities
we don’t mean that no one will be
through its “Cities Combating Hunger
include Salt Lake City, which ended
homeless at all, because life happens
through Afterschool Meals Programs”
chronic homelessness among veterans
and we can’t prevent that. However,
to help communities take advantage of
in early 2014, and New Orleans and
if an individual or family is homeless,
available funding.
Houston, both of which effectively
we want it to be a temporary situation
ended veteran homelessness in 2015.
and we want to have the systems and
ized assistance, access to best practices
resources in place to move them quickly
and national experts, and opportuni-
to permanent housing,” says Donald.
ties for peer learning and exchange as
Matthew Doherty, executive director of USICH, says there are key
29
elements the agency sees in these communities, including:
NLC provides cities with custom-
they develop and implement strategic Combating Hunger
approaches for increasing utilization
The school lunch program has long
of the program. Emphasis is placed on
using a full range of programs
been a way to feed school-age children
cross-system collaboration among city
and services in response
during the school day, but the linchpin
agencies, school districts and local
to homelessness
has been the school itself. Due to
anti-hunger groups.30
• Operating like a system and
14
The federal Afterschool Meals Pro-
homelessness and understanding
He alth+ Human S erv ic es | S P ECIAL REP OR T
CONNECTIONS
Health and Human Services: Interdependent and Inseparable
T
o solve the challenges of health care, including high costs and poor outcomes, we must
DAVID KIDD
understand the drivers of those costs
If it sounds depressing, that’s
When Poverty Means Poor Health — and Poor Health Means Poverty
because it is. People and families with low or no incomes are not just poorer,
In most of America, your ZIP code
they’re in poorer health, as evidenced
and the reasons for less-than-stellar
says a lot about you. There’s the obvious
by the Robert Wood Johnson Founda-
results. More than ever before, the
geographic location of your residence
tion’s (RWJF) annual County Health
problems associated with health care
— East Coast, West Coast or Midwest —
& Roadmaps report.31 The 2014 report
are inextricably interwoven with
and whether you live in a rural or urban
found Americans are living longer and
those of human services — including
area. However, ZIP codes increasingly
healthier lives in general, but large
economic inequality, poverty, mental
also tend to say something about your
gaps exist between the least healthy
health and substance abuse. If gov-
wealth (or lack thereof ), the likelihood
and healthiest places. The least
ernments are to solve the challenges
you are overweight, the probability of
healthy counties have twice as many
related to health care, they must also
you having illnesses such as diabetes or
children living in poverty, with higher
address the problems of human
heart disease, and your chances of living
unemployment rates, too many people
services — and vice versa.
a long life.
paying more than they can afford for
ZIP codes increasingly indicate income, likelihood of obesity, probability of chronic illness and mortality rate. He a l t h +Hu ma n S e r vi c e s | SPECI A L R E P OR T
15
The linkage between health and
housing and more people without
wealth is even more prominent when
enough social support. While it may seem obvious that
looking at homelessness. “The expe-
wealthier individuals are more likely to
rience of homelessness exacerbates
have access to better health insurance
chronic health conditions people
and can afford more preventive care
already have,” says Richard Cho, deputy
and medical interventions, there are
director at USICH. “In other cases, the
less conspicuous contributing factors
complex health needs some people have
to health disparities.
will put them further at risk, or make
According to an Urban Institute
their homelessness more persistent.”33
report, residents of economically challenged neighborhoods are more likely to live in food deserts and turn to fast food restaurants
The Role of Mental Illness and Substance Abuse in Health Care Each year, nearly 1 in 5 American
and convenience stores for meals.
going to work.34 For those diagnosed with a mental illness, this can be a
Advertisers often target low-income
adults experiences a diagnosable
vicious cycle of despair. Mental illness
neighborhoods to sell tobacco,
mental illness, and 4 percent of
— particularly serious mental illness
alcohol and unhealthy food products.
Americans — approximately 9.6 million
— can lead to job loss, which leads to
Additionally, residents in these
people — live with a “serious” mental
poverty or homelessness.
neighborhoods are exposed to water
illness, which impedes their ability to
and air pollution at higher rates.
perform day-to-day activities such as
32
People with mental health challenges also struggle with physical
Lack of preventive attention to mental illness and poorly planned policies increasingly land people struggling with mental health or substance abuse in jails, emergency rooms or on the streets.
DAVID KIDD
16
America’s least healt hy counties have twice as many children living in poverty, with highe r unemployment rates, too many people payin g more than they can afford for housing and more people without enou gh social support.
He alth+ Human S erv ic es | S P ECIAL REP OR T
health issues at alarmingly higher
Efforts to integrate health and human services are:
rates than the rest of the population.
Vital to solving problems in both areas, as there are strong interconnections between the two
For example, individuals living with depression have a 67 percent increased mortality rate from cardiovascular
Only possible if we have significant changes
disease and a 50 percent increased mortality rate from cancer. People
Only possible if we have significant technology investments
diagnosed with schizophrenia and bipolar disorder die an average of 25 years earlier than the general
Strongly agree
population, largely because of
32% 35%
physical health problems such as cardiovascular disease, respiratory
52%
disease and infectious disease.35 Substance abuse may also be part
Somewhat agree
40% 45% 42%
of the equation. Studies have found people diagnosed with mood or anxiety disorders are about twice as likely as the general population to also struggle with substance abuse, often in an effort to self-medicate.36 Lack of preventive attention to mental illness and poorly planned policies increasingly land people
Neither agree or disagree
4% 15% 14%
struggling with mental health or substance abuse in jails, emergency rooms or on the streets — all of which can come with exorbitant costs in the short or long term. Often, these individuals don’t receive any care for their core problem. According to the 2012 National Survey on Drug Use and Health, close to 8.4 million adults in the United States have both a mental illness and substance abuse disorder, but only 7.9 percent of those individuals receive treatment for both conditions and 53.7 percent receive no treatment at all.37 And only 62.9 percent of adults nationwide diagnosed with a serious mental illness received mental health treatment in the year they reported their illness.38
Somewhat disagree
2% 5% 6% Strongly disagree
1% 2% 2% Don’t know
1% 1% 1% Source: Governing Institute HHS Survey, 2015
He a l t h +Hu ma n S e r vi c e s | SPECI A L R E P OR T
17
CENTER FOR CHILD AND FAMILY POLICY
INNOVATION
18
He alth+ Human S erv ic es | S P ECIAL REP OR T
Durham Connects provides free in-home nurse visits to all parents of newborns to improve the health and wellbeing of infants born in Durham County, N.C.
Smarter Policies and Programs for Better Results
case, you would bring all of the case managers a family has around the table and say, ‘We need to come up with a shared plan that addresses all of the family’s needs and their full set of challenges.’” Addressing individuals and families holistically goes beyond helping the
agencies to know a family well enough
homeless. In North Carolina, the
to say, ‘Wait a minute. That family is
Durham Connects program is focused
roblems never occur in a vac-
also struggling with housing or they are
on understanding diverse family needs
uum. But the way government
in a domestic violence situation where
to improve the health and well-being
has traditionally approached
the mom is going to have to leave and
of infants born in Durham County.
she may become homeless.’”
The program provides free in-home
Looking at Individuals and Families Holistically
P
solving problems is through programs that address one issue at a time without
Donald, who has all D.C. human
nurse visits to all parents of newborns
regard for the complex challenges a
services agencies under her purview,
family or individual might be facing.
says the district is working on a model
“Families experiencing home-
in the county. “Families can be struggling
for integrated case management
with issues ranging from financial
lessness often are connected to many
for families who are involved in the
instability to mental health to
different services,” says USICH Deputy
homeless system, the department of
problems with breastfeeding,” says
Director Cho. “The challenge is these
mental health and child welfare.
Dr. Kenneth Dodge, founder of Durham Connects and the director
“
Families experiencing homelessness often are connected to many different services. The challenge is that these services are not necessarily coordinated and oriented toward addressing the whole family’s needs.” — Richard Cho, Deputy Director, U.S. Interagency Council on Homelessness
of the Center for Child and Family Policy at Duke University. “We assess the family’s individualized needs and develop a profile so we can connect them to the community to meet those needs. They might need help finding the best child care agency. Or they might need to be referred to a
services are not necessarily coordi-
And Cho says USICH is working
mental health center for treatment of
nated and oriented toward addressing
to provide communities with tools
substance abuse. Whatever the issue
the whole family’s needs.”
to bring services around the table.
might be, it’s all about connections —
“USICH is focused on implementing
connecting with a family to help them
programs are working to change this.
coordinated entry systems in
connect to a community so they can
“We used to have a one-size-fits-all
communities across the country. For
connect with their baby.”39
approach to addressing homelessness,”
example, there’s a model known as
says D.C.’s Deputy Mayor of Health
the system of care that’s been used
and Human Services Donald. “Now
for children with behavioral health
we are looking at the reasons why a
challenges and for families with high
holy grail for people who want to move
family became homeless. While we are
needs that we are trying to replicate
the needle on reducing health care
addressing a substance abuse problem
in communities addressing family
costs — not having a problem to begin
or a mental health issue, I want our
homelessness,” says Cho. “In this
with is the cheapest way to solve it.
Some government agencies and
Prevention Pays Off Prevention is often pursued as a
He a l t h +Hu ma n S e r vi c e s | SPECI A L R E P OR T
19
In an 8-hour period, San Diego County conducted
20,434
programs, conducts public health
others who have diseases that can be
surveillance, and develops tools and
prevented or controlled before they
resources for stakeholders at all levels. Local entities, too, are launch-
blood pressure screenings and approximately 80 people were sent to the emergency room for urgent hypertension care.
ing programs with a preventive
importantly, a huge cost to themselves and their families.”41 Preventive measures also have a
focus, such as San Diego County’s
place in addressing homelessness, says
lauded Live Well San Diego pro-
Donald of the Department of Human
gram (www.LiveWellSD.org). As
Services in Washington, D.C. “In the
one example of the sheer success of Examples of success-
create a huge cost to society, and, more
Live Well, the county hosted its fourth
past, the focus on prevention has occurred when families come to the
ful prevention are easy to find.
annual Love Your Heart event in Febru-
front door of the services center to
Prenatal care has long been touted as
ary 2015 to encourage county residents
get processed for eligibility into
a way to lower risk of complications
to check their blood pressure as a way to
the shelter system. It’s been more of
and improve the infant and maternal
prevent or detect heart disease or stroke.
a diversion focus. My goal is to focus
“We had 88 sites across the county
mortality rates. Immunizations have
on upstream prevention.” Donald points to her work in
dramatically reduced or eradicated
and in an 8-hour period we conducted
diseases such as polio, hepatitis B,
20,434 blood pressure screenings,”
child welfare agencies and success in
measles and tuberculosis, among
says Nick Macchione, director of
reducing the number of children placed
others. Even something as simple as
San Diego County’s Health and Human
in foster care by identifying — and
adding fluoride to the public water
Services Agency.
addressing — the drivers. “People don’t
The county established a national
supply has prevented cavities and
wake up one day and decide they want
tooth decay, which would have
achievement, but more importantly
to be homeless,” she says. “There are
created costly interventions.
the event saved lives. “What was really
many opportunities for early alerts to
stunning is one out of every two people
identify what is going on in the life of a
there is increased interest in strategies
reported an elevated blood pressure
family where we can intervene earlier
and programs aimed at averting health
level,” Macchione says. “We had
to stabilize them.”
issues. At the national level, the Centers
80 people with urgent hypertension
for Disease Control and Prevention’s
issues who were sent to the emergency
support its human services programs —
(CDC) National Center for Chronic
room for immediate attention.”
including nearly $30 million in additional
In an effort to bend the cost curve,
Macchione says the event highlights
Disease Prevention and Health Pro-
The district is increasing funding to
funding in the 2016 budget as well as a
motion works to prevent and control
the importance of prevention. “The
$100 million Housing Production Trust
chronic diseases such as diabetes,
people we treated needed immediate
Fund that will help build and develop
cancer, heart disease, stroke and lung
attention. But there are thousands of
affordable housing for the future.
disease. The Center notes chronic diseases are responsible for 7 out of 10 deaths among Americans each year, and they account for 86 percent of U.S. health care costs.40 As part of its mission to improve the nation’s health by preventing chronic diseases and their risk factors, the Center helps support states’ implementation of public health
20
Chronic diseases are responsible for
7 10 deaths out of
among Americans each year – and they account for 86% of U.S. health care costs.
He alth+ Human S erv ic es | S P ECIAL REP OR T
However, despite these benefits, preventive programs and policies around both health and human
might have a role in helping another department or agency realize theirs. Still, even with these constraints,
Houston has decrea sed homelessness by 37% since 2011. Los Angeles is on track to end veteran homelessness by 20 16.
services can sometimes be a tough
things are changing. As the focus on
sell. Dodge of Durham Connects
integrating health and human services
explains: “We’re paying way too much
intensifies, so too does the attention
for tertiary care, rehabilitation and
on how other programs and agencies
remediation. These are very expensive
can be better, together. For example,
after-the-fact types of services. If we
USICH Executive Director Doherty
were to start over, we could spend the
says successful communities make sure
same amount of money — or less — in
they don’t have a standalone system for
agencies to think through how to part-
preventive services that would yield
planning how to address homelessness.
ner their resources to be more efficient and access the kinds of support they
“
need to deliver strong programs in support of ending homelessness.”
We’re paying way too much for tertiary care, rehabilitation and remediation. If we were to start over, we could spend the same amount of money — or less — in preventive services that would yield better outcomes. The problem is it might take a double payment for a period of time to get there.”
This could include health care funds, housing dollars and philanthropy, among other resources. “Sometimes these agencies issue a joint notice of funding availability (NOFA) for how the funds will be awarded to agencies
— Dr. Kenneth Dodge, Director, Center for Child and Family Policy, Duke University
so they can put together the full range of resources and identify how they will
better outcomes. The problem is it
“Mainstream programs, including
strengthen their programs or expand
might take a double payment for a
county or city HHS programs,
services available in their community,”
period of time to get there.”
housing agencies and employment
says Doherty.
agencies, need to be part of the
Cities approaching funding in this
planning process and look for how
way include Houston and Los Angeles.
to align HUD-funded programs in
Following are some examples of
conjunction with resources such
their success:
collaboration and coordination are
as Temporary Assistance for Needy
• Houston has decreased homeless-
critical to better results and greater
Families (TANF), Medicaid and
ness by 37 percent since 2011. The
efficiencies, but what works in theory
Social Security benefits,” Doherty
strategy to end homelessness in
is often difficult to accomplish in reality.
says. “They need to coordinate how
the city is a coordinated effort of
Government has operated for
they are administered on a day-to-day
more than 60 different agencies.42
decades with departments dedicated
basis so it becomes a systematic use of
to solving specific challenges. Those
a broad range of resources to respond
tracking and placement system
departments also have separate funding
to the crisis of homelessness.”
in an attempt to end chronic and
Coordinating Programs and Funding Efforts Many government leaders know
streams and budgets — often tied to
Doherty says agencies also stand to
• Los Angeles is expanding a
veteran homelessness in the county
specific programs — and siloed data and
gain from collaborative funding mod-
by 2016. The expansion is made
systems. Staff shortages mean agencies
els. “We are seeing more communities
possible by $213 million in funds
must focus on their own objectives —
at the local level bring together local
from a coalition of public and
there is little time to consider how they
philanthropic organizations and public
private agencies.43
He a l t h +Hu ma n S e r vi c e s | SPECI A L R E P OR T
21
SOLUTIONS
Technology as a Cure to HHS Ills Data and Analytics
D
r. Kenneth Dodge of Durham Connects succinctly sums up the importance of data in HHS: “We
wouldn’t build a bridge across the river whether it’s going to hold up. We develop
The Missouri Department of Health and Senior Services’ data-sharing project with the state’s departments of Mental Health and Social Services resulted in a 12 percent decrease in emergency room visits among Medicaid enrollees — saving the state $8 million annually.
stoplights at streets based on traffic patterns. We decide to do surgery based on scientific evidence on whether it is going to be successful. It’s critical we use data in the same way to determine what is
For example, Indiana used data and
Health and Senior Services has a
analytics to determine that the state’s
data-sharing project with the state’s
youngest mothers on Medicaid (ages
greater amount of untapped potential
departments of Mental Health and
15 to 20), who are not getting the
for HHS than any other type of
Social Services. The project includes
recommended number of prenatal
technology because for far too long,
the implementation of an online por-
visits, comprised 1.6 percent of all
government data has been siloed across
tal that can be accessed using Mis-
births but accounted for nearly
departments or imprisoned in systems
souri’s health information exchange
50 percent of all infant deaths. Addi-
unable to talk to each other.
(HIE). Within the portal, data can be
tionally, nearly 65 percent of infant
working in our HHS programs.” Data and analytics have perhaps a
This is changing as technology
shared with primary care physicians
deaths were to mothers with 10 or
evolves to process huge data sets and
and community mental health facili-
fewer prenatal visits. The state found
policymakers and department heads
ties, which often treat patients with
infants born to the highest-risk moth-
realize the benefits of data-driven
severe chronic conditions. Under
ers comprised 5 percent of all Medicaid
decision-making — particularly in real time.
the strategy, hospital use is down by
births, but they accounted for 35 percent
20 percent and emergency room visits
of its birth-related expenses.
Many states are in the early stages
22
In Missouri, the Department of
Armed with this data, Indiana is
of realizing what better utilization of
fell by 12 percent among Medicaid
data can do for them. As previously
enrollees. The drop in emergency
encouraging women to attend all of their
mentioned, Arkansas is leveraging
room visits alone will save the state
prenatal visits, but is also investigating
claims data to provide report cards on
the reasons why women don’t go in the
episodes of care and communicating
$8 million annually.44 But state and local governments are
average costs to providers. This
also using data to predict problems.
is lack of transportation — the mother
information is part of a bigger push to
Using data, states can intervene before
simply did not have a way to get to the
improve outcomes and lower costs for
issues occur and be better prepared for
appointment — so the state is finding
Medicaid services in the state.
challenges as they arise.
ways to connect expecting mothers with
He alth+ Human S erv ic es | S P ECIAL REP OR T
first place. One of the primary reasons
SHUTTERSTOCK.COM
without some science-based estimate on
transportation options.45 It’s another
resources and preventive measures
high-priority homeless cases and
example of the interconnectedness of
in specific neighborhoods.
commit less time to low-risk candidates
human services and health care.
or individuals who may not qualify
In Washington state, the Depart-
Insurance companies are also
for assistance.48
ment of Social and Health Services’
using data to reduce the number of
integrated client database provides a
preventable hospital readmissions by
comprehensive view of the life experi-
predicting which patients are likely to
ences of residents and families who are
be hospitalized within three months.
part of the social services system. The
have made it challenging for agencies
They are able to make this prediction
database allows the state to move away
to share data to gain insights, but
based on algorithms of huge amounts
from simply processing transactions
additional problems occur when data
of health data, including billing claims,
and take a proactive approach. Wash-
is collected, managed and stored
lab readings, medications, height,
ington uses data to understand which
across disparate systems — it’s often
weight, family history and the client’s
early interventions make the most
inconsistent and contains duplications,
neighborhood. Once a high-risk
difference and which services can best
errors and incomplete entries.
individual is identified, the insurance
help each client.
Improving Data Management Siloed departments and systems
These discrepancies in citizen
47
company assigns a “health coach” and
Similarly, NYC’s Department of
a coordinated effort ensues to provide
Homeless Services (NYC-DHS) is using
and programs across the enterprise,
the patient with health information,
a Web-based application to aggregate
including HIXs, Medicaid, unemploy-
make medical appointments,
data from multiple sources and present
ment and other benefits. The lack of
resolve medication issues or arrange
it in a map-based view. The application
a consistent citizen record can cre-
transportation. With this method,
allows NYC-DHS to divert resources to
ate flawed and inefficient service
records and data impact agencies
insurance companies have already realized a 40 to 50 percent reduction in expected hospital admission rates for congestive heart failure patients.
46
Human services agencies, too, can greatly benefit from this technology.
When asked if the use of analytics is critical to lowering health care costs and improving outcomes, HHS leaders: Strongly agreed
41%
Data and analytics provide agencies with greater insight into their customer base. Much like private
Somewhat agreed
41%
corporations mining Internet data or using geospatial mapping to target advertising, agencies can leverage data to customize the design and delivery of services. In this way, governments can move away from the flawed one-sizefits-all approach that has traditionally dominated social services programs. For example, agencies can use data
Neither agreed nor disagreed
12% Somewhat disagreed
2% Strongly disagreed
1%
to map hotspots for child abuse and
Didn’t know
neglect, which enables child welfare
3%
employees to investigate what is driving these cases of abuse and focus
Source: Governing Institute HHS Survey, 2015
He a l t h +Hu ma n S e r vi c e s | SPECI A L R E P OR T
23
However, data and analytics tech-
delivery, opportunities for fraud and
sustainability, the elephant in the room
missed chances to collaborate on
is often fraud. In March 2015, the
nology is making it easier for agencies
decision-making.
Health Care Fraud and Abuse Control
to efficiently identify possible fraudu-
Program (HCFAC) announced its
lent activity. Two of the largest targets
management technologies, which
prevention and enforcement efforts
for fraud reduction are Medicare and
allow organizations to create master
recovered $3.3 billion in taxpayer
Medicaid. With urging from CMS,
records from existing data while
dollars in FY 2014 from companies
forward-thinking states are moving
preserving agency investments in
and individuals who had attempted
away from the pay-and-chase model —
individual applications. Master data
to defraud federal health programs.
also known as retrospective recovery
management technology manages
HCFAC noted that for every dollar
— to a cost avoidance strategy. The
data regardless of its source, format or
spent on health care-related fraud and
pay-and-chase approach is problematic
application and can develop common
abuse investigations in the last 3 years,
because it can be time consuming and
data governance and life cycle rules
the administration recovered $7.70. Fraud is a multifaceted problem
labor intensive — often involving audits
across the enterprise. By creating a master data record of citizens across
in HHS. Not only do successful fraud
be prolonged by provider appeals.
the government enterprise, agencies
attempts siphon money away from
can gain a holistic view of citizens or
legitimate beneficiaries, it’s also
data about claims and providers, Med-
program recipients for better, more
traditionally costly for government
icaid agencies can prevent improper
integrated service delivery.
agencies to ferret out illegal activity.
payments. The state of Iowa is a leader
Persistent, manual investigation is
in Medicaid fraud prevention and
often needed.
reduction and has applied predictive
One solution to this is master data
Government can also reduce fraud as multiple HHS agencies can
50
of paper records and files — and can By applying predictive analytics to
more accurately determine eligibility, eliminate duplicate transactions and fraudulent claims, and decrease the amount of improper payments. Finally, consistent data records can provide a foundation for research
When asked if analytics is critical to identifying fraud in health and human services, HHS leaders: Strongly agreed
42%
and analysis to address key policy questions and identify and develop more effective initiatives and programs.
Somewhat agreed
35%
For example, public health, health care and transportation departments can
Neither agreed nor disagreed
16%
use data from multiple organizations to more accurately identify geographic and demographic trends, forecast
Somewhat disagreed
3%
problems, allocate resources more appropriately and model scenarios for
0%
Reducing Waste and Identifying Fraud
Didn’t know
As state and local governments wrestle with questions of financial
24
Strongly disagreed
better planning.49
4% Source: Governing Institute HHS Survey, 2015
He alth+ Human S erv ic es | S P ECIAL REP OR T
analytics across the entire Medicaid claims process since 2011. For every dollar Iowa spends in its Medicaid program integrity initiative, it earns $7.50. In 4 years, the state saved nearly $129 million, with approximately 40 percent of the savings attributed to cost avoidance activities.51 Iowa Workforce Development (IWD) is also utilizing sophisticated big data analytics in the cloud to
determination and providing a real-
For every dollar Iowa spends in its Medicaid program integrity initiative, it earns $7.50. In 4 years, the state saved nearly
time interface with the state’s MMIS. In 2015, the state began expanding the solution to support human ser-
$129M,
vices such as TANF, SNAP and other income-driven eligibility programs.55
with approximately 40 percent of the savings attributed to cost avoidance activities.
Document and Case Management Systems As the focus on integrating health and human services and implementing integrated eligibility systems has
target fraudulent unemployment compensation claims. IWD’s caseload
to expire in December 2015). As part
heightened, so too has the emphasis on
is high — in 2013 it processed 190,000
of the rule, CMS also provides up to
reducing silos among disparate human
claims, paying out approximately
75 percent of the funding for ongoing
services agencies through enterprise-
$432 million in benefits in 2012 and
maintenance and operations of these
wide case management systems.
2013. The new initiative, which began
systems. Additionally, the Office of
in March 2014, uses publicly available
Management and Budget (OMB)
increasingly moved from document-
data sets in conjunction with IWD
extended the Circular A-87 waiver
centric solutions that simply house
data to generate potential fraud leads.
through December 2018, which will
paperwork to client-focused platforms
The software used by IWD analyzes
continue to support the integration
that provide a more complete picture
incoming claims using predictive
of eligibility systems among HHS
of an individual or family. They have
modeling, data mining and matching,
programs such as SNAP and TANF. Upgrading Medicaid eligibility
also increased in sophistication, fea-
and geospatial and search engine technologies to investigate and prevent
systems provides states with opportuni-
productivity of frontline caseworkers,
potential fraud before it occurs.52
ties to integrate eligibility for human
allowing them to focus on improving
services into these systems as well. By
the lives of those they serve rather than
doing this, HHS agencies can better
manually inputting what was often
collaborate through shared data, reduce
redundant information.
Integrated Eligibility Systems In the last several years, states have
Case management systems have
54
turing automated tools to increase the
renewed their focus on integrated
redundancies and provide faster, stream-
eligibility systems and the elusive “no
lined services to benefit recipients.
wrong door.” In preparation for ACA
For example, one place an integrated case management system can
When it comes to integrated
be critical is in child welfare agencies,
enrollment, many states took advantage
eligibility systems, Ohio is a standout,
where lack of information can have
of CMS’ 90/10 matching funds — in
receiving the National Association of
negative or even tragic consequences
which the federal government provided
State Chief Information Officer’s
for our nation’s most vulnerable citi-
90 percent of the funding for Medicaid
(NASCIO) 2014 State IT Recognition
zens. Case management systems can
eligibility system upgrades. Nineteen
Award for cross-boundary collaboration.
be used to house and organize data
states have issued contracts for
Initiated in April 2013 and completed
about a child from sources both inside
upgrades to Medicaid eligibility and
in October 2013, Ohio’s modernization
and outside the government, giving
enrollment systems since 2012.53
project was the fastest eligibility sys-
caseworkers a clearer shared under-
This focus will continue as CMS has
tem upgrade in the nation. The initial
standing of what is happening with that
proposed extending the 90/10 funding
lift was to streamline Medicaid eligibil-
child. Information about emergency
rule indefinitely (it was previously set
ity by facilitating real-time eligibility
room and doctor visits; TANF, SNAP
He a l t h +Hu ma n S e r vi c e s | SPECI A L R E P OR T
25
or other benefits the child’s family
Websites, Mobile Devices
receives; missed school days and more
and Apps
can all help caseworkers make connections and spot potential problems. Boulder County, Colo., implemented
On USA.gov, there is a running
By offering robust websites and apps, HHS agencies empower social services beneficiaries with real-time
list of apps provided by government
information about their accounts. For
agencies. The CDC has 14 apps. CMS
example, SNAP participants can access
an integrated case management system
has four. The Department of Health
their balance at the grocery store and
when it merged its housing and social
and Human Services has 13. NASCIO
know exactly how much money they
services agencies, creating the unified
also maintains an online catalog of state
have to spend. With mobile solutions,
Department of Housing and Human
government apps. The current total
citizens can access services in the most
Services. The system provides case-
as of April 2015 was 350. This doesn’t
streamlined and efficient way possible.
workers with a comprehensive view of
include apps built and maintained by
each client’s situation and helps iden-
city and county governments.
tify opportunities to apply early inter-
All of this is a testament to the rise
Mobile devices — particularly those that have been hardened or made rugged for work outside of the
vention with access to wrap-around
of mobility in government. Mobile
office — can also dramatically increase
services. Through the system, case-
solutions are a good bet for government
the productivity of social services
workers can more closely track clients’
agencies because they are popular
caseworkers who predominantly spend
progress. Boulder County expanded the
with the public, and while they don’t
their time in the field. Trips to and
number of residents receiving services
cost much to implement (an app can
from the office to input information
by 140 percent, mostly by focusing on
be built for a couple hundred to a
become unnecessary and allow ever-
front-end and early intervention.56
couple thousand dollars), the agency
burdened social services agencies to
can quickly see savings, particularly in
do more with less.
increased productivity. This is especially true for HHS agen-
If any entity understands the need to do more with less, it’s Los Angeles
cies, which typically serve populations
County’s Department of Public
more likely to depend on their phone
Social Services (DPSS). The agency
for Internet access. According to a Pew
has a caseload larger than any other
Research Center study, 13 percent of
jurisdiction other than the states
Americans with an annual household
of California and New York, and its
income of less than $30,000 per year
annual budget exceeds $3 billion.
are smartphone dependent.57
To keep pace with growing caseloads, the agency made more services available through alternative means, including over the telephone,
HHS agencies are serving citizens through mobile applications — including resources for everything from prenatal care to elder care. As of April 2015, NASCIO cataloged 350 state and local government apps — many of them are HHS apps.
through Web portals, and via mobile devices and corresponding mobile applications. DPSS built an enterprise electronic document management system putting its 3 million-plus cases online, allowing caseworkers to share information more effectively. The agency also has a robust informational website and an interactive portal called “YourBenefitsNow!”
26
He alth+ Human S erv ic es | S P ECIAL REP OR T
for customers who want to apply for benefits or retrieve and review their case information. A mobile app, DPSS Mobile, makes it easier for customers to comply with eligibility requirements and submit supporting documentation for their cases.58
Telemedicine Since telemedicine was first introduced in the 1980s, the number of patients seen using this technology has increased from a few thousand to more than 10 million.59 Telemedicine’s initial promise individuals who had barriers to access. This largely included rural areas with a shortage of primary care physicians. Telemedicine was also used to connect primary care doctors in remote areas
WIKIPEDIA.ORG
was in providing medical services to
In Mississippi, the Diabetes Telehealth Network is providing people with diabetes more consistent and timely access to clinicians through the use of telemedicine.
with specialists who were based out of larger cities with sophisticated medical
in the nation, with more than 12 percent
showing promise — less than 20 percent
and research centers.
of adults in the Mississippi Delta — one
of patients using the device were
of the most underserved and impover-
hospitalized within 30 days compared
deployed in prisons as a way to provide
ished regions in the nation — diagnosed
with a national average of 24.7 percent.61
care and consultations for individuals
with Type 2 diabetes. Medical expenses
However, even given these advances,
who were incarcerated without
in Mississippi related to diabetes totaled
hurdles remain for telemedicine, includ-
incurring the costs or safety issues
more than $2.7 billion in 2012.60
ing cross-state licensure issues, insur-
Telemedicine then became widely
associated with transporting them to
Other states are using telemedicine
ance reimbursement for services and
a physician’s office. But now states are
to improve outcomes and prevent
broadband connectivity. In many cases,
recognizing telemedicine’s benefits in
costly hospital readmissions. On the
state regulations haven’t kept pace with
a variety of ways.
west coast, Oregon Health and Sciences
technology. But the benefits of substan-
University (OHSU) uses a device to
tially improved access — particularly to
to address costly chronic diseases,
connect with discharged congestive
individuals in rural and remote areas
particularly in areas with little access
heart failure patients. The device can
— make it important for governments to
to health professionals. In Mississippi,
operate through a phone line or cable
address and overcome these challenges.
the Diabetes Telehealth Network is
connection and requires patients to
providing people with diabetes more
enter their weight, heart rate and blood
progress. In more than 40 states,
consistent and timely access to clini-
pressure each day. OHSU receives
Medicaid now covers telehealth62
cians through the use of telehealth
alerts regarding patient data, which
and in 22 states, telehealth visits are
technology in their homes. Mississippi
are then shared with the individual’s
required to be reimbursed at the same
has the second-highest rate of diabetes
primary care physician. The system is
rate as in-person visits.63
Some states are using telemedicine
State governments are making
He a l t h +Hu ma n S e r vi c e s | SPECI A L R E P OR T
27
CONCLUSION
Exceptional Care and Improved Services at an Affordable Price
H
ow do governments provide effective, comprehensive care and services in a way that is fis-
cally sustainable? That was the question posed in the beginning of this report and the challenge leaders at every level are grappling with every day. There are no easy answers, but pieces of the puzzle are falling into place. The biggest piece is the integration of health and human services — through policy, practice and technology implementations. But as one astute practitioner interviewed for this report observed: That’s a very easy thing to say and a much harder thing to do. Five years after the ACA passed, most people would agree that chaos no longer reigns. But the goal of the ACA was not to simply give more people access to a broken system — it was to improve the system and the health of our country as a whole. As governments move forward from HIX implementations, they will strive toward new goals in more efficiently delivering better care and services in the most cost-effective way. Increasingly, the future includes Medicaid payment reform, as well as models that provide incentives for value over volume. It also includes policy changes that allow agencies to collaborate and share data to serve citizens in a way that recognizes they are complex beings and families with needs that almost always span multiple
SHUTTERSTOCK.COM
departmental silos.
28
He alth+ Human S erv ic es | S P ECIAL REP OR T
What is clear is government leaders are up to the challenge and, as this report shows, there are pockets of innovation everywhere with people who are finding processes and programs that work.
R
A
reduce costs, provide better care and potentially revolutionize health care delivery. To aid the state’s efforts, General Dynamics Health Solutions (GDHS) crafted an advanced analytics solution to collect clinical and quality dataSPONSORS from doctors and hospitals, and then share the results and related best practices with those providers Using the Quality Care Insight tool, providers can now learn how their peers address specific health concerns, such as congestive heart failure or cancer, and related treatments, costs and outcomes. Using the GDHS Quality Care Insight tool, Arkansa providers have fine-tuned their treatments to improve patient outcomes, drive down costs and share in the savings.
FT
Sponsors:
Propelling Results
© 2015 e.Republic. All rights reserved.
With its ability to integrate clinical, quality and administrative data for a holistic view of patients, Quality Care Insight is aiding Arkansas to transform health care from fee-for-service to value-based rewards. Results include: • Reduced antibiotics use for unspecified upper respiratory infections by 23.5 percent • Improved screening of pregnant women for chlamydia by 9.3 percent, and decreased the C-section rate by 7.4 percent • Improved conditions for heart failure patients by reducing readmissions by 6.1 percent and decreasing 30-day outpatient observation care by 7.9 percent • Reduced Medicaid costs resulting in a savings of about $720 million since July 2012
The Quality Care Insight helps agencies and providers connect the dots between individual patients, health care services and overall population health. This integratio of data can lead to improved outcomes and significant cost savings.
To learn more, vis
®
He a l t h +Hu ma n S e r vi c e s | SPECI A L R E P OR T
29
ACKNOWLEDGEMENTS
THE GOVERNING INSTITUTE advances better government by focusing on improved outcomes through research, decision support and executive education to help public-sector leaders govern more effectively. With an emphasis on state and local government performance, innovation, leadership and citizen engagement, the Institute oversees Governing’s research efforts, the Governing Public Official of the Year Program, and a wide range of events to further advance the goals of good governance. www.governing.com/gov-institute
THE CENTER FOR DIGITAL GOVERNMENT is a national research and advisory institute on information technology policies and best practices in state and local government. Through its diverse and dynamic programs and services, the Center provides public and private sector leaders with decision support, knowledge and opportunities to help them effectively incorporate new technologies in the 21st century. www.centerdigitalgov.com Both are divisions of e.Republic.
30
He alth+ Human S erv ic es | S P ECIAL REP OR T
JEANA BRUCE BIGHAM is the custom content specialist for e.Republic’s Custom Media department. She has written, edited and conceptualized editorial content focused on technology in government and education for the last nine years and is particularly passionate about simple, innovative technologies and policies that improve the lives of citizens. She has held various positions within the Center for Digital Government, including director of Publications and director of Custom Media. Jeana resides in St. Louis, Mo.
SOLU T ION SP O T L IGH T: UNIS YS
UNISYS MOBILITY SOLUTIONS:
SUPPORTING CASEWORKERS, PARENTS AND CHILDREN
H
ealth and human services agencies, caseworkers and clients jump through many hoops in order to provide, manage and access assistance programs. Unisys is easing this process, and helping agencies drive cost savings and efficiency, while also empowering clients to be more self-sufficient through mobile applications. In addition to a full suite of health and human services solutions, Unisys offers standalone mobility applications that work with users’ smartphones and tablets to support:
Sponsored Content
Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) — Unisys set the standard with its award-winning smartphone app that enables clients to submit photos of documents needed to initiate and maintain eligibility right from their phone or tablet. Documents are automatically made available for workers to approve, streamlining the review process. Additionally, clients can view their available balance and identify fraudulent activity before getting to the cash register. The ability to easily submit records and access benefits information and account balances without visiting the office adds convenience for clients and reduces caseworkers’ workload.
Unisys can help public agencies save money, improve productivity and better help clients succeed.
To learn more, visit: www.unisys.com/hhs
Child Welfare — Unisys’ Secure Family Net mobility solution gives field workers, birth parents and foster parents the tools they need to provide better outcomes for children. Using a mobile device, caseworkers can create reports in the field using voice-to-text features. They can collect images, record conversations and maintain records during home visits, take videos, geo-tag information and easily access the information in court. The app also offers the industry’s only panic button to silently summon police during a potentially dangerous child removal scenario. Likewise, foster parents can instantly locate safety and health information, such as a child’s food allergies or medical needs. Birth parents can use the app to see all steps required to reunite with their children and access related resources such as anger management classes, therapy and housing. Child Support — The soon-to-be-released Unisys ENFORCE mobile app allows parents to apply for child support, calculate a support estimate, view recent balances and transactions, make a payment and more. Parents can even report changes to income and residence through the app — eliminating a trip to the office for parents while also freeing caseworkers to focus on higher-level tasks.
SOLU T ION SP O T L IGH T: A DOBE
Q&A: Adobe
Leveraging Technology for Improved Services & Efficiencies The OMB Circular A-87 Cost Allocation Exception Helps Streamline Integrated Eligibility
Kumar Rachuri, Director, Healthcare Innovation National Government Solutions, Adobe As a long-time public servant, most recently serving as the CIO for the Ohio Department of Job and Family Services, Kumar Rachuri provides his perspective on how states can leverage Adobe solutions and the Office of Management and Budget (OMB) Circular A-87 cost allocation exception to improve services, drive policy change and lower operating costs.
Q: What is OMB Circular A-87?
The OMB Circular A-87 establishes principles and standards to provide a uniform approach for determining costs and to promote effective program delivery, efficiency and better relationships between governmental units and the federal government.¹ Kumar Rachuri: OMB Circular A-87 is the result of federal agencies recognizing that integration and interoperability of HHS eligibility systems are key to improving citizen services and increasing efficiencies. Before OMB Circular A-87, states weren’t able to leverage hardware across program areas, so even though one program may have had hardware functioning at 10 to 20 percent efficiency and 80 to 90 percent of that hardware was available, it could not be used for another program area. The beauty of OMB Circular A-87 is it gives state governments an opportunity to wipe out those demarcations between the program areas and the supporting technology. Now, states can use the funding to build one eligibility system that spans nutrition services, Medicaid, family and children services, child welfare and other HHS programs.
Sponsored Content
¹www.whitehouse.gov/omb/circulars_a087_2004
Q: Why is this important to state HHS departments?
Kumar Rachuri: OMB Circular A-87 allows funding to go a lot further. States are now able to receive a 90/10 match toward the design, development and implementation of an eligibility system — the federal government will fund 90 percent of the project and the state covers the remaining 10 percent. And since data from various program areas can be housed under one umbrella, it can be more easily analyzed and used to facilitate healthier citizen outcomes and drive policy changes. It’s a very attractive proposition for states — helping them to make data-driven policy decisions, improve outcomes and lower expenses. Q: How can states leverage Adobe technologies through the OMB Circular A-87 cost allocation exception? Kumar Rachuri: The federal government has identified several elements that need to be included in state eligibility systems, including “front door” technologies such as document systems, client portals, workflow management solutions and customer service systems. Adobe technology offerings can help meet these requirements. For example, the Adobe Experience Manager is a platform-based solution that enables states to build self-service portals for citizens. It has five modules that can be purchased together or individually, including Web and content management, digital asset management, social communities, forms and documents, and customer-facing mobile apps. The Adobe Experience Manager technology stack can provide responsive and adaptive front-end operations in HTML5 and a workflow management engine in the back end to enhance the efficiencies of large-scale centralized case management systems. With Adobe, the program eligibility life cycle can be completely digital, including signatures with the Adobe Document Cloud eSign service. With the OMB Circular A-87 cost allocation exception and Adobe solutions, states can streamline eligibility systems and HHS services while reducing operating expenses and improving the quality of service delivery to constituents. Implementation of these technologies has helped several states reduce operating costs by millions of dollars while trimming workflow process times from weeks to minutes.
Adobe transforms public sector customer experiences with digital capabilities that improve engagement, cut costs and make government more efficient. Adobe’s solutions enable organizations to create and deliver content in a way that citizens, warfighters and employees have come to expect. Adobe provides the public sector with tools to digitize services and measure its impact while securing mission-critical content across all devices. To learn more about Adobe Government Solutions, visit adobe.com/government or call us at 1-800-87ADOBE.
BETTER DATA COORDINATION CREATES BETTER SERVICE DELIVERY It’s Always Been Difficult to Work Together From administering healthcare and child welfare programs to providing
MarkLogic® Enterprise NoSQL Platform Supports Your Mission
employment training and legal assistance – health and human services
•
Build apps faster with flexible information architecture and data models
(HHS) agencies are hard-pressed to meet the growing needs of their communities. Keeping up with regulatory changes is tough enough, but
•
Integrate and analyze information from multiple sources and formats
the agencies need to ensure that decisions made will produce cost
•
Quickly find and deliver information anytime, any place, over any channel
containments and the delivery of better services to the public. Despite outward appearances, agency insiders know how challenging it is to effectively coordinate services when crucial data is often difficult to access and interpret within context of the individual recipient and the law. Ultimately, disjointed operations and lack of insights force HHS agencies
•
Advance interoperability, HIE and care coordination
•
Secure, share and manage information
•
Build a 360-degree view of client communities
•
Streamline operational processes to contain costs
to say “no” more often than not to requests for faster turnaround of
MarkLogic empowers agencies to integrate and operationalize data from
eligibility verification and expedited coordination of benefits.
across departments and systems for faster, well-informed decision-mak-
But It’s About to Get a Whole Lot Easier Today, MarkLogic is changing all that. Our agile, powerful and secure Enterprise NoSQL database empowers HHS organizations to turn “no” into “now.” Deployed as a data services hub capable of integrating any type of data across disparate silos, systems and formats – MarkLogic
ing. Let’s rethink what’s possible for HHS organizations and their growing client communities. You aim to better serve the community. We make it easier for you to do so. To learn more about MarkLogic solutions, visit us at www.marklogic.com/solutions
equips agencies to deliver efficient, cost-effective services to the community. With a unified point of access and smart analytics platform, HHS employees spend less time hunting down elusive information and have more time to focus on improving service and fulfilling the critical missions of their agencies.
To learn more about MarkLogic visit: www.marklogic.com
SOLU T ION SP O T L IGH T: A E T N A
Protecting Health Information in the Digital Age
Aetna is leading the charge in health care data security
D
ata breaches abound in the digital world, and few are harder hit by these attacks than health care companies and their customers. This comes as no surprise — the information used in health care transactions, including names, addresses, employment information, Social Security numbers and more, is some of the most sought — after data by cyber thieves. As more health-related data and personally identifiable information move to a digital format, it is imperative health care companies shore up security measures to maintain consumer trust. Aetna realizes this and utilizes several strategies to secure data while also leveraging shared information for further protection. In a recent report, Aetna was identified as the only health care company receiving a passing grade in security. In fact, it scored a perfect 100 for email security protocols. It’s the only health care company in the world that uses the DMARC standard, which means emails are checked against a record on company servers and a notification is sent to the company warning of any spoofed, malicious or suspicious emails.1
This strategy, combined with other security technologies, decreases spam to consumers, results in fewer phishing attempts and ultimately betters the member experience. “What Aetna is doing is protecting all members and consumers from receiving fraudulent email, some of which is phishing attempts,” said Jim Routh, Aetna’s chief information security officer. “In our case, 60 million fraudulent emails are not going to be delivered to consumers or members this year because of DMARC.”2 As a leader in the application of cybersecurity controls, Aetna participates in the exchange of best practices with national coalitions and companies in the data intelligence community to learn from each other and become better prepared to handle threats. Aetna follows the technical details of every reported breach to look for opportunities to improve its security measures. While hackers and data thieves exchange information to get a leg up on health care companies — Aetna is doing the same to expose bad actors and help prevent breaches from occurring.
Sponsored Content
1. http://fortune.com/2015/02/19/aetna-dmarc-email-security/?utm_source=twitterfeed&utm_medium=twitter 2. Ibid.
Aetna is one of the nation’s leading diversified health care benefits companies, serving an estimated 46 million people with information and resources to help them make better informed decisions about their health care. Aetna offers a broad range of traditional, voluntary and consumer-directed health insurance products and related services, including medical, pharmacy, dental, behavioral health, group life and disability plans, and medical management capabilities, Medicaid health care management services, workers’ compensation administrative services and health information technology products and services. Aetna’s customers include employer groups, individuals, college students, part-time and hourly workers, health plans, health care providers, governmental units, government-sponsored plans, labor groups and expatriates.
For more information, see www.aetna.com and learn about how Aetna is helping to build a healthier world. @AetnaNews
SOLU T ION SP O T L IGH T: K P MG
Making Medicaid Transformation a Reality Value-based purchasing delivers better quality of care, improves outcomes and reduces costs
D
Sponsored Content
espite the fact the United States spends more per capita on healthcare than any other industrialized nation, it consistently ranks last or near last in terms of quality and outcomes compared to health systems in other Western countries. Given the combination of both increased opportunities and cost pressures created by the Affordable Care Act, state Medicaid programs are often leading the way to change the direction of healthcare by reducing costs and improving outcomes for beneficiaries. Real transformation is achieved when providers are paid for successful outcomes instead of services performed — paying for value rather than volume. Through its Government Healthcare Transformation (GHT) practice, KPMG is spearheading this value-based purchasing approach within Medicaid. Using a state’s own data, KPMG’s GHT practice builds upon a population-focused analytical approach that helps state Medicaid programs reimagine the way they operate, deliver and pay for services, by providing: 9 Rapid access to a fully interactive, customizable, dynamic interface to explore the total costs and outcomes of care delivered in Medicaid based on population, health condition, geography or provider 9 Insight to where value is being created and leaked out of the system (e.g., high costs and poor outcomes due to fragmentation, inadequate delivery infrastructure, etc.)
To learn more, visit: www.kpmg.com/us/hhs
9
9 9
9 9
Rapid access to complementary data sources for multi-payer analyses where a more comprehensive analysis is required Insight into how managed care organizations deliver the most value and where opportunities lie for improvement Built-in capabilities to support value-based payment initiatives, including bundled payments as well as total cost of care (capitation) arrangements Robust experience in linking insights to action, tailored to the specific challenges that vary significantly per state In-depth experience in supporting delivery and payment reform initiatives driven by states
New York, which engaged KPMG to support its delivery and payment reform programs, is a front runner in Medicaid payment reform. Care for almost 6 million beneficiaries will be contracted through value-based arrangements within 5 years. In parallel, the state is targeting a 25 percent reduction in avoidable hospital use through a combination of performance payments and shared savings opportunities. Through its GHT practice, KPMG is uniquely positioned to help states achieve these results. KPMG has the expertise and the toolsets to make Medicaid transformation a reality.
SOLU T ION SP O T L IGH T: GENER A L DY N A MIC S HE A LT H SOLU T IONS
IMPROVING QUALITY OF CARE AND REDUCING COSTS WITH ADVANCED DATA ANALYTICS Treatment approaches, the amount of care provided and total cost to patients for a specific illness can vary widely by doctor and hospital. In the wake of the Affordable Care Act, the state of Arkansas believed narrowing these differences within its Medicaid program — and offering doctors incentives to do so — could help reduce costs, provide better care and potentially revolutionize health care delivery. To aid the state’s efforts, General Dynamics Health Solutions crafted an advanced analytics solution, Quality Care Insight, to collect clinical and quality data from doctors and hospitals, and then share the results and related best practices with those providers. Using the Quality Care Insight tool, providers can learn how they and their peers address specific health concerns, such as congestive heart failure or hip replacement surgery, and related treatments, costs and outcomes. Using the General Dynamics Health Solutions Quality Care Insight tool, Arkansas providers fine-tuned their treatments to improve patient outcomes, drive down costs and achieve savings.
Propelling Results With its ability to integrate clinical, quality and administrative data for a holistic view of patients, Quality Care Insight is helping Arkansas move from from a fee-for-service model to a value-based health care system. Results include: • Reduced Medicaid costs resulting in a savings of approximately $720 million in the last three years • Reduced antibiotics use for unspecified upper respiratory infections by 23.5 percent • Improved screening of pregnant women for chlamydia by 9.3 percent, and decreased the C-section rate by 7.4 percent
Sponsored Content
• Improved conditions for heart failure patients by reducing readmissions by 6.1 percent and decreasing 30-day outpatient observation care by 7.9 percent Quality Care Insight helps agencies and providers connect the dots between individual patients, health care services and overall population health. This integration of data has led to improved outcomes and significant cost savings throughout the Arkansas Medicaid Program.
One-Stop Application: Quality Care Insight The General Dynamics Health Solutions Quality Care Insight solution acts as a one-stop application for health care data and services, including: Bundled payment calculations Analytics and dashboard reporting in real time Quality metrics for payers and provider systems
Drill-down reporting, customizable to a user’s role or identity
Content aggregated from multiple data sources
Notifications and alerts via email and dashboards
To learn more, visit: www.gdit.com/health
The ‘90s called, and they want their paper back.
Your current document management system isn’t working. Why else would your caseworkers still be buried in all this paper and creating workarounds that generate even more paper? There are many Ài>Ãð9ÕÀÃÞÃÌi>ÞÌ
>ÛiLii`iÃ}i`ÜiÌ
iwÀÃÌ«>Vi° Maybe it isn’t up to date with current work processes or it hasn’t kept pace technologically. Whatever the reason, your current document management system is causing you to struggle to meet mandated requirements. At the same time, you’re being asked to provide greater access to services, and your clients are expecting to get information how and when they want it. That means you want to provide clients all new options to interact and submit documents with things like smart phone apps and ÃivÃiÀÛVi«ÀÌ>ÃÌ
>Ì`½ÌÀiµÕÀiÌ
iÌViÌ>vwVi°/
à adds a whole new level of complexity to your document management challenges that wasn’t even fathomed when your current system was implemented. As a result, clients are forced to continue waiting in the lobby to drop off documents. And caseworkers continue making paper copies because Ì
iÞV>½ÌÌÀÕÃÌÌ
iÞ½Li>LiÌw`>`VÕiÌÜ
iÌ
iÞii`Ì>}>° Workers are frustrated. Clients are frustrated. Your system is broken. Northwoods can help. Exclusively serving state and local human services agencies for over 12 years, we are your document management experts.
teamnorthwoods.com 614.781.7800
Don’t be the next headline.
SOLUTIONS FOR HEALTHCARE.
Manage risk to protect your brand.
Cyber threats are not a probability, but a certainty. Verizon’s complete set of security solutions helps you identify threats and take the appropriate steps to mitigate attacks, so you can stop problems before they become headlines.
verizonenterprise.com
Find out more about how Verizon is enabling the healthcare ecosystem verizonenterprise.com
© 2015 Verizon. All Rights Reserved.
Keeping business and IT in balance
Complex HHS programs require leadership across multiple departments and stakeholders, expert navigation of evolving requirements and regulations, and hands-on knowledge of the various capabilities of IT providers. An independent Enterprise Program Management Office (EPMO) is a practice trending with a growing number of governments. Offering powerful support for agencies implementing programs that require complex stakeholder ecosystems, CGI’s independent EMPO provides extraordinary rigor around processes and communications to mitigate project risk and improve outcomes.
cgi.com/epmo
Experience the commitment®
Endnotes 1.
The ACA requires nearly everyone to have health insurance that meets minimum standards. With some exceptions, people who do not maintain health insurance coverage have to pay a penalty.
2.
http://www.nytimes.com/interactive/2015/03/03/us/potential-impact-of-thesupreme-courts-decision-on-health-care-subsidies.html?_r=0
3.
http://www.forbes.com/sites/danmunro/2015/01/04/u-s-healthcare-spending-ontrack-to-hit-10000-per-person-this-year/
4.
http://aspe.hhs.gov/health/reports/2015/MedicaidEnrollment/ib_MedicaidEnrollment.pdf
5.
http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adultsin-states-that-do-not-expand-medicaid-an-update/
6.
In 1917, Western Clinic in Tacoma, Wash., began providing prepaid physician services for the lumber industry; the practice came to Baylor Hospital in 1929. (Fairfield, G. et al. “Managed care. Origins, principles, and evolution.” BMJ. 1997.
7.
http://www.hhnmag.com/Magazine/2015/Jan/feature-medicaid-reform-states
8.
http://www.governing.com/topics/health-human-services/gov-medicaid-managedcare-rules-takeaways.html
9.
Ibid.
10.
http://www.governing.com/topics/health-human-services/tns-ohio-medicaidsavings.html
11.
http://www.hhs.gov/news/press/2015pres/01/20150126a.html
12.
http://innovation.cms.gov/initiatives/state-innovations/
13.
33.
All quotes and information from an interview with Matthew Doherty and Richard Cho conducted on March 24, 2015.
34.
http://www.newsweek.com/ nearly-1-5-americans-suffer-mental-illness-each-year-230608
35.
http://www.mentalhealth.org.uk/our-work/policy/ physical-health-and-mental-health/
36.
http://www.newsweek.com/ nearly-1-5-americans-suffer-mental-illness-each-year-230608
37.
http://www.nih.gov/news/health/jan2014/nida-03.htm
38.
http://www.newsweek.com/ nearly-1-5-americans-suffer-mental-illness-each-year-230608
39.
All quotes and information from an interview with Kenneth Dodge conducted on June 18, 2015.
40.
http://www.cdc.gov/chronicdisease/resources/publications/aag/nccdphp.htm
41.
All quotes and information from an interview with Nick Macchione conducted on April 3, 2015.
42.
http://usich.gov/blog/ houston-drives-down-homelessness-through-community-collaboration-and-housin
43.
http://www.latimes.com/local/lanow/la-me-ln-homeless-collaborative20140909-story.html
44.
http://www.govtech.com/health/Data-Sharing-and-Analytics-Changing-HHS-Forthe-Better.html
http://www.kpmg-institutes.com/content/dam/kpmg/governmentinstitute/ pdf/2015/dsrip-issue-brief.pdf
45.
http://www.govtech.com/data/Data-Analytics-Helps-Indiana-Change-itsApproach-to-Infant-Mortality.html
14.
http://www.kpmg-institutes.com/content/dam/kpmg/governmentinstitute/ pdf/2015/new-york-dsrip.pdf
46.
15.
http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/4/17/ some-states-pay-doctors-more-to-treat-medicaid-patients
http://www.npr.org/sections/health-shots/2015/06/08/408190121/insurer-usespersonal-data-to-predict-who-will-get-sick?utm_source=facebook.com&utm_ medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=20150608
47.
16.
http://www.governing.com/topics/health-human-services/gov-missouri-medicalresidency-law.html
http://www.governing.com/columns/smart-mgmt/col-technology-rise-customercentered-human-services.html
48.
17.
http://www.governing.com/topics/health-human-services/gov-rural-hospitals-onlife-support.html
http://www.arachno.com/casestudy.html?id=1D7ewxcLOa5V_Bqd2gj0bxJjfjbvYzb9a4Id2YPpOzM&title=NYC%20Department%20of%20Homeless%20 Services
18.
http://www.governing.com/papers/A-Handbook-for-MMIS-Reform-1556.html
49.
19.
All quotes and information from an interview with Jessica Kahn conducted on June 30, 2015.
http://www.govtech.com/library/papers/The-Public-Sector-Master-Data-Management-and-the-Elusive-Golden-Record-1336.html?
50.
http://www.hhs.gov/news/press/2015pres/03/20150319a.html
51.
https://dhs.iowa.gov/sites/default/files/IME_Saves_$49.5_Million_Last_Year.pdf
52.
http://www.govtech.com/data/Iowa-Employs-Big-Data-to-Identify-Potential-UIFraud.html
53.
https://iq.govwin.com/index.cfm?fractal=blogTool. dsp.blog&blogname=public&alias=Medic aid-eligibility-and-enrollment-systems-Which-states-still-need-to-modernize
54.
http://www.medicaid.gov/medicaid-chip-program-information/by-topics/dataand-systems/downloads/medicaid-90/10-funding-extension.pdf
55.
http://www.nascio.org/awards/nominations2014/2014/2014OH1-NASCIO%20 State%20IT%20Award-Ohio%20Integrated%20Eligibility%20FINAL1.pdf
56.
http://www.govtech.com/local/Boulder-County-Colorado-Integrated-ServiceDelivery.html
57.
http://www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015/
58.
https://afd34ee8b0806295b5a7-9fbee7de8d51db511b5de86d75069107.ssl.cf1. rackcdn.com/CDG15_ANNUAL_TLP_V.pdf
20.
http://www.governing.com/papers/A-Handbook-for-MMIS-Reform-1556.html?
21.
All quotes and information from an interview with Dr. William Golden conducted on July 16, 2015.
22.
http://www.motherjones.com/kevin-drum/2014/09/ poverty-keeps-getting-worse-and-worse-working-age-adults
23.
http://www.washingtonpost.com/news/wonkblog/wp/2014/10/29/ child-poverty-in-the-u-s-is-among-the-worst-in-the-developed-world/
24.
http://www.usmayors.org/pressreleases/uploads/2014/1211-report-hh.pdf
25.
http://america.aljazeera.com/articles/2015/3/3/billions-in-food-stamp-cutsfinance-new-policies-to-combat-child-hunger.html
26.
All quotes and information from an interview with Ester Fuchs conducted on March 18, 2015.
27.
http://www.governing.com/topics/health-human-services/gov-city-pilot-uses-latewater-bills-help-poor.html
28.
All quotes and information from an interview with Matthew Doherty and Richard Cho conducted on March 24, 2015.
59.
29.
All quotes and information from an interview with Brenda Donald conducted on June 11, 2015.
http://www.govtech.com/health/Remote-Medicine-Tests-Physician-LicensingRules.html
60.
http://www.govtech.com/health/Using-Telemedicine-to-Manage-Diabetes.html
61.
http://www.govtech.com/dc/Telehealth-Command-Center-Connects-Doctors-inJackson-Miss-with-Patients-Statewide.html
62.
http://www.fiercehealthit.com/story/ regulatory-action-key-telemedicine-boom/2015-04-01
63.
http://www.fiercehealthit.com/story/new-york-enacts-telehealth-parity-law/2015-01-12
30.
http://www.nlc.org/find-city-solutions/institute-for-youth-education-and-families/ afterschool/afterschool-and-summer-meals
31.
http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf411678
32.
http://www.governing.com/topics/health-human-services/gov-urban-institutehealth-income-report.html