Health and Human Services Special Report


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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

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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.

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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

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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/

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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

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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

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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

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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

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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.

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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:

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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.

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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

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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



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to say “no” more often than not to requests for faster turnaround of

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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.

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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

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• 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>ܘð9œÕÀÃÞÃÌi““>Þ˜œÌ…>ÛiLii˜`iÈ}˜i`Üiˆ˜̅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 Ãiv‡ÃiÀۈVi«œÀÌ>Ã̅>Ì`œ˜½ÌÀiµÕˆÀi̅i“̜Vœ“iˆ˜Ìœ>˜œvwVi°/…ˆÃ 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 ̅iÞV>˜½ÌÌÀÕÃÌ̅iÞ½Li>Li̜w˜`>`œVՓi˜Ì܅i˜̅iÞ˜ii`ˆÌ>}>ˆ˜° 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.

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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