Auto-Enrolling Patients into Medicaid Could Reduce Health Inequalities-The HSB Blog 3/15/21
Our Take: As one of the steps towards improving coverage and access to health care coverage in the United States, Medicaid should shift to an auto-enrollment mechanism, whereby beneficiaries are automatically-enrolled in coverage by some sort of mechanism (separately determined), without requiring them to actively seek out coverage or submit an initial application. Medicaid, is designed to cover people near or below the Federal Poverty Level (FPL), but unlike Medicare, its federal counterpart for those over 65 or with a disability, Medicaid and the Children's Health Insurance Program (CHIP) do not have any auto-enrollment mechanism in place. As a result, low income individuals, many of whom live in underresourced areas and lack transportation, must currently take affirmative action to seek out and sign up for their government-funded health insurance benefit. Intended or not, this effectively leaves millions of eligible Americans without healthcare coverage leading to a debate as to whether costs and quality would be improved if they were automatically enrolled in the system.
Description: The current U.S health insurance system is dominated by employer sponsored coverage (ESI) which covers approximately 155M employees and their beneficiaries. Many others get access through the health insurance marketplaces set up under the Affordable Care Act (ACA) and may or may not receive subsidies to help them pay for premiums under the ACA as a function of income. Medicare currently covers nearly all citizens and permanent residents over age 65 or with a disability automatically. This is also true of the CHIP which covers children whose parents or guardians have income too high to qualify for Medicaid but low enough that affording insurance for an entire family is difficult. This patchwork system still leaves a large portion of the population lacking access to health insurance coverage through these means, but generally eligible for Medicaid. Medicaid is a state-run but majority federally-funded program with the federal government setting baseline benefit and eligibility standards but different states have different eligibility and coverage thresholds. However, as noted above, while many may be eligible for coverage they still must enroll to receive benefits, which leaves many uninsured. According to Kaiser Family Foundation, 27% or 8.8 million of the 32.3 million total non-elderly uninsured in the US were eligible for Medicaid or CHIP in 2016. While the age composition of this eligible unenrolled group varied by state, Kaiser found that 18% were adults eligible for Medicaid and 10% were children eligible for CHIP. Moreover, another study found that if those who were eligible had been enrolled by a parent or guardian, the number of uninsured children in the US would have been cut from 3.7 million to 1.6 million. We believe auto-enrollment would help solve the problem of many being eligible for Medicaid but not enrolling, and there is evidence it works. By way of illustration, studies indicate that auto-enrollment is helpful in retaining beneficiaries who may have let their coverage lapse. For example, a September 2019 article in the Journal of the American Medical Association (JAMA) found that people who had insurance from the ACA marketplaces that allowed for automatic re-enrollment were 30% more likely to retain coverage the following year than people whose offerings did not include auto re-enrollment. JAMA found while there were several factors that lead to people not re-enrolling in a plan, they included reasons other than a lack of knowledge or willingness to re-enroll. Auto-enrollment is not without its issues for the states, which would face their own set of challenges to implement it. A report from the Brookings Institute found four policy problems for auto-enrollment in health insurance, two of which would pertain to exactly this issue with Medicaid; obtaining eligibility information and managing false positives and false negatives. These eligibility and verification issues both hinge on the availability of comprehensive and quality data. While Medicaid must already obtain eligibility information, this process expands in both scope and difficulty when states are required to find every person who qualifies and enrol them. By contrast, managing false positives is already something done as part of the Medicaid program’s current operations given that they have to deal with fraud cases, however, managing false negatives would be a new task. In determining what method to connect auto-enrollment to a number of solutions have been proposed including enrollment at tax filing (many who qualify for Medicaid are working poor), when people file for unemployment insurance and even when renewing drivers licenses. While none of these methods are perfect, increasing access to coverage would help more people get into the system, improve the quality of their care and ensure that they are receiving care at the right sight of care.
Implications: Closing the gap for insurance coverage is essential to promoting the health of Americans. The people who are uninsured are often referred to as the “donut hole,” those whose income falls in between eligibility for Medicaid and the amount necessary to afford private insurance. Policies like CHIP and the ACA were designed to meet that need, and the potential for expansion of subsidies under the Biden administration is promising. Yet, if people who are eligible for Medicaid are not enrolled, the donut has a bite taken out of it, and there is more space to fill. According to Kaiser, a majority of eligible unenrolled people are people of color. In non-expansion states, close to a third are Black, and in total nearly a third are Hispanic. The health metrics for these populations are lower across the board than those of White people. The barriers to enrollment are often unique to underserved communities such as an experience with government and healthcare that has been less than forthright. As a result, there is a history of distrust that is not unreasonable. In addition, given the political divisions around immigration, the federal government has enacted and enforced anti-immigration policies that have an impact on healthcare access. For example, according to the Urban Institute these policies have led to 1 in 5 adults in immigrant families with children to be less likely to claim public benefits such as Medicaid in 2019. Interestingly, as a result, while many of the positions opposing immigration are rooted in the financial burden on state and Federal governments, this may lead to even more accessing of care when a condition is acute and often via the most expensive means (typically the ER). Improving coverage via Medicaid has always been a matter of health equity, but auto-enrollment for Medicaid would help improve coverage for a portion of uninsured Americans who are arguably most vulnerable.
A Closer Look at the Remaining Uninsured Population Eligible for Medicaid and CHIP; Association Between Having an Automatic Re-enrollment Option and Re-enrollment in Health Insurance Marketplaces; Three Ways to Make Health Insurance Auto-Enrollment Work
NQF Reassess Telehealth Parity and Health Outcomes
Event: On March 8th, mHealthIntelligence reported the National Quality Forum (NQF), a not for profit, nonpartisan membership-based organization working to catalyze improvements in healthcare, is planning to update their 2017 framework for measuring the success of telehealth. NQF is going to review it’s 2017 guidance and examine where improvements need to be implemented. In partnering with the Centers for Medicare and Medicaid Services, the organization hopes to improve telehealth platforms to achieve better health outcomes. The organizations are looking to improve health system readiness, especially in areas severely impacted by the COVID pandemic.
Description: The NQF is a membership-based organization that brings together diverse organizations such as patients, caregivers, hospitals, healthcare systems, clinicians, insurers and employers. It is made up of over 400 organizations and institutions across the healthcare sector that learn, influence, connect, and become informed on healthcare issues. In partnership with the Centers for Medicare and Medicaid Services, the organization plans to measure how connected health tools and platforms have impacted clinical outcomes, access to care, patient engagement, and the cost of care. According to the article, telehealth resources were scarce and only existed in large health systems in urban areas, disregarding the need for these resources in rural areas that lack access to healthcare due to distance, cost, and lack of physicians. The new studies conducted can help to examine if rural healthcare delivery has been affected by telehealth, particularly looking at usage during COVID. As noted by Sheri Winsper, SVP of Quality Measurement for NQF “telehealth existed in pockets, primarily in large health systems in urban areas. When COVID hit, however, everyone sought to push as much care as possible from in-person to virtual channels, in essence pushing the telehealth development curve ahead by 10 years.” As a result, Winsper added, “the NQF’s mission now is to take the data gathered by the surge in telehealth use and figure out whether it’s solving barriers to care or improving outcomes.” The organizations stress the need to update these measures, especially during a period where all different populations are heavily relying on these platforms to maintain their health and have direct access to healthcare providers at an affordable cost.
Implications: With the continued surge of the COVID pandemic, patients continue to rely on telehealth platforms since in some cases, they are still unable to see their physicians unless the situation is critical. It is important to reassess these platforms to ensure that they are meeting the current needs of patients, especially in the case of patients with chronic or life-threatening diseases, where lack of access, or missed follow-up appointments could have been exacerbated due to concern of COVID exposure. Some of the key takeaways NQF can learn from the data include: 1) how telehealth should be compared to in-person care, especially in areas where access to in-person care is limited, 2) how to measure different modalities, should they be measured differently or evaluated against similar standards of care, 3) what information patients should receive when selecting different platforms to access care. This report not only hopes to link the quality of telehealth care with outcomes but also to compare telehealth to in-person care. Clinical evidence of both of these outcomes would be positive to influence post-COVID reimbursement of telehealth which is critical to maintaining usage and expanding into underserved communities.
Automated Reminders Help Warren Clinic Reduce Vaccine Waste
Event: On March 9th, Healthcare IT News ran an article about the Warren Clinic in Tulsa, Oklahoma which is the hub seeking to provide three million people with the COVID vaccine. Warren is the hub for Tulsa, OK as well as seven surrounding counties. As a result, Warren Clinic's priorities were to develop an effective way to communicate with its patients and at the same time make sure that vaccine doses don’t get wasted, especially given the vaccine's short shelf life.
Description: As noted in the article, Warren Clinic is a 450-provider employed medical group that is part of the Saint Francis Health System which would be responsible for distributing the vaccine to 3 million people in Tulsa and the surrounding counties. Given the strong expected demand for the vaccine Warren Clinic wanted to minimize “no-shows'' via automated appointment reminders to ensure none of the vaccine that had been thawed to room temperature would go unused and have to be thrown out. Warren Clinic worked with their long time health IT vendor Relatient which provides their bi-directional appointment-reminder solution that had been seamlessly integrated into their Epic EHR. The Relatient solution helps with direct-to-patient reminders that allows staff to automate text, email, and phone reminders. We spoke with Relatient CEO Michele Perry who added that “you have to engage patients in a way that is going to be super easy...you need a vaccine, here are your options but you still need the basics, how do you get updated medical histories and other information to the doctors.” For example, once Warren Clinic’s patients make an appointment, they receive reminders and their responses, including cancellations, which are then noted in the department appointments report. This way the team can see any new vacancies opened up from appointment cancellations. In addition, as part of Warren Clinic's new Epic EHR build, the first vaccine appointment automatically triggered a second appointment 21 days later at the same time as the first. This strategy was used in an aim for zero waste in vaccine doses as well as minimizing no-shows. Warren Clinic, which had been working with Relatient for five years, had piloted the Relatient automated reminder system earlier at six of its provider locations with the highest no-show rates (unrelated to COVID), and saw an immediate drop in no-shows by 52%.
Implications: As noted in the article, among the lessons learned by the Warren Clinic were: 1) patient’s receiving information directly on their phones where the information was easily accessible seemed to contribute directly to the decline in “no-shows”, 2) have vendors who are integrated, such as Relatient and Epic and don’t be afraid to ask them to move fast to help get your strategy in place, and, 3) ensure that when asking vendors for solutions IT integration has already occurred and put until later asking for things that are not integrated, As noted by Collin Henry, Vice President of Operations and Physician Recruitment for Saint Francis Health System, “[have] a myriad of vendors who offer great service, are responsive and act more like partners than vendors. Then leverage those relationships so you can respond quickly and get a plan in place.” Relatient’s Perry added that to achieve this type of partnership with customers from the vendor side “you have to have a healthy balance between anticipating customer needs so you are there for them, and hearing what they say. Customers want to know they have a voice and that they will be heard”. From the Warren Clinic side Henry added that having vendors who “most importantly, ... understand the values and expectations of one's organization – makes the rollout of any new project or technology easier.” As a result, Warren Clinic has been able to use some of the best practices to reduce no-shows including: 1) Setting automated client appointment reminders via multiple mediums (text and email), 2) Allowing patients to confirm via text/email, 3) Automating bi-directional reminders where a patient’s response to the text reminder either confirms their appointment or provides alternative appointment times for them to select, and, 4) Automated patient instructions that include, clinic addresses traffic routes and COVID safety protocols.
How Femtech is Breaking the Taboo Around Women’s Health
Event: A recent article in MobiHealthNews reviewed femtech's roles in tackling subjects such as pregnancy, miscarriages, physical shame, menopause, periods, and fertility. Lina Chan, founder, and CEO of women’s fertility platform Parla, noted that these areas have always been understudied because women find it uncomfortable to discuss their health issues. The new femtech movement is working to support these issues and close the health gap to ensure women live happier, healthier, shame-free lives.
Description: Women's health care has been shrouded in taboo because women have traditionally been taught from a young age to be ashamed of their bodies. Their health has always been understudied because there have long been various cultural norms that women are always supposed to look pretty, have no flaws, and stay small. Often, women are discouraged from sharing their experiences involving miscarriages and fertility struggles because they are ashamed. However, when women do share these experiences they find out that they aren't the "only ones" who have experienced these situations. As noted in the article, the unnecessary stigma associated with this misguided belief system can lead to isolation and affect a woman's mental wellbeing and physical health. In addition, this can cause women to withdraw from support networks and feel uncomfortable sharing things with providers. According to the article, the only way to end this cycle is to open up the conversation and break the taboo. If women do not reach out for professional help and medical advice, it can lead to delayed diagnosis and possibly a more severe condition. A recent study showed that 70% of women who experience a miscarriage would have some symptoms of PTSD because it isn't something many medical professionals are prepared to deal with. The rise of femtech brands should help break the cycle and end taboo thereby resulting in women's health no longer being on the sidelines, and ending the shame around women's health. Brands like Elvie (who caters to pelvic floor dysfunction and breastfeeding), Clue (menstrual cycle tracker), and Bayer (who specializes in menopause) all can break the taboo. Women who have been affected by underlying issues are included in the design process to ensure companies and products are catering to women's needs and are sensitive to their feelings.
Implications: Because a taboo exists, sometimes even the most well-meaning medical professionals can find themselves under-informed and ill-prepared to offer practical solutions and support for sensitive women’s health issues. To break the taboo, women need to have the confidence to talk about their feelings and experiences to transform their overall health and wellbeing. Indeed, many businesses at the forefront of the femtech movement have been founded by women who have felt under-served by the traditional approach to healthcare which in and of itself should help the problem. They are providing support by creating more products and services they weren't able to access themselves and putting the needs of women at the forefront of design and user-experience. Investors have begun to recognize the importance of this sector and are slowly giving companies financial backing to help more women. These companies help close the care gap caused by shame and technology, making it easier for women to connect with healthcare professionals remotely and at their leisure. Technology can make it easier for women to connect with healthcare professionals from the comfort and emotional security of their own home. Consequently as noted by Ms. Chan, “this means it can be done anonymously, encouraging women to deal with conditions they may have previously avoided”. Moreover, femtech founded companies don’t just develop a product that solves a clinical problem, they also create brands that start a conversation which should elevate the discussions around women’s health issues and help reduce the stigma.