Medical homes are a simple, compelling idea: Give primary-care doctors resources to reduce preventable medical crises for diabetics, asthmatics and others with chronic illness — reducing hospital visits, improving lives and saving money.

But it’s not so easy in practice.

New reports show that two big experiments run by the health law’s innovation lab, known as the Center for Medicare & Medicaid Innovation, delivered mixed early results in enhancing primary care. The programs reduced expensive hospital visits in some cases but struggled to show net savings after accounting for their cost.

Consultants evaluated the first year’s results for the Comprehensive Primary Care Initiative, a four-year program in Colorado, New Jersey and several other states; and the Multi-Payer Advanced Primary Care Practice Demonstration, a three-year test in eight states including New York and Pennsylvania.

The CPC initiative cut costs by $168 per participating Medicare beneficiary, thanks largely to declines in hospital admissions and emergency visits, compared with results of practices not part of the initiative. Results were “more favorable than might be expected” in the test’s first year, said a report by Mathematica Policy Research.

But that wasn’t enough to cover the extra $240 per patient that HHS paid practices to hire extra nurses, improve electronic records, set up 24-hour call lines and make other adjustments. The goal was to identify high-risk patients, keep them on the right medicines and diets and steer them to lower-cost treatment.

“As a taxpayer — are we really making a difference?” said David Nash, dean of Thomas Jefferson University’s School of Population Health and an authority on improving care quality. “I can’t tell from this report.”

Nor was there a big change in quality-of-care indicators, such as follow-up visits after a hospital discharge and making sure patients got recommended diabetes tests. The reports gave little information on whether the added resources improved patients’ health, saying it was too soon to tell.

But those who believe medical homes, also known as patient-centered medical homes, are one answer to America’s expensive, uncoordinated health system found encouraging spots in the evaluation.

“The numbers don’t take your breath away,” said Marci Nielsen, CEO of the Patient-Centered Primary Care Collaborative, a consortium of payers and caregivers. “But … the fact that the early results look as good as they do we take to be very good news.”

Almost all practices that signed up were still participating in the $322 million CPC test at the end of the first year. The complex tasks of identifying patients who could benefit from extra management and setting up care plans “proceeded relatively smoothly in the first program year,” Mathematica said.

Other payers including state Medicaid programs and commercial insurers joined Medicare in the CPC experiments to give primary doctors extra resources to coordinate care. Together they generated substantial extra revenue — $70,045 per clinician for a median practice — for about 500 participating primary practices.

“It is especially promising to see savings from reduced emergency department, hospitalization and readmission rates so soon,” the National Committee for Quality Assurance, which certifies medical homes, said in a prepared statement. Getting medical homes to their full potential “will likely require a longer commitment to the principles of coordinated care,” it said.

Another innovation-lab model, the multi-payer primary care demo, or MAPCP, did produce a small savings for Medicare — $4.2 million — after counting extra patient-management fees, according to an evaluation by RTI International.

MAPCP payers reimbursing primary doctors for care management also include state Medicaid programs and numerous insurance companies.

Although private insurers’ results aren’t included in the MAPCP evaluation, the report said some are unhappy with the program. Commercial insurers may be more impatient than government agencies to see care-coordination money for primary doctors pay off with lower overall costs.

“Payers are noticeably frustrated with the lack of data showing either a positive return on investment or an improvement in health outcomes for participants,” said the evaluation. “Multiple payers” have said they intend to quit Pennsylvania’s MAPCP test, it said.

Both MAPCP and the CPC initiative had start-up challenges involving training, communication and data management, the evaluations said.

Patrick Conway, HHS’ top innovation and quality officer, called the results “promising” in a blog post and said the cost reductions in the CPC program “were nearly enough” to cover agency fees paid to doctors for care management.

There has been little information released by HHS on another medical-home test, a three-year, $57 million experiment involving federally qualified health centers that ended last year.

The latest reports follow other research showing mediocre results for medical homes. A widely discussed study last year in the Journal of the American Medical Association found a medical-home pilot in Pennsylvania didn’t cut the overall cost of care.

But many of the medical-home experiments evaluated so far, including the Pennsylvania pilot, MAPCP and CPC, don’t include potent-enough incentives for doctors, say some reform advocates.

Rather than simply giving primary doctors extra funds to manage care, payers need to additionally reward them for cost and quality improvements and possibly penalize them for missing goals, they say. Similar incentives are found in accountable care organizations or bundled-payment arrangements that involve groups of caregivers working under a budget.

“If you change the economic incentives, you will change physicians’ practice behavior,” said Nash.

The CPC program intends to offer “shared savings” of cost efficiencies with primary physicians in its third year.

A medical-home program run by CareFirst BlueCross BlueShield in Maryland and the D.C. region that includes shared savings has more than paid for itself in total cost cutting while improving care, the company says.

After launching the arrangement for privately insured members, CareFirst got a $24 million grant from the HHS innovation lab to include Medicare patients. The company has hired outside evaluators to try to confirm its results, said Nielsen.

But she argues that cost savings aren’t the ultimate measure of medical-home success.

“If you put in incentives to save money you’re going to see practices save money,” she said. “But if all we do is save money and we don’t improve care, we’ll be cutting off our noses to spite our face.”

CPC and MAPCP are among dozens of experiments being run by HHS’ innovation center, which has a 10-year, $10 billion budget.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

HHS proposes path to improve health technology and transform care

  Over five years after the global financial crisis, jobs are still scarcer than they used to be in the United States – but not everywhere! In true American spirit, for example, thousands of people looking for jobs – or better-paying jobs – have been trekking north and west to “men camps” in rugged states Continue Reading

Nearly half of Americans lacking health insurance during the first year of the health law’s marketplaces appeared to be eligible for government assistance, but two-thirds of them said they found the health plans too expensive or were told they didn’t qualify, according to a survey released Thursday.

Far fewer cited reasons often mentioned in political circles: a philosophical opposition to the 2010 health law or sign-up difficulties cause by the early technical problems experienced by the government’s healthcare.gov enrollment website, according to the Kaiser Family Foundation survey of 10,502 non-elderly adults. (KHN is an editorially independent program of the foundation.)

“Lack of awareness of new coverage options and financial assistance appear to be a major barrier,” the report said.

About 30 million Americans lack health insurance. Some of them are not eligible for financial assistance, either because they are not in the country legally or because their incomes are too high. Others live in a state that has not opted for a health law provision to expand Medicaid, the state-federal health program for the poor, to cover people earning up to 138 percent of the federal poverty level, which is $32,913 for a family of four.

Those people in the so-called “coverage gap” —about 4 million — don’t qualify for their states’ existing Medicaid program and don’t earn enough to qualify for the other financial assistance created in the 2010 health law. (As of this week, 22 states have not expanded their programs.)

The survey found that nearly six out of 10 uninsured people who appeared eligible for coverage through the health law did not attempt to get it last year. Cost was the main reason cited by more than half the people who seemed eligible for coverage but who remained uninsured.

When seemingly eligible people did try to obtain coverage, 37 percent said they were told they were ineligible and another 30 percent found the cost was too much, even with financial assistance. Under the health law, low-income people who earn too much to qualify for Medicaid have to pay between 2 percent and 9.6 percent of their incomes on premiums before the government subsidies start. Many of the plans also carry sizable deductibles and cost sharing.

“While premium subsidies are based on a sliding scale, it appears that many still find the coverage unaffordable,” wrote foundation researchers Rachel Garfield and Katherine Young.

While most people who were interviewed for the poll did not blame red tape in enrolling, six in 10 eligible people reported difficulty with at least one aspect of applying for insurance, including trouble collecting all the required paperwork or submitting an application.

The national survey was conducted between Sept. 2 and Dec. 15 and has  an overall margin of error of  +/- 2 percentage points At the time of the survey, few of the people questioned said they had plans to get coverage for this year.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

As the popularity of electronic cigarettes continues to grow, California’s top public health official warned residents Wednesday about their dangers and announced a new campaign to reduce their use.

Dr. Ron Chapman, director of the California Department of Public Health, said he feared that the increased use of e-cigarettes could chip away at the gains California has made in reducing smoking rates and changing the culture of smoking. The state has the second-lowest adult smoking rate in the nation, he said.

“E-cigarettes represent a new public health challenge that threatens to undo and reverse the progress we’ve made by re-normalizing smoking behavior and tempting a new generation of youth and young adults into the cycle of nicotine addiction,” he said during a call with reporters.

Chapman warned residents that electronic cigarettes emit an aerosol that contains at least 10 chemicals – including formaldehyde and lead — known to cause cancer or birth defects. He also emphasized the health effects and addictive nature of nicotine, which is in the liquid used in e-cigarettes.

He acknowledged that e-cigarettes are not believed to be as dangerous as conventional cigarettes. “But e-cigarettes are not harmless,” Chapman said. “The people of California need to know … the harmful effects of the chemicals that are found within e-cigarettes.”

The health department issued a report Wednesday detailing the concerns and is planning an advertising campaign to educate consumers. The department also plans to work with health providers, child care centers and schools to raise awareness about the devices.

Regulatory efforts are also underway in California and the rest of the country to limit the harms of e-cigarettes. A state senator proposed legislation this week that would define e-cigarettes as tobacco products and would ban people from using them in bars, hospitals, restaurants and other locations that already prohibit traditional smoking. New Jersey, Utah and North Dakota already have similar restrictions.

“Like traditional cigarettes, e-cigarettes deliver nicotine in a cloud of toxic chemicals, and their use should be restricted equally under state law,” Sen. Mark Leno said in a statement.

The U.S. Food and Drug Administration has taken steps to increase regulation. And dozens of cities and counties around the state have passed ordinances over the past few years restricting “vaping,” as e-smoking is known.  At the same time, however, the number of stores in California that sell the devices and liquids quadrupled between 2011 and 2013.

The American Vaping Association, which advocates on behalf of such stores, argues that e-cigarettes are an effective smoking cessation tool and that California’s public health officials are sending an irresponsible message to adult smokers by telling them to avoid e-cigarettes.

“It’s appalling,” said Gregory Conley, president of the association. “It is going to lead to continued smoking.”

Chapman said e-cigarettes are not FDA-approved cessation aids, however, and that people should call the quit line (1-800-NO-BUTTS) if they want help to stop smoking.

Health officials are particularly concerned about the marketing of e-cigarettes to young users through cartoon characters and flavored liquids including chocolate, cotton candy and bubble gum. Data on 430,000 California middle and high school students showed that in 2013, about 6 percent  of 7th graders, 12 percent  of 9th graders and 14 percent of 11th graders had used e-cigarettes in the previous 30 days.

The state has seen a “staggering” increase in use among young adults ages 18 to 29, Chapman said. Between 2012 and 2013, e-cigarette use jumped from 2.3% to 7.6% among this age group.  Nearly one in five of young adult users have never smoked conventional cigarettes, suggesting that those who otherwise might never have never smoked are picking up the electronic devices.

In addition, California poison control centers are receiving more calls of accidental e-cigarette poisoning. The number of calls involving children five and under jumped from 7 in 2012 to 154 two years later. Part of that is due to the lack of child-resistant caps and the potency of the liquid, which may accidentally be ingested or come into contact with the child’s eyes or skin, according to the state report.

“It actually may be more dangerous to have these around the household than conventional cigarettes,” said Cyrus Rangan, a physician with the California Poison Control System.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

When it comes to health insurance, Californians seem to value consistency.

Of the 944,000 people who were could renew their coverage for 2015 through Covered California, the state’s health insurance exchange, 94 percent stayed in the same plan that they were in last year.

About a third of them shopped for other plans available on the exchange, but few ended up making a change. The other two-thirds took no action and were automatically re-enrolled in their plan from last year.

Executive Director Peter V. Lee said one reason was that the prices remained fairly consistent. “While consumers might have saved a few dollars by changing plans, they didn’t face draconian price increases if they stayed,” Lee explained during a conference call with reporters on Wednesday.

Larry Levitt, senior vice president at the Kaiser Family Foundation, called  the stability “stunning.” (Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.)

“On the one hand, it may suggest that people were generally happy with the coverage they had,” he said. “On the other hand, it may suggest that people were confused or reticent to change even when they might save money.”

That sort of  reluctance to switch plans, he said, is also generally what happens in the Medicare Advantage and federal employee markets, “where inertia generally takes hold.”

“More active shopping would certainly put greater competitive pressure on insurers, but there’s also a lot of new customers in this market, so insurers still have an incentive to keep prices down,” Levitt said.

Attrition rates varied a bit by carrier in the Covered California market, but in all plans, at least 90 percent of consumers chose to stay. Kaiser Permanente, which is not affiliated with Kaiser Health News,  managed to hang on to 99 percent of customers who purchased coverage through Covered California.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

California’s Medi-Cal program has grown to cover nearly half of the state’s children, causing policymakers and child advocates to question the ability of the taxpayer-funded program to adequately serve so many poor kids.

In the past two years alone, the program has added nearly 1 million young people up to age 20,  including those newly eligible for Medi-Cal coverage under the Affordable Care Act. The increase brings the total number of young people on Medi-Cal to 5.2 million, more than ever before.

Medi-Cal is California’s version of Medicaid and the largest program of its kind in the nation.

Many pediatricians and specialists already refuse to accept new Medi-Cal patients, at least in part because the program offers among the lowest payment rates in the country. New rate cuts took effect this January. Health care advocates say adding more children to the mix will only worsen the likelihood of timely treatment.

Evidence is emerging that the public insurance program is falling short in some key respects. According to an ongoing study led by Ninez Ponce at UCLA and funded by the California Healthcare Foundation, children on Medi-Cal were five times more likely than kids on private plans to have visited the emergency department for asthma care because they couldn’t see their own doctor.

And according to a state report based on 2013 data, more than two-thirds of California’s Medicaid managed care plans performed below the national average for Medicaid plans in ensuring that children had required immunizations by age 2.

Advocates and some policymakers say the state has downplayed problems with children’s care and not provided adequate data to help evaluate and improve services. They say officials have traditionally paid more attention to Medi-Cal’s more costly adult population.

“When you have half of all of California’s children in Medi-Cal, it’s essential that the state keeps its promises to children that they can get access to the care that they need. This is our future,” said state Sen. Richard Pan, D- Sacramento, a pediatrician who has been pushing the agency to provide better data on children’s care.

State officials say they are working to improve access to care for children but do not see widespread problems or a need to raise reimbursement rates.

“At this time, we feel the rates are sufficient,” said Anastasia Dodson, associate director of policy at the California Department of Health Care Services, which oversees Medi-Cal.

Over the past two years, Medi-Cal absorbed about 750,000 children when California eliminated its Healthy Families child health insurance program, which was aimed at working families with higher incomes than the Medi-Cal population.  An additional 232,000 children joined with the expansion of Medi-Cal under the Affordable Care Act, according to a spokesman for the health care services department.

Nearly all of these children are enrolled in managed care plans, which pay a fixed monthly rate per patient in an effort to save money and streamline care.  Most families pay small monthly premiums for each child depending on income.

The transition from Healthy Families, which generally paid higher rates to doctors,  saved  about $39 million in the 2013-2014 budget year, said Dodson, less than the agency’s initial estimate of $52 million. (Overall, the Medi-Cal budget is projected to be $95.4 billion in 2015-2016.)

The transition went smoothly for many families, but had its share of serious challenges.

Some children lost access to critical services, such as autism behavioral therapies, that had been previously covered by Healthy Families. The autism services were eventually restored, but advocates faulted the Department of Health Care Services for being slow to react, and families are still dealing with the fallout of trying to regain services for their children.

Glaiza Santiago of San Jose lost autism therapy for her 6-year-old son, Ernesto, for about a year after her children were transferred from Healthy Families to Medi-Cal. Only after filing complaints with her managed care plan, Santa Clara Family Health Plan, and the Department of Health Care Services was she able to get Ernesto reevaluated so that his therapy could resume.

“It’s just been a battle to get him therapy and the other things that he needs,” said Santiago, who has two other young children and is studying to become a medical assistant. “I felt so helpless…I never realized it would be that hard. I never had problems before.”

Other families have experienced long waits for care, particularly dental services.

Diana Vega, an elementary school teacher in San Pablo, has mixed feelings about her three children’s experience with Medi-Cal managed care. She appreciates that her premiums to participate in the program have declined by about 25 percent since switching from Healthy Families; her kids also were able to keep their pediatrician.

Like Santiago, she had trouble restoring therapy services for her son, diagnosed with autism and Prader-Willi syndrome, a genetic condition that weakens muscles. But she also was taken aback by how much more difficult it was to get eyeglasses and dental care.

After waiting nearly eight months for an appointment with a dentist who would accept her children’s Denti-Cal insurance, Vega said, the dentist said the insurance would not pay for him to fill a small cavity in her daughter’s mouth because it wasn’t yet “visible to the eye.” So Vega purchased a separate dental insurance policy for her children and abandoned Denti-Cal.

Medi-Cal’s dental services have drawn particular criticism, including a state audit released in December that found that dental services had been provided to less than half of the program’s children, mostly because so few dentists were willing to accept the low reimbursement rates.

Dodson of the health care services department said that families can call a telephone service center (800-322-6384) when they are having problems finding a dentist or a timely appointment with any provider, and the state is working to recruit new dentists willing to accept new Denti-Cal patients.

Dodson said her agency regularly monitors the networks of Medi-Cal managed care plans to ensure there are enough doctors to care for patients and that she has not heard of widespread problems for children who need specialty care.  Efforts are underway statewide to increase the number of doctors willing to accept Medi-Cal patients, particularly in Riverside and San Bernardino counties, where the Inland Empire Health Plan is offering physicians bonuses of up to $100,000 to treat its members.

The agency also is working with a new committee of experts, the Medi-Cal Children’s Health Advisory Panel, to develop better pediatric data that will help identify any gaps in care, she said.

At the panel’s first meeting in January, Sen. Pan, who pushed legislation to create the panel – against the Department of Health Care Services’ wishes – cast the stakes for the committee’s work in stark terms:

“When you’re covering half of California’s children, it’s hardly ‘those kids’ anymore,” he said. “It’s all our kids.’”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.