Poor Health

PORTLAND, Ore. — Better — and cheaper — health care for the poor could lie in the answer to this question:

Can an air conditioner be considered medicine?

Janet Meyer, CEO of Health Share Oregon, says it can.

"There is the case of a guy with a heart problem," said Ms. Meyer, adding that the man keeps going to the emergency department, where doctors stabilize him and send him home, only to find him back again.

"Come to find out, he's in a walk-up with no AC — he has trouble managing his fluids," Ms. Meyer said. "We say, 'Maybe what he needs is an air conditioner.' Instead of going back and back to the ER, we buy him an air conditioner and help him manage his fluids."

The end result: Less money spent and the patient's health improved.

Health Share is part of an aggressive effort by Oregon to lower costs and improve medical care in its Medicaid system, a high-stakes undertaking that uses an unorthodox approach and is funded by a $1.9 billion waiver from the federal government.

The relentless economics of the U.S. health-care system have sapped resources in poor areas for decades as hospitals and doctors follow the money in the form of well-insured patients. Doctors and medical care facilities serving large numbers of poor patients have trouble staying afloat because uninsured patients and those on Medicaid are expensive.

Although most systems tried to skirt financial losses by avoiding those patients, a handful — from hospitals in Camden, N.J., to Philadelphia to those involved in the Oregon effort — have decided to focus on the poor, making them the centerpiece of efforts to spend less and give better care.

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Oregon's effort is centered on the high utilizers — patients who show up frequently for emergency care and readmissions after hospitalization — among the approximately 971,000 enrollees in its Medicaid program.

"We all realized that a small percentage of this population drives expenses," said George Brown, CEO of Legacy Health, the second-largest health system in the Portland area. "Between 5 and 15 percent drives somewhere between 35 and 50 percent of costs."

The Oregon program, backed by Gov. John Kitzhaber, is being closely watched around the country to see whether the state can bring down health-care costs. As provisions of the Affordable Care Act take hold, programs tailored for the poor could end up being models for patients of all income levels.

The health care law is changing how funding works — money is increasingly being tied to outcomes, rather than pegged to tests and procedures.

The Oregon program is based on fixed, or "capitated" contracts, so health-care providers have incentives to keep expenses down to avoid eating costs that exceed what the contract pays.

The timeframe is short to show that a statewide program can rewire the way health care works. Those involved feel the pressure of justifying the large-scale funding. Oregon's waiver goes through June 30, 2017. An additional $17.3 million federal grant awarded to Health Share runs through 2015.

"One of our board members said black helicopters are going to come in about two years, and people with sunglasses are going to jump out and say, 'where is our money?'" said Meyer.

It started with the "frequent fliers," the term paramedics and ER docs use for patients who make repeated trips to the emergency department.

Most across the country have long viewed such patients as unfortunate souls or frustrating nuisances.

Then, in 2007, Dr. Jeffrey Brenner started a patient management system that came to be known as the "hot spotters" program. He had used data to map hot spots of high utilizers in Camden, N.J. and found that 1 percent of patients were driving about a third of the city's medical costs. One patient had gone to the hospital 113 times in a year. The most expensive patient cost insurers $3.5 million.

Dr. Brenner created care management teams, each with a social worker, nurse, community health worker and health "coach" (an AmeriCorps volunteer). The teams visited patients in the hospital and at home after discharge, and coordinated things such as medications, appointments and finding support services.

Similar experiments targeting such patients and using outreach to try to give better, cheaper care had cropped up over the years, but Dr. Brenner's work targeting high utilizers drew national attention and resonated with many in the field.

There are high utilizers who are well-off and well-insured, of course, but many are uninsured or underinsured people who use the emergency department as their sole source of health care.

Many large health-care systems avoid such patients by moving out of poor areas and declining to take Medicaid patients. But some can't do that because their flagship hospitals are in low-income urban neighborhoods. And some saw what Dr. Brenner and other innovators were doing and changed their approach to care for the poor.

They are paying for transportation, since a missed appointment wastes resources and can mean the condition worsens. They are hiring outreach workers to help patients navigate medical care systems. They are putting more services under a single roof — so patients can get primary care, dental care and specialty care in one place, for example. They are targeting patients with complicated medical problems.

"What's surfaced is that we're getting more nuanced about thinking about this population and why they are where they are," said Ron Stock, a director at the Oregon Health Authority Transformation Center. "We need to think more about the individual patient and what their health needs, social needs, psychiatric needs, family needs are."

Until recently, no one had tried to reimagine health care for low-income patients on a large scale, and it's not clear if there's enough room to maneuver inside a system in which all the incentives remain skewed toward patients with private insurance.

In August, a letter from the Centers for Medicare and Medicaid Services raised concerns that the state could lose the flexibility it was granted. It questioned the state's rate-setting system, seeming to ask for rates on a fee-for-service basis in a system that was no longer operating on that basis, said Ms. Meyer, the Health Share CEO.

"Actuaries are anxious," she said. "We need to take the old system and improve it in a way that makes actuaries comfortable."

Health Share is one of 15 coordinated-care organizations — made up of previously unaffiliated hospital systems, behavioral health agencies, physician groups and others. Each of the organizations gets a per capita monthly payment for all care during the five-year pilot program, which runs through June 30, 2017. They provide medical, dental, psychiatric, addiction treatment and case management for about 90 percent of the approximately 971,000 people covered by Medicaid in Oregon.

Most health-care systems work on modified fee-for-service — they are reimbursed set amounts for certain services. A key feature of the Portland system is the capitated contracts. This requires a fundamental shift. The provider gets a set amount for all services, and thus has incentive to stay below that amount so as not to have to make up the difference.

It's put enormous pressure on the coordinated care organizations, which are trying to spend less but show that they can produce better outcomes. Further, they are using unconventional approaches such as air conditioners but still working within a system that emphasizes payment for specific medical services.

"We're not Facebook, where the saying was, 'Work fast and break things,' said Ms. Meyer. "We can't break things — we don't want to disrupt patient care — but we have to work fast. We're trying to repave the freeway at rush hour."

Once the Health Share members began working with such contracts, though, their perspective quickly changed on how best to deploy their staffs.

Rebecca Ramsay, director of community care at CareOregon, a Medicaid health plan, talked about the case of a 30-year-old homeless man who was in Portland-area emergency rooms 19 times over a four-month period in 2013.

A note in his records indicated "aggressive behavior," and he had been escorted out of a clinic after yelling at a doctor who wouldn't give him pain medication.

The list of his diagnoses included alcohol dependence, marijuana abuse, antisocial behavior and self-injurious behavior.

High utilizers are usually people with a lot going on: chronic disease, mental health problems, addiction. Some might be in an emergency room dozens of times a year, and be admitted to the hospital for problems related to "noncompliance" — not taking their meds, not going to follow-up visits, not following the doctors' orders.

"The high utilizers are people who are in some sense on fire," said Ms. Ramsay.

They often need more individual attention.

When the homeless patient showed up again at the clinic where he'd been disruptive, the doctor turned him over to Lisa Achilles, an outreach worker for Health Share.

Ms. Achilles spent time with him and learned about him. She found that he loved dogs, was meticulous, and enjoyed landscaping. She learned he had been physically and emotionally abused by an alcoholic father. She helped arrange care for his various issues, working with him and with the doctors who treated him to help them understand each other.

"We were asking, how do we use Medicaid in a nontraditional way," said Cindy Becker, director of health, housing and human services for Clackamas County, and a member of the Health Share board. "We were allowing people to bring their common sense to the table."

That emphasis led to practical solutions like the air conditioner, which lowers the humidity that causes COPD patients to struggle to breathe.

In Jackson County, the coordinated-care organization used money to pay a shelter for the homeless that was normally open only at night to keep a man with an infected foot there during the day until he could heal. Had he been back on the street, the chance of re-infection was high, and instead of the $15 a day to keep him at the shelter, it could have been thousands for an inpatient stay at a hospital.

In clinics, staff members text appointment reminders to patients and doctors do telephone consults with patients; they didn't do it before because the system did not allow reimbursement for it.

In Clackamas County, Ms. Becker said that because she can immediately connect to county services, she can often help with issues such as housing, clothing and education.

Ms. Meyer said they realized another issue playing into emergency department usage was on the ambulance end. Emergency services in Portland are paid only if they deliver the patient to the emergency department.

"We thought, can we pay them NOT to take the patient to the ED?" she said.

So Health Share launched a pilot program in the Portland metro area in which ambulance services are paid to take patients to a clinic, or help set up a medical appointment or provide on-scene treatment in non-emergency situations.

Those on the front lines of treating the poor have long known poverty itself was contributing to their patients' ill health, and that without addressing those issues, medicine is only providing stopgap measures.

Jack Geiger, a pioneering doctor who founded clinics for the poor in the 1960s, says the concept crystallized for him in medical school.

"One day I was standing on the steps of the medical school, and beyond where I stood I could see the university hospital and beyond that I could see the city of Cleveland, and I had this moment of epiphany. It occurred to me that who got sick and how it happened was not just a biological phenomenon but a social phenomenon."

People were made sick by their poverty, and medicine was treating them and then sending them back to the circumstances that had made them sick.

"I thought I'd invented social medicine," says Dr. Geiger, now 88. "The idea that population health isn't determined by health care — it's determined by the situation under which people live."

Some quick research showed him England and Germany were 150 or so years ahead, and the concept stretched back at least to 1790, when a German physician named Johann Peter Frank gave a lecture called "The People's Misery: Mother of Diseases" at the University of Pavia in Italy.

Dr. Geiger and his colleague, Count Gibson, put the idea of addressing social causes of illness into motion in the mid-1960s, starting the Tufts-Delta Health Center in Mississippi and a similar center in Dorchester, Mass. (now the Geiger Gibson Health Center).

Modeled on clinics Dr. Geiger had studied in South Africa, they were fueled by the civil rights movement and funded by the Office of Economic Opportunity, the agency deployed to fight the War on Poverty.

Dr. Geiger and his colleagues attacked the causes of diseases they found as well as the diseases. When they saw people in Bolivar County, Miss., drinking water drawn from drainage ditches or that had been stored in pesticide barrels, they and residents dug wells. They worked to bring better sanitation, education and jobs to the area as well as running clinics to treat illnesses.

When they found persistent cases of diarrhea at the Bolivar clinic, they took action.

"We kept finding families in acute distress with infants with infectious diarrhea — and no food," said Dr. Geiger, who is now professor emeritus at the Sophie Davis School of Biomedical Education in New York City.

The clinic served 10 towns, and every town had an African-American section, and every one of those areas had a grocery store, Dr. Geiger said.

"So we started a system in which our physicians wrote prescriptions for food — enough for all the people in the family because no mother was just going to feed just one child" while the others went hungry.

"So the system was, a family could take these prescriptions and fill them at one of these grocery stores. We called it a loan to preserve people's dignity. The grocery store would send a bill and we'd pay for it through the pharmacy department."

They would continue with the food prescriptions for the weeks it took until a family got back on its footing.

The program didn't sit well with Mississippi officials in the Cold War era; they accused Dr. Geiger of Soviet-style socialism. When officials complained to the federal Office of Economic Opportunity, which provided funding for the clinic, the agency sent a representative to talk to Dr. Geiger.

"He said, 'What do you think you're doing, giving away food. The pharmacy is for dispensing drugs to treat illness.'

"I said, 'The last time I looked the recommended therapy for malnutrition is food.'"

The community health center movement grew, and there are now nearly 1,200 centers across the country serving about 22 million patients annually.

Known as federally qualified health centers, they work with underserved areas or populations, offer a sliding fee scale and a range of primary care services. They are reimbursed at higher rates than other primary care providers for Medicaid, and get discounted pharmaceuticals, access to National Health Service Corps clinicians, and medical malpractice liability protection.

But the social service component has been scaled back.

Many of the clinics now are caught up in the day-to-day struggle to deliver basic health care services on tight budgets.

One of the aims of the Affordable Care Act was to strengthen them to provide service for increased numbers of insured patients.

Dr. Ronald Yee, who recently began work as chief medical officer for the National Association of Community Health Centers, said clinics have long addressed patients' non-medical needs — transportation, translation, linking to social services — without being reimbursed for it. He said one of his organization's aims is to work with insurers to get reimbursement for such "enabling" services.

State regulations can make providing comprehensive services challenging.

In Wisconsin, a Medicaid patient can't get two types of services in a single day. So, for example, a patient can't be seen for a primary-care appointment and then get dental care at the same center, said Jenni Sevenich, CEO of Progressive Community Health Centers in Milwaukee.

This makes it inconvenient for the patient and decreases the likelihood that he or she will get all the services needed.

"We don't get reimbursed for case management, translation, transportation," said Ms. Sevenich.

"To hire an interpreter to interpret for a deaf patient costs much more than we make from that patient, for example," said Ms. Sevenich.

She has had to figure out how to address such costs.

The center raises funds for bus tickets for patients by having a 50-50 raffle at its staff meetings.

"You find a way, right?" said Ms. Sevenich.

In Oregon, the effort to find a way is beginning to pay off, as data on changes between 2011 and 2013 shows.

The 15 coordinated-care organizations provided care for about 90 percent of the state's Medicaid population and had a 17 percent decrease in emergency department visits.

Adoption electronic health records by providers went from 28 percent to 58 percent. Readmissions within 30 days of discharge dropped by 8 percent.

Primary-care enrollment increased by 51 percent over 2012, and the state's Coordinated Care Organizations reduced hospital admissions for congestive heart failure by 32 percent, chronic obstructive pulmonary disease by 36 percent and adult asthma by 18 percent.

Now Oregon projects a potential cost savings of more than $3 billion over the next five years from the coordinated-care organizations. The state's model is expected to reduce the overall growth in spending by 2 percent over the next two years, according to the National Academy for State Health Policy. If the Oregon experiment survives the challenges it faces and continues to have promising outcomes, the poor and vulnerable could prove to be the key to savings and better care — after decades of being an unwanted expense for health care systems.

If the Oregon experiment continues to fare well, the poor and vulnerable could prove to be the key to savings and better care — after decades of being an unwanted expense for health-care systems.

"Because I'm a geriatrician, I've always seen them as canaries in the mine," said Ron Stock, the Health Authority director, of the poor and vulnerable.

"If you don't take care of them, the health system won't work for others."