HealthyCal.org

By Bruce Chernof, MD

California’s next governor will have an opportunity to play a major role in the health and well being of the state’s growing senior population.

Right now, the system is inadequate to support vulnerable older adults who find it increasingly more challenging to live independently as they age. Roughly 70 percent of individuals age 65 and above will have long-term care needs at some point in their lives. When learning of this real likelihood, people feel deeply worried and unprepared.

According to a March 2010 poll we commissioned with the UCLA Center for Health Policy Research, 66 percent of California voters 40 and older worry about being able to pay for long-term care that they or a family member may need in the future. Concern crosses party affiliation, with majorities of Democrats (72 percent), Republicans (59 percent), and independents (63 percent) worried about being able to afford needed care.

The federal Affordable Care Act lays the foundation for a more cost-efficient and person-centered approach to care, but it will take leadership and vision from the next governor to get there. Cuts to the state’s already beleaguered long-term care system will not make the issue go away. California has the opportunity to restructure services and build a more sustainable network of home- and community-based services to meet the emerging need. Here are three recommendations for the next administration to consider in constructing a more rational system of care for the state’s aging and disabled population.

As a first step, the next administration should support implementation of the Community Living Assistance Services and Supports (CLASS) program. This program is a voluntary federally-administered insurance product that will, without any taxpayer dollars, provide Californians with the opportunity to access services through a cash benefit. The state can encourage residents to be more invested in their own futures through public education campaigns about the high likelihood of needing long-term care in old age. State and local governments are collectively the largest employer in California and can take the lead in making community living assistance available to its employees. By encouraging personal responsibility for future health care needs, more individuals will be prepared to age with dignity and independence.

Second, the state can apply for a number of home-and community-based program options in the Affordable Care Act that will bring increased federal dollars to the state, while keeping more individuals out of nursing homes.

Proposals include “Community First Choice,” which provides community-based services and supports to eligible individuals with an increased federal Medicaid match. The state already has a “Money Follows the Person” grant and the changes made in the federal law will extend this program and expand eligibility to a broader group of seniors and people with disabilities currently in institutions. This valuable program will help these individuals transition back from a nursing home to the community of their choice. These are important tools for California to serve individuals in the most integrated setting possible, building a strong continuum of care, and meeting the state’s obligations under the Americans with Disabilities Act.

Third, the state could support the growth of the direct care workforce, which provides the employment core of personal care workers to those with disabilities.

According to the California Employment Development Department, projected demand in this field will grow by over 260,000 direct-care jobs from 2008 to 2018. The state and local entities have already applied for federal dollars to encourage students to become nursing assistants and home health aides but there is more to be done to support enriched training efforts that consider the unique needs of older people, all the while supporting job development in these tough economic times.

The state’s next chief executive will have the opportunity to create a new system of care for older and disabled adults that is truly greater than the sum of its parts. While it may not be perfect, the new health reform law will give the new governor the power to transform long-term care in California toward a more person-centered, accessible, and affordable ideal, promoting individual responsibility so people can age how they want and where they want.

That’s fodder for the next administration that resonates with today’s and tomorrow’s older Californians, no matter on which side of the aisle they sit.

Bruce Chernof, MD, is president and CEO of The SCAN Foundation.

By Micah Weinberg

Federal health reform will add as many as two million more people to California’s seven million person Medi-Cal program. What will it take to guarantee this expansion exists not only on paper but results in meaningful access to quality health care for new enrollees?

The first thing to understand is that this may require a substantial commitment of state resources. The California Budget Project estimates that the cost of the expansion to California will be approximately $5 billion dollars over the next ten years. California has to pick up only a small share of the cost of those newly eligible for the program. But the state will continue to split evenly with the feds the cost of those people who were eligible before the law was passed but will be newly enrolled.

This is likely to be a very large number of people. Conservative politicians like to talk about individuals accessing benefits to which they are not entitled, but the opposite dynamic is much more common. In California, there are hundreds of thousands of people eligible for our state’s Medi-Cal program but not enrolled in it.

The California Budget Project estimates that there will be about 500,000 new enrollees in Medi-Cal who were eligible before the law was passed. This is a result, in part, of the law’s streamlining eligibility criteria and processes. The law also provides funds for significant outreach, in particular through the actions of the California Health Benefit Exchange, the new state agency that will be the portal to coverage.

The Urban Institute estimates that if those who are implementing federal health reform engage in effective outreach, it could cost the state as much as $6.5 billion from 2014-2019. In this “higher participation” scenario, fully $4.5 billion will come from covering previously eligible but newly enrolled beneficiaries. On the other hand, in Urban’s “lower participation” scenario, the total additional cost to the state for the Medi-Cal expansion during this time is only $2.9 billion.

The vast difference between these scenarios highlights the fact that state spending on health care can be controlled, in large part, by policies and actions that encourage or discourage enrollment. However, many of these practices are effectively ended by the “maintenance of effort” provisions of federal health care reform.

It is an important public goal to ensure that everyone who is entitled to and desires access to public programs is enrolled in them. On the other hand, state resources are limited for the foreseeable future. Every dollar spent on Medi-Cal expansion is one that cannot go, for example, to the UC and CSU system. An increase of $5 billion in state spending on health care represents only a 2% increase in the amount of money our state is expected to spend on health care over the next ten years. But any amount of money measured in billions deserves to be taken seriously, particularly until we have resolved the state’s ongoing structural budget deficit which is itself at least $10 billion per year.

Expanding access to the Medi-Cal, however, does not necessarily mean having to raise taxes to balance the budget. There are many strategies the state can pursue to increase efficiency without compromising quality. An extremely important step was taken toward getting better value for the state’s medical spending through the process of renegotiating the agreement, or “waiver,” with the federal government that governs Medi-Cal payments to hospitals and for uninsured care.

This effort resulted in a plan to move some of the state’s highest-cost beneficiaries – seniors and persons with disabilities – into integrated care systems. Innovations in chronic disease management, palliative care, and in the use of “medical homes” also show promise and will be encouraged by provision in the federal health reform law.

The state also may be able to use its health care spending – in particular effective interventions in mental and behavioral health early in people’s lives – to create savings in the two other main areas of state spending: education and prisons. However, California’s system of budgeting by formula sometimes makes it difficult to actually capture savings that are created through good governing practices.

In the end, though, you get what you pay for and, arguably, the state is already paying far too little for its Medi-Cal program. In particular, our provider reimbursement rates are among the lowest in the nation. This has helped contribute to a dynamic in which, according to the California Health Care Foundation, only 57% of physicians were accepting new Medi-Cal patients in 2008, and twenty percent of all practices were providing care to 80% of these patients.

Guaranteeing that the Medi-Cal expansion results in meaningful access to quality health care therefore also means taking a close look at our provider capacity. Is the existing network of doctors, nurses and other health professionals who provide services to Medi-Cal enrollees adequate? Can we increase our capacity quickly enough to handle the significant Medi-Cal expansion without decreasing the quality of care to those current enrolled? How can we use our existing providers more efficiently to provide higher quality care? Are their innovative new models for care provision that will benefit not only Medi-Cal enrollees but all patients throughout the state?

The incoming administration is going to have to be extraordinarily creative and open-minded about how to fulfill the promise of the Medi-Cal expansion. Federal healthcare reform made near-universal coverage possible, but it is going to be up to Californians to make it real. We’ve got a huge task ahead of us.

Micah Weinberg, PhD, is a senior research fellow in the Health Policy Program at the New America Foundation.

By Randi Sokol

Patients generally come to the doctor’s office expecting that their doctor will do stuff. And, doctors often feel a sense of satisfaction the more they can do for their patients. Psychologically, it makes sense: as doctors, we feel a sense of purpose by providing, measuring, injecting, prescribing, cutting, and ordering. We want to help set our patients down a healthier pathway, which often requires change in their current status; naturally, we respond to this call to duty to promote change by doing, doing, doing. But is all this doing really necessary?

The mentality to do permeates all areas of medicine, regardless of whether evidence supports the utility and outcomes of such efforts:

OB/GYN
Monitoring pregnant women in labor is a classic example of doctors’ desire to do something despite evidence-based guidelines. When a woman is admitted to Labor & Delivery Ward of hospital, an external fetal monitor (EFM) is placed on her belly to monitor her baby’s heart rate and make sure that the baby is getting enough oxygen. Should the monitor reveal the baby’s oxygenation is compromised, the woman might get rushed to a c-section. As physicians on the L&D wards, we spend countless hours of our day following and reading all our laboring women’s fetal heart monitors. We have computer displays set up in our break rooms, in our board room, and displays all over the floor with nurses and physicians watching the monitor at all hours. But is this really even necessary?

Use of the EFM became popular in the 1960s and 1970s to help physicians diagnose when fetal distress was occurring to prevent neurological damage. But, there is another option: instead of placing the pregnant mom on an external monitor, she can have periodic evaluations of her baby’s heart rate- deemed intermittent auscultation. Now which method is best for mom and baby? Neurological abnormalities are actually not caused by intermittent asphyxia during delivery, and numerous studies have documented that fetal outcomes are the same regardless of which method is used: there are no differences in fetal mortality, Apgar scores (which predict how healthy the baby will be), or the need to place the baby in the intensive care unit between the two monitoring methods. And, EFM has been shown to increase the number of c-sections. This means mom might have an unnecessary and very invasive operation, the baby is not born naturally, and there is possible delay in opportunities to breastfeed and bond.

The US Preventive Services Task Force, which makes recommendations about how physicians should practice based on sound evidence, even states that there is “fair” evidence that “routine EFM for low-risk women in labor is not recommended.”3 For high-risk women, the Task Force states, “There is insufficient evidence to recommend for or against EFM.”

Yet, as physicians, we center our care around the EFM- it seems bizarre, doesn’t it? If training were different and more physicians and nurses were taught how to do intermittent auscultation, we could take a much more hands-off approach to patient care that might actually produce better health outcomes in the long-run. Granted, a change in practice comes with numerous obstacles: legal, financial, educational, and technical. Because this practice has been in place for several decades, physicians would likely be more vulnerable to malpractice lawsuits if they stopped using EFM despite being trained in intermittent auscultation. And, intermittent auscultation would require increased staffing of nurses, which of course requires increased funding. Clearly, this issue is not so black and white. Yet ,we continue to engage in a practice that evidence does not support as the drive to do, to assess, to monitor, to act persists.

Pediatrics
The Newborn Nursery world is also not immune from the mentality that more is better. One of the lab values that pediatricians carefully monitor is the amount of bilirubin, a pigment that a newborn has in their blood– the great fear being that too much bilirubin can cause neurological damage (a condition known as kernicturus or bilirubin encephalopathy). As physicians, we thus monitor bilirubin levels carefully, which often requires drawing blood from the baby and even placing the baby under special lighting that helps remove the bilirubin. The time receiving phototherapy means less time bonding with mom, compromise of breast feeding, and infant weight loss.

Yet, the evidence does not support this practice. According to the U.S. Preventive Services Task Force, ‘the evidence is insufficient to recommend screening infants for hyperbilirubinemia to prevent chronic bilirubin encephalopathy.’ In fact, infants that develop bilirubin encephalopathy can have NORMAL levels of bilirubin. There is actually no known screening test that will reliably identify all infants who are at risk of developing bilirubin encephalopathy. And, its incidence is so rare (occurring in as few as 0.9 individuals per 100,000 live births), is it really worthwhile to screen? Do the benefits of catching that 1 individual in 100,000 live births outweigh the risks of subjecting infants to unnecessary blood draws, worrying mom and dad when levels are high, subjecting infants to phototherapy and exchange transfusions, removing the infant from maternal bonding time, not to mention the cost to the medical system and the time physicians spend measuring and analyzing bilirubin levels? While we like to be pro-active in our management of a newborn life and give infants the best possible beginning, our intentions are certainly respectable, but are the ultimate outcomes equally worthwhile?

Preventive Efforts
Even preventive efforts that encourage more labs and do more evaluations are often not evidence-based. For example, beginning at the age of 50, it is common to screen men for prostate cancer. So, should all physicians be ordering a lab (called PSA) that can assess for early prostate cancer? For men at high risk, this makes more sense: African American men, men with a brother or a father who had prostate cancer, and men with female relatives who have a specific type of breast cancer (with the BRCA gene) are at increased risk for prostate cancer; obviously the best chance for curing prostate cancer is by finding it in an early state and then treating it with radiation or surgery; and finding it early means it is more likely to be confined to the prostate gland and has not spread to other areas of the body (which would make it much less treatable).

However, for many men (without risk factors), a PSA can be falsely positive- which leads to unnecessary worry and unnecessary biopsy procedures and even unnecessary treatments. In fact, one study showed that 75% of men with an elevated abnormal PSA who had a subsequent biopsy did not have prostate cancer. Additionally other studies have shown that prostate cancer screening did not reduce that chance of dying from prostate cancer. Additionally, men who are diagnosed with prostate cancer (from PSA and then biopsy) often do not die from prostate cancer- prostate cancer often grows so slowly that men will die of other causes before they even begin to develop symptoms related to prostate cancer. And, not all prostate cancer kills (and thus does not warrant treatment), yet many men will suffer the side effects of treatment from a cancer that would otherwise not kill them.

Thus, as physicians, we should see our role as providers of information- laying down the risks and benefits of screening and allowing our patients to decide if they do or do not want to be screened. Based on their personal experiences and backgrounds (which we may not be privy to), patients often have their own reasons for wanting or not wanting particular things done. Still, the same notion rings true: doing is not necessarily in the patient’s best interest and physician providers must remain vigilantly conscious of this.

And one final example because it is just so common:

One of the most common complaints in an outpatient setting is back pain. The reality is that most back pain (unless it is something very serious like cancer, an infection, or cauda equina syndrome) gets better by its own after 6 weeks.

The “Six week rule” has been proven: no matter who provides care to the patient (private PCPs, HMO PCPs, chiropractors, or orthopedic surgeons), at six weeks after initial presentation, most patients improve and have the same degree of very minimal functional impairment. Yet, at initial evaluation of back pain, the tendency is to evaluate as much as possible, and often times patients even come in requesting X-rays or MRIs. Yet, the utility of imaging at initial presentation is poor and often can be to the patient’s own detriment. Studies have shown that many patients without symptoms have abnormal imaging studies.

And many with back pain will have abnormal studies, but most of these findings will be unrelated to the patient’s symptoms and might thus provoke an unnecessary surgery that ultimately does not resolve the back pain. In fact, the mantra of the “One-third Rule” holds true for back surgery: One-third of patients will get better, one-third will feel no change, and one-third will actually get worse. And, then there is the cost, time, and patient distress associated with all these actions. The bottom line is that most patients will naturally improve on their own, and back pain is often best managed conservatively with minimal testing and minimal doing.

Obviously patients come to doctors for a reason. As physicians, we have the knowledge and experience that makes our clinical judgment valuable in helping our patients achieve optimal health. But, with that knowledge and experience, we must remember that doing more is not always better.

Often times, simple listening, reassurance, and equipping our patients with information is all that is needed. We must be cautious in our tendencies to order more images, perform more procedures, track more labs, and prescribe more medications. We must change our patients’ expectation of what we are willing to do so that they understand that our intentions are well-meaning and follow evidence- based practice. Explaining the risks and benefits of subsequent management options to our patients and why we recommend for or against a certain approach empowers them with the knowledge and rationale for moving forward, inspiring collaborative decision making between patient and provider.

Thus, while it might seem counterintuitive to do less, this approach will ultimately benefit our patients more. And, by engaging our patients in this decision-making process, their care truly becomes patient-centered.

Randi Sokol is a Second Year Resident in the Department of Family & Community Medicine at UC-Davis. The views expressed in this article are her own and do no represent those of UC-Davis.

By Robert Phillips

Health isn’t just about the doctor’s office. For all of us, but especially for a young person, health begins in our community. That truth was echoed throughout a two-day national town hall in Los Angeles to address the health disparities facing boys and young men of color.

Community leaders and experts from across California and the nation convened because a growing body of research shows that the health of boys of color stems from their neighborhoods, their schools, their environments.

If you grow up in a neighborhood with a good school, where the streets are safe for kids to play outside and where there is access to good food, you are far more likely to have a good job, be stress-free and live a long and healthy life.

But if you grow up in a neighborhood where you’re not safe, where your school is failing you and where the nearest park or basic grocery store is miles away, your health suffers. If you are viewed as more of a problem than an asset to the point that you begin to see yourself that way, too, then research shows that you are far more likely to die younger, earn less money, experience violence and to be less healthy emotionally and physically.

In California, African-American, Latino, Southeast Asian and Native American youth are likely to face not just one of these challenges, but many or even all of them.

Researchers who spoke at the town hall conversation looked at how communities either foster or limit the life chances that young people have. Their research shows how communities can give you access to resources like transportation, good schools, parks, health services and jobs. But communities can also expose young people to stressors – like crime, environmental hazards, joblessness and inadequate housing.

In other words, in some places, there is real opportunity. In other places, opportunities are limited or non-existent. While these issues touch every part of our communities, they are particularly tough for boys and young men. This is because the bad policies and practices that institutionalize disadvantage disproportionately affect boys and young men of color.

Here’s one example: The state’s efforts to make schools and communities safer with “zero tolerance” policies have produced the exact opposite effect. Rather than making our schools better places to learn, boys and young men of color are more likely to do worse. Studies have linked suspensions to an increased likelihood that a young man of color will drop out, which means that he will find it harder to get a job, is more likely to be connected to crime and prison and is less likely to be connected to community.

Of course, we want our children to grow up with a strong sense of responsibility to themselves, their families and their communities. But that’s only one half of the equation. We must also take responsibility to protect them from harm and provide them with an open door to opportunity.

How do we do this? The first step is to recognize that place – homes, schools and neighborhoods — matters. The second is to change the policies and practices that shape place.

To do this, The California Endowment is supporting work in three communities – Oakland, Fresno and Los Angeles – to build the community leadership that is needed to overcome the challenges facing boys and young men of color. At the same time, we are supporting the work of advocates, organizers, public officials and researchers to promote policies and programs to change the systems that limit life opportunities.

We will measure our success at achieving four big goals, which we see as the strongest indicators of a healthy community. These include ensuring that everyone has a health home (or usual source of care); reducing childhood obesity; reducing youth violence; and improving school attendance.

Doing so will have positive implications for California and the nation.

The good news that emerged from the town hall is that we know how to keep a child in school; we know how to help a young man become a productive community member. According to the California Dropout Research Project, doubling high school graduation rates would drive down the number of juvenile crimes in California and save the state $550 million per year.

One outstanding question remained: Do we have the collective will to do what it takes?

We’ll only do this if we all band together – businesses and beat cops, social workers and social change organizations, politicians and philanthropists – to take responsibility to make our communities places that foster health, hope and opportunity for everyone.

Robert Phillips is the Director of Health and Human Services for The California Endowment.