Population Health Blog

Population Health Blog

Why It Matters

‘Avoiding’ hospital emergency facilities will be a difficult lesson for many to learn

By Dennis Archambault
When the Patient Protection and Affordable Care Act became law, its detractors presented a litany of reasons it would fail. Among them: “You’ll never educate the expanded Medicaid population to stop using emergency services for primary care, chronic disease management, and minor injuries.” It was difficult to argue the point – in the short term. This area of behavior modification, coupled with health literacy, would require several years and a lot of support.

Until recently, hospitals had little incentive to prevent or redirect “avoidable” emergency visits. They were reimbursable and the volume was good for medical residency training programs. Emergency physicians and hospital administrators have long known that a large portion of emergency visits could and should be treated elsewhere. Despite assurances of being seen by a physician in many emergency departments, reasonably educated, insured people have increasingly selected urgent care as an alternative to the emergency visit and their busy primary care provider. But many people still think “E.R.” when they become sick or injured after hours.

Health insurers are being to scrutinize the “avoidable” treatment. As noted in a recent New York Times article (https://www.nytimes.com/2018/05/19/upshot/anthem-insurer-resists-paying-emergency-room-visits-if-avoidable.html) at least one has floated a trial balloon to get people talking about what is bound to occur in time. Some health systems, like the Detroit Medical Center, have tested the efficiency of primary care practices adjacent to emergency departments, for referral and ongoing care of patients with “avoidable” conditions. There is also a public health track within the Emergency Medicine Department of the Wayne State University School of Medicine to address chronically ill people whose care could be better managed in ambulatory setting.

The best way to avoid an emergency visit is to prevent injuries, manage chronic disease, and use an urgent care center if the primary care provider isn’t available. But when you’ve been using emergency services for much of your life, you’re not likely to change your behavior quickly – especially without support and incentives.

Dennis Archambault is vice president, Public Affairs, at Authority Health.

Fewer new low income housing units: an unintended consequence of the tax law?

By Dennis Archambault
Few are likely to complain about a tax cut, even if it so obviously favors wealthy populations over the rest of society. But aside from increasing the wealth disparity in the country, there are consequences of the new tax law, unintended as they may be: low income housing.

It’s bad enough that many cities like Detroit with large numbers of low income and homes people are living in cars or under cardboard shelters – waiting for their names to rise on the waiting list for vacancies in public housing. Now, prospects for new low income housing have dimmed due to the loss of incentive for affordable housing developers to cover the fiscal gap in these projects, usually compensated for through low income tax credits. According to an article in the New York Times (https://www.nytimes.com/2018/05/12/upshot/these-95-apartments-promised-affordable-rent-in-san-francisco-then-6580-people-applied.html) thousands of low income housing projects will not be built due to the loss of tax credit options,  leaving many to wait on a list until an opening arises.

Municipalities have responded by creating funding pools to replace the loss of federal commitment to financing housing. For example, the City of Detroit earlier this year announced plans to raise $250 million to help underwrite the construction of 2,000 new low income housing units. (https://www.freep.com/story/news/local/michigan/detroit/2018/03/12/detroit-affordable-housing-fund/415749002/). Low income housing developers, housing advocates, and others are challenged to create new social enterprise models to get people off the street and into a stable habit. The new tax law isn’t helping.

Dennis Archambault is vice president for Public Affairs at Authority Health.

Kaiser Releases More Extensive Backgrounder on Social Determinants

By Dennis Archambault
Providers and community health organizations have increasingly come to understand social determinants of health, and how they become “determinants.” In a less fatalistic way, we might call them “influences” that individuals and collectives can alter, thereby giving folks a fighting chance.

In any case, it’s important to understand these social factors and monitor the many policy changes that are impacting them and the ability of individuals to overcome then. The Kaiser Family Foundation just came out with a new, more detailed backgrounder on social determinants, which is worth studying. What’s most interesting was a sidebar on states that integrated social determinants into Medicaid managed care contracts. In a way, it seems amazing that more aren’t, given the how removing social determinants can have a positive effect on health, and thereby save money for the managed care provider.

No matter, check out the latest KFF report on social determinants: https://www.google.com/search?q=Beyond+Health+Care%3B+The+Role+of+Social+Determinants+in+Promoting+Health+and+Health+Equity&rlz=1C1JPGB_enUS596US596&oq=Beyond+Health+Care%3B+The+Role+of+Social+Determinants+in+Promoting+Health+and+Health+Equity&aqs=chrome..69i57j0.28459j0j4&sourceid=chrome&ie=UTF-8

Dennis Archambault is vice president, Public Affairs, for Authority Health.

Why threaten unemployed people with loss of Medicaid health coverage?

By Dennis Archambault

The reasoning behind the current Michigan Senate legislation instituting work rules on Healthy Michigan doesn’t seem to make sense (https://detne.ws/2rr1mIP). People may be unmotivated to sign up for (and renew) health insurance for a variety of reasons. The threat of losing it or not qualifying for it because of their employment status is unlikely to motivate many of them to try harder.

Most people who receive Healthy Michigan and are able to work have some form of employment. Some even work two jobs and still need the program. Those who don’t work may have psychological challenges, or may simply not want to work. Taking away their coverage won’t change that. In fact, it’s likely to further hinder their productivity given that their health will deteriorate. And, the cost of their use of emergency facilities for otherwise manageable primary care or management of chronic disease will inevitably cost society more. Has there been a cost equation done to estimate how much it will cost if Healthy Michigan is taken from those who aren’t working?

Also, you’d think that the proponents would try to soften the blow by confirming that this unemployed population needs work-readiness help. Where’s the offer to provide job training and placement services? Maybe it’s there but under publicized.

Proponent s of universal health care argue that citizens of this affluent country deserve a certain standard of living – which is largely determined by their health. Whether they work or not is a different question.

The Senate certainly is serious about this. To hold the pay of public officials as ransom for instituting this program is quite a threat.

Dennis Archambault is vice president, Public Affairs for Authority Health.