Rishi Manchanda MD MPH

Founder, HealthBegins

Author, The Upstream Doctors

The question your doctor

is not asking you &

how everyone, including you,

could save money and live

healthier lives if she did

“Where do you live?

Tell me about it.”

“p.s. Where do you work, eat and play?”

What would your health look

like if doctors’ offices routinely

asked about and could help

address problems where you

live, work, eat, and play?

Photo taken with permission

Mrs. M

Photo taken with permission

Mrs. M had a chronic

headache. After exhausting

primary care options, she

visited 3 Emergency Rooms

(ER) in 1 month, but still had

neither a diagnosis nor a

treatment plan.

Overall, she had:

2 CAT scans of her head

1 Lumbar puncture

Blood tests

Pain medicines

Out-of-pocket charges

Missed work

Lost income

And she was still sick.

Good

Care?

Photo taken with permission

After 3 ER visits, a clinic noted

that Mrs. M lived in an area

endemic for unhealthy housing.

A medical assistant screened

her for housing risks.

Mrs. M lived in a damp, moldy

home.

With that key social data, the MD

correctly diagnosed her in 12

minutes with a housing-related

illness.

He treated her with meds and a

healthy housing program.

Mrs. M & her home got better.

Better

Care

The Social Determinants of Health

– The conditions in which people are born, grow, live, work and age, including the health system.

• These conditions are shaped by the distribution of

money, power and resources at global, national and local levels, which are themselves influenced by policy.

– Major contributor to health inequities

• “Health inequities are unfair and avoidable differences in health status seen within and between countries often over generations.”

At the Intersection of Health Care

and the Social Determinants of Health,

the Current Standard of Care

Isn’t Good Enough

Schroeder S. N Engl J Med 2007;357:1221-1228

Contribution

of Social

Factors to

Premature

Mortality

What’s the big deal about housing

& other ‘social determinants’?

The sickest, costliest patients

often have unmet needs

in social & built environment

• Cohen, S. The Concentration of Health Care Expenditures and Related Expenses for Costly Medical

Conditions, 2009. Statistical Brief #359. February 2012. Agency for Healthcare Research and Quality,

Rockville, MD. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st359/stat359.shtml

In 2009, 5% of the

population accounted for

nearly 50% of overall US

health care spending

Propietary/ Confidential

Addressing Social Factors

improves care

Addressing social factors

lowers costs

Glimpses

of this better standard

of care are out there

But 4 out of 5 physicians still

feel under-equipped to

address their patients’

social needs.

-RWJF “Health Care’s Blind Side” Dec 2011

Propietary/ Confidential

Smart medicine starts upstream

Stories of

Upstreamists

A new conceptual

model for the

health care

workforce in the

context of the

Affordable Care

Act

A new model for the

healthcare workforce

By 2020, 24,000 260,000 450,000

Population- level Impact

Our Work:

Improve Care

Train & Equip Upstreamists

Our Goal: 2.5K Upstreamists by 2015

25K Upstreamists by 2020

Propietary/ Confidential

Courtesy: Community Scholars 2012, Ben Palmquist

Housing and Health

Housing is linked to:

– Asthma

– Allergies

– Lung Cancer

– Injuries

– Mental Health

– Brain Development

– Respiratory Infections

Courtesy: Dr. Jim Krieger, Seattle Public Health

Housing Hazards • Biological agents

– allergens, mold • Toxics

– lead, secondhand smoke, carbon monoxide, radon, asbestos, VOCs, etc.

• Temperature extremes • Injury hazards • Crowding

• Conditions:

– Ventilation

– Energy efficiency

– Structural integrity

– Sanitation and plumbing

– Siting

– Building materials

Courtesy: Dr. Jim Krieger, Seattle Public Health

Can health care transformation help more clinics

help improve conditions where we live?

Community-Centered

Health Home

Community-Centered Health Home

• Coordinate with policymakers and

community stakeholders to address social

and environmental conditions

Medical Neighborhood

• Coordinate care for patients and

populations with clinical and community

“neighbors”

• Potential role for ACOs

Medical Neighborhood

PCMH

Ambulatory ICU

• Integrate and coordinate care for high-

need, +/- high-utilizer patients with clinical

and community partners

AICU

PCMH

• Coordinate care for patients and clinic

population, primarily within clinical system

R. Manchanda MD

Medicaid Health Homes

A “Medical Neighborhood”

• One of the coordinated care models that states can pursue with funding from the Affordable Care Act

• For patients with:

– mental health condition,

– substance use disorder,

– asthma,

– diabetes,

– heart disease, AND/OR

– body mass index over 25 (overweight) http://familiesusa2.org/assets/pdfs/health-system-reform/Health-Homes-in-Medicaid.pdf

Medicaid Health Home • Includes:

– Comprehensive care management

– Care coordination

– Health promotion

– Comprehensive transitional care

– Individual and family support services

• Must coordinate with behavioral health providers

• Required to help enrollees obtain non-medical supports and services, such as:

• public benefits, housing, transportation, legal services, and social support services.

http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Approved-Health-Home-State-Plan-Amendments.html

http://familiesusa2.org/assets/pdfs/health-system-reform/Health-Homes-in-Medicaid.pdf

Propietary/ Confidential

Not found in

most PCMH

States with

Medicaid Health Homes

1115 Waivers: A chance for housing

under ACA?

• Under section 1115 of the Social Security Act, the federal government can allow states to develop comprehensive demonstration, experimental projects that modify (waive) federal Medicaid and State Children’s Health Insurance Program (SCHIP) requirements related to benefits, cost-sharing and eligible populations.

• Any new waivers must be “budget neutral” to the federal government.

• Several states have combined coverage expansions with a new managed care delivery system and used the anticipated managed care savings to offset the cost of the coverage expansion.

Minnesota example: Reform 2020 • Reform 2020 is an initiative to reform Medical Assistance (MA)

Minnesota’s Medicaid program.

• On Nov. 21, 2012, DHS resubmitted the Reform 2020 waiver

proposal to the Centers for Medicare and Medicaid Services

(CMS). This proposal would have made the following housing stabilization services as eligible for Medicaid reimbursement up

to $600 for each member per month:

– Service coordination

– Outreach/InReach

– Tenancy Support Services

– Community Living Assistance

• The target population included: (a) Medicaid recipient who

were receiving General Assistance and homeless; and (b)

Medicaid recipients who were eligible of Group Residential

Housing.

TO LEARN MORE

HealthBegins.org

Read the Upstream

Doctors http://www.ted.com/pages/tedbooks

_library#RishiManchanda