With flanneled teens attempting tricks ramps and rails

Summer 2014

Professor Nahavandi

Published: Jun 12, 2014

By Phil Galewitz , Kaiser Health News

The hope is that giving people a financial incentive to change their behaviors will improve their health and control Medicaid spending.

Other states, such as Pennsylvania, are also seeking to tie Medicaid coverage to personal responsibility by seeking federal approval for a plan that would prod unemployed people to search for jobs and get annual wellness exams in exchange for lower premiums.

"We know from the employer world, this is very hard to do," she said.

She said the complexity will also make it harder for the state to implement the plan. "The legislation adds a lot of red tape," she said.

Michigan did not expand Medicaid until April because the legislature did not approve the move until last September, and Republican opponents included a provision delaying the implementation until at least 90 days after the lawmakers adjourned their 2013 session. Michigan is the 25th state and one of eight led by Republican governors to expand the program. Gov. Rick Snyder also waited to make sure the state's online enrollment was working to avoid a repeat of the botched federal exchange rollout.

Nonetheless, more than 270,000 low-income Michigan residents have signed up for Medicaid since April 1 -- over half the estimated 477,000 eligible for the program. The signup pace has exceeded that of most of the 25 states that expanded Medicaid in January, which benefited from the publicity surrounding the open enrollment period for private plans. Unlike buying private coverage, people can sign up for Medicaid any time.

Alcendor, though, is concerned that hospitals and other providers will get stuck with extra costs if enrollees don't pay into the health savings accounts.

Michigan health officials said their enrollment efforts gained from the publicity surrounding the Obamacare marketplace enrollment so there was still huge demand when Medicaid signups began in April. They also were able to switch 60,000 adults into Medicaid automatically on April 1 who had more limited coverage in a state basic health insurance program. Unlike a number of states such as California, which have a large backlog of people waiting to get insurance cards, Michigan officials say new enrollees have received their Medicaid cards within weeks -- with coverage retroactive to first day of the month they signed up.

Doc-in-the-Box Meets Docs-Outside-the Box

Published: Jun 5, 2014

She said she was a little confused, but went home, filled the prescription, started taking it, and called them as directed the next morning. She said she reached them easily, they were very polite on the phone, told her that her culture was negative, that she should stop the antibiotic, and that she probably had a virus.

Now we know it is easy for us to second-guess someone's clinical care. Someone working in an urgent care center sees someone only for a brief snapshot, a single moment in time, having no long-term relationship with the patient. The same is true of emergency departments. They get to see someone only in that slender window of opportunity when they are dropped into their realm, and usually have no choice but to maximize to optimize care.

We know that ideal care requires 24/7/365 access but, as we know, none of us want to be on call 24 hours a day, 7 days a week, 365 days a year.

I recently had a nearly perfect interaction with an urgent care center and the staff who provided care. My patient was seen there urgently late on a Friday night, and they actually followed up with her 2 days later (then Sunday morning) and provided ongoing, and appropriate, care for this clinical situation. Monday morning I arrived in my office and received an email communication from the provider at the center, detailing what had happened, explaining their thought process, and recommending follow-up with me.

Recently our practice, in conjunction with our affiliated emergency department, developed a plan to allow protected next-day appointments at our practice for patients being sent home from the emergency department, who need this urgent interim care as a safe "conclusion" of their discharge plan.

We are "hanging" multiple appointments frozen in our next day's schedule, on a website which the emergency department physicians have access to. When they find an appropriate patient who needs a next-day appointment in primary care, they enter the patient's demographics, contact information, medications, and plan, and our scheduler picks that up first thing the next morning.

But an urgent need is clearly there.

3. In the article below, innovative ideas are put to work in and around Las Vegas for providing medical care. Using economic model(s) discuss the intent of these innovations.

LAS VEGAS -- On a Friday night in mid-May, part of Fremont Street in Las Vegas is shut down and converted into a skate park, with flanneled teens attempting tricks on ramps and rails. Alternative rock band Taking Back Sunday is set to take a pop-up stage flanked by Zappos.com banners. Old industrial buildings converted into funky restaurants host tech geeks and startup CEOs. Street murals brighten drab concrete fences.

Here in the desert, there's a tech city vibe reminiscent of Seattle or Silicon Valley, although it's probably the last place anyone would expect such a thing. This party city of 2.5 million people has never had much of a cultural identity before, especially not in a downtown area that has long been considered a wasteland -- until Zappos CEO Tony Hsieh, known for his love of all things quirky, pumped $350 million into a revitalization project to turn it all around.

There are plenty of challenges. What happens when patients leave the clinic walls? Who covers their hospital bills? Is this model scalable to other clinics? And he'll need some 4,000 to 5,000 patients to make the numbers work -- can downtown attract the businesses and employees?

They're hard questions, but Damania has been given the opportunity to think big in a place famous for drawing in dreamers.

Members pay $80 a month for what Damania calls "all you can treat" access to a buffet of care, which includes all of these programs, as well as on-demand access to a doctor or health coach.

Health coaches are the front line of the clinic. They're not nurse practitioners or physician assistants. Instead, they've come from various walks of life -- paramedics, yoga instructors, accountants -- hoping to find a better way to connect with people.

Matt Dallmann, president of Creative Practice Solutions, a practice management firm, said he hadn't heard of the idea of letting health coaches be the gatekeepers of a primary care clinic, but that the strategy could work to help keep overhead costs manageable -- especially at an office that's catering mostly to well patients.

Iora's model also includes a strong mental health component, with social workers hired to do the heavy lifting. But health coaches certainly lend an ear and can refer when necessary.

Damania is also pleased to point out that there are no individual doctors offices, since it's a non-hierarchical environment.

"It's a culture that all works together with the sole focus of taking care of patients," Damania said.

Damania has had many discussions with Hsieh about changing the culture of medicine: "His philosophy is that your career should involve things that make you happy and effective." People need to have a feeling that they have control and a stake in what they're doing every day, and they also need to perceive that they're making progress, he explained.

Both of those tenets feed into getting the culture right: "If you get the culture right first, the rest falls into place with decent business ideas," Damania said. "If you get the culture wrong, you're constantly fighting against that headwind."

It's buy-in from this type of patient that will make Damania's vision work, Dallmann says. "Will you sign up for a year and take a couple of classes, and then not go anymore?" He also needs buy-in from the employers, which will be driven by demand from employees.

"The first question is will he be able to get the companies on board, and the second is will he be able to keep up the supply based on demand," Dallman said. "A lot of models are similar to what an insurance company does: they're looking for a premium hoping a lot of people don't come in."

Although Zappo's hasn't signed up yet, Damania says parent company Amazon is investigating the possibility.

TurnTable isn't just working with companies; it's also working with insurers. It recently signed up Nevada Health Co-Op, a nonprofit insurance plan created as part of the Affordable Care Act's state-based exchanges, to provide coverage under its Neighborhood VIP plan.

But Damania insists his method is translatable to the smaller practice: "We went a bit overboard on our flagship facility, but this can be done economically."

One key is in cutting overhead expenses. There's no billing of insurance, which saves 10% to 30% of those costs, Damania estimates.

Building out economies of scale can also help with costs, Damania says. The goal is to be able to "run the Iora Health software" like an app so that the model can easily be applied to any clinic.

For now, Damania wants to continue to focus on culture in order to continue to generate the necessary volume of patients.

But that doesn't seem to be the case just yet, so ZDogg may have to lay low a little longer: "The problem since moving to Vegas," Damania explains, "is that I'm doing something that makes me so innately happy because I'm trying to effect change in the system. So the fire from ZDogg had somewhat been quenched."

It shouldn't be too hard to rekindle, though: "All it takes is one visit to the hospital."