Meeting the Challenges of
Health Care Reform
Presented to the SIU School of Medicine
Carolyn A. Pointer, JD
April 14, 2014
Neither my husband nor I have a personal or
professional financial relationship or interest
in any proprietary entity producing
healthcare goods or services.
• Increase quality and affordability of health
• Lower the uninsured rate
• Reduce health costs for individuals and the
• Improve healthcare outcomes
• Shift healthcare system to quality over quantity
• 342,000 Illinoisans newly eligible for health
insurance through Medicaid expansion
• Illinoisans who earn up to 138% of the federal
• $15,860 for an individual or $32,500 for a
family of four
• 957,000 residents will be eligible for subsidized
health insurance in the form of a federal tax
credit via Illinois Health Insurance Marketplace
• Demonstration grants for alternatives to
current tort litigations.
• Consultation with relevant stakeholders
• Enhance patient safety by reducing medical
errors and adverse events
• Likely to improve access to liability
Medicare as a model
• Allow providers organized as accountable care
organizations (ACOs) that voluntarily meet quality
thresholds to share in the cost savings they achieve for
the Medicare program.
• ACOs must agree to be accountable for the overall care of
their Medicare beneficiaries, have adequate participation
of primary care physicians, define processes to promote
evidence-based medicine, report on quality and costs, and
ACO management strategy
• Lower individual
• Medical Home
Health care spending in the United
States is unevenly distributed, with
the sickest 5%of patients causing
more than 60% of health care costs.
Rx: Super-utilizer Savings?
• The Camden Coalition – Camden, New Jersey
• 36 super-utilizers averaged 62 hospital and E.R. visits per
month before joining the program and 37 visits after
• Their hospital bills averaged $1.2 million per month
before and just over $0.5million after
• Does not take into account personnel costs, or the costs of
the medications the patients are now taking as prescribed.
Patients have long-term partnerships with clinicians, not
a series of sporadic, hurried visits.
Clinician-led teams coordinate care, especially for
prevention and chronic conditions.
Medical homes coordinate other clinicians’ care and
community supports, as needed.
Medical homes offer enhanced access through expanded
hours and online communication.
They promote shared decisions, so patients make
informed choices and get better results.
Medical homes coordinate care and improve quality but
do not deny care.
Rx: Medical Homes?
Not the answer
• PACCI –Utilization did
not significantly differ
between pilot and
• Total costs also did not
between the groups.
Part of the answer
• PACCI based on outdated
NCQA PCMH standards
• Contradicts several other
studies that have shown
improvement in cost,
quality, access and patient
Social determinants of health
The circumstances in which people are
born, grow up, live, work, play, and
age, as well as the systems designed to
improve health and treat illness – have
a significant impact on the health and
well-being of individuals and
WHY DO I NEED A LAWYER?
This sounds like social work to me…
What is a MLP?
A medical-legal partnership addresses
the multiple needs of low-income
Make individual and systemic
changes to switch legal and medical
care to a preventive model
The MLP Mission
To build a better healthcare team
that can identify, address and
prevent health-harming legal needs
for patients, clinics and
Legal Aid in IL
• 1 legal aid lawyer for every 4,752 legal
problems faced by low-income
Illinoisans in 2006
• 2,080 work hours in a year
Legal aid attorneys are facing the same
resource issues as medical providers.
JDs and MDs share goals
• Prevention and early intervention maximize benefits
• Improve systems for clients/patients
• Provide direct services as efficiently as possible
A Case Study In MLP Advocacy at
UVA Medical Center
• John is a former 26 week preemie, and is ready to
be released after a 14 week stay in the NICU
• His temperature stability is improving, and he
will be going home with an apnea monitor
• John’s parents have been out of work while
staying at the Ronald McDonald House
• The electricity will be disconnected for lack of
• Local charities
• Referral for LIHEAP
• Keeping John in the NICU to watch for
• Ask utility company for payment plan
Public Utilities Access
• States regulate public
• The Low-Income Home
Program (LIHEAP) is a
program that helps low-
income households pay
their home heating and
• Most states protect
seasonally and for at-
• Utilities access impacts
ability to regulate
Virginia MLP Meeting
PCPs did see lack of utilities
shut off as a problem
Goal: Utilities Shut-Off law
Building the dream team
•Law and Medical Students
•Physicians and Attorneys
• Research other state
• Learn who in
• Draft potential new
• Gather compelling
• Survey patients in
Selling the Idea
• Met with the statewide poverty law
• Learned we had only needed a few key
legislators on board
• Told consumer advocates had failed to get
these protections for years.
Where does the buck stop?
Virginia’s shutoff policy
• An electric utility, or public utility providing water
service shall, upon request from a residential customer
who has a Serious Medical Condition Certification Form
filed with the utility, delay termination of service for a
minimum of 30 calendar days beyond the expiration of
the disconnect notice.
• Service termination will be delayed for 10 calendar days
pending receipt of the Serious Medical Condition
• Permits two delays in a 12-month period. The 30-
calendar day delays may be consecutive.
• Adding shut-off protections based on
• Standardize seasonal shut-off
protections across the state
• Advocacy coming from “not the usual
• Business Case for Breastfeeding
• Baby-friendly hospital designation
in one Virginia hospital
• Donor Banked Milk for Preemies
• Pump cost
• Time to pump on the job
• Cost of donor milk
• The Golden Hour for NICU moms
• Lactation support
Pump availability options
• Added hospital grade
pumps to rental
equipment when entering
a new preferred rental
• Pumps available via
• Increase # of WIC pumps
• Change Medicaid/WIC
rules to distribute pumps
Time to pump at work
• PPACA amended FLSA
(Fair Labor Standards
• Requires employers to
provide reasonable time
and place to pump.
• Business Case for
• Educating L&D nurses on importance
of the Golden Hour for future milk
• Getting NICU moms pumping within
that hour to boost milk supply
• Breastfeeding Medicine Department created
• Lactation consultants visit with every new
mother after delivery.
• NICU provides support to families on a variety
of breastfeeding issues unique to NICU babies.
• Follow-up phone calls to all breastfeeding moms
for ongoing support.
• Services are offered seven days a week.
• EPSDT argument for donor milk
• Finding the best test case
• Will private insurance pay?
SSI and Patient Compliance
• Average 18 month wait for SSI
• Multiple requests for documents from
SSA to physicians
• Patients often give up
• Time consuming cases for legal aid-
limited capacity to accept appeal cases
Medical school, internship,
residency, fellowship… I’ve
been a pediatrician for 15 years.
I know what a disabled child
• Pediatric Grand Rounds on SSI Rules
• Translate SSA regulations
• Create form letters to show providers
what SSA is looking for them to
• Harness power of new EMR system
by adding form letters
• A medically determinable physical or mental
impairment or combination of impairments that
• marked and severe functional limitations, and
that can be
• expected to cause death or that has lasted or can
be expected to last for a continuous period of not
less than 12 months.
SSA defines Childhood
On date, Name had a FEV1 of ____ (must be equal to or
less than the value specified in Table I). Name’s height
(without shoes) was xx centimeters on that date.
On 9/26/2010, Jose had a FEV1 of .65. Jose’s height
(without shoes) was 128 centimeters on that date.
Asthma – Option A
• Ability to retain and recall information.
_mild or no limit _moderately limited _seriously limited _extremely limited
• Ability to solve problems through intuition, perception,
verbal or nonverbal reasoning.
_mild or no limit _moderately limited _seriously limited _extremely limited
• Evaluate difference in time from
application to SSI approval in patients
with/without MLP assistance
• Track time required by medical and legal
How to meet the health care reform challenges?
• Health care reform requires addressing
the social determinants of health
• Building the right health care team will
improve the efficacy of the Patient
Centered Medical Home
• Medical providers need advocacy skills to
successfully treat patients
Building the Right Team
• Primary Care Provider
• Specialist Medical Providers
• Social Workers
Goals of Doctor Advocacy
• Access appropriate services for
• Minimize time needed for advocacy
• Develop good relationships with
Anyone who can
learn the Krebs
cycle can learn
how to be a child