News & Notes

ICER review of evidence for integrated care:The Institutefor Clinical and Economic Review (ICER) has released a reportsummarizing evidence on the comparative clinical effective-ness of integrated care. The 141-page report, Integrating Be-havioral Health Into Primary Care: A Technology Assessment, isbased on draft reports that were discussed at recent meetingsof two independent groups: the California Technology As-sessment Forum (CTAF) and the New England ComparativeEffectiveness Public Advisory Council (CEPAC). Both groupsvoted unanimously that research shows that the collaborativecare model (CCM)—the integration approach with the stron-gest evidence base—improves health outcomes related to de-pression and anxiety and results in higher patient satisfaction,compared with usual care. For integration models other thanthe CCM, both groups judged the evidence to be insufficientfor determining effects on key outcomes, emphasizing that thisjudgment indicates a need for more research rather than thefailure of other models to provide benefit. In practices thatimplement the CCM, patients are screened for depression andanxietywith validated tools. Caremanagersworkwith primarycare physicians to support medication management, pro-vide brief counseling and other services, and coordinate acrossproviders. Psychiatric consultants are available to support thecare team. Patient progress is systematically tracked andmonitored in a central data registry. The economic anal-ysis used in the ICER review had three objectives: to as-sess comparative care value, to describe publicly availableresources for planning and implementing integration, andto estimate the budgetary impact of implementing twodifferent models—the CCM and another promising model,the behavioral health consultant model—in a 200,000-member Medicaid plan. The ICER final report is availableon the Web sites of CTAF (ctaf.org/reports/integration-behavioral-health-primary-care) and CEPAC (cepac.icer-review.org/adaptations/integration).

PCPCC calls for implementation of peer support in patient-centered medical homes: Provisions of the Affordable CareAct (ACA) have begun to shift the health care system awayfrom one that treats illness after it occurs to one that reliesmore on the promotion of population health through team-based primary care and through stronger connectionsto community and social supports for patients and families. Toachieve these goals, primary care providers are encouragedto practice as a patient-centered medical home (PCMH). InApril 2015, the Patient-Centered Primary Care Collaborative(PCPCC), in partnership with Peers for Progress (a programof the American Academy of Family Physicians Foundation)

and the National Council of La Raza, held a conference todiscuss the role of peer support in primary care, inviting tenmodel programs to make presentations. In addition to de-scribing the ten model programs, the 46-page conferencereport, Peer Support in the Patient-Centered Medical Home,summarizes key conference discussions and offers a picture ofwhere the health care field is headed in terms of integratingcommunity healthworkers (CHWs) into advancedprimary careand the PCMH. “Community health workers” is the umbrellaterm used in the report for a range of peer support workers,including promotores de salud, lay health advisors, healthcoaches, and navigators. The report addresses issues such aslinking CHWs into the primary care team, building relation-ships with communities, maintaining “peerness” in the bio-medical culture of health, and adapting emerging financingmechanisms. The report emphasizes the culture shift that isneeded to fully realize the value of peer support. “Instead ofviewing peer support and CHWs as an ‘add-on’ to healthcare and trying to roll their services into existing protocolsand payment structures, we should be asking how we canchange health care to bemore attuned to peer-to-peer support.As a ‘disruptive innovation,’ the potential of peer support is fargreater than incremental improvements, but holds the promiseof transforming primary care and community health.” Thereport is available on the PCPCC Web site (www.pcpcc.org/webinar/integrating-peer-support-primary-care).

Activation of National Housing Trust Fund described inTAC report: The shortage of affordable rental housing isa major barrier to community integration of people with dis-abilities. The National Housing Trust Fund (NHTF) programis a new tool for states to use to address the affordable housingcrisis. The NHTF was authorized by Congress primarily toaddress the shortage of housing affordable to extremely low-income (ELI) households (incomes between 0 and 30% of areamedian income). In December 2014, the Federal HousingFinance Agency lifted its six-year suspension of Fannie Maeand Freddie Mac’s obligation to contribute to the NHTF. Thisdecisionmeans that NHTF funds are scheduled to be allocatedto state housing agencies in 2016. It is currently estimated thatbetween $250 and $500 million will be available in 2016, witheach state and theDistrict of Columbia receiving aminimumof$3million. A new report from the Technical Assistance Center(TAC) calls the activation of NHTF “an important new op-portunity for states to begin shaping the future of our nation’sELI housing policies, including a robust expansion of in-tegrated permanent supportive housing units for the mostvulnerable ELI populations.” The purpose of the report is to

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provide advocates with the information they need to undertakeNHTF policy conversations with state housing officials abouttested strategies that can maximize the number of new ELIunits created with the 2016 allocation. Over the past decade,a number of state housing agencies have pioneered financingapproaches to increase the supply of permanent supportivehousing units. The TAC report documents strategies devel-oped by Pennsylvania, North Carolina, and Illinois that couldbe adapted for NHTF capital and operating subsidy funding.The 55-page report, Creating New Integrated Permanent Sup-portive Housing Opportunities for ELI Households: A Vision forthe Future of the National Housing Trust Fund, is available onthe TAC Web site (www.tacinc.org).

AHRQ technical brief reviews strategies to reduce psychi-atric admissions: Readmissions are costly and disruptive toindividuals and families and can be demoralizing for all con-cerned. In recent years, the perception has grown that in-patient stays are too short, although little is known about thecomparative effectiveness of different lengths of stay forpatientswith seriousmental illness. A review by the Agency forHealthcare Research and Quality (AHRQ) examines evidencefor four core strategies for decreasing repeated hospital-izations: implementing longer stays, providing support servicesfor the transition to outpatient care, creating short-termoutpatient alternatives for those not at significant risk ofharm to self or others, and implementing long-termapproaches.Of 64 studies that assessed the link between a managementstrategy and readmission, two addressed length of stay, fiveaddressed transition support services, four addressed short-term alternatives, and 53 addressed long-term approaches, suchas assertive community treatment (ACT), intensive casemanagement, and involuntary outpatient commitment(compulsory treatment orders). Although the review sought toidentify key components of the strategies that could be linkedto reductions in readmissions, it found no broad theoreticalmodel, other than ACT, that articulated key components. Im-portant next steps include determining the components,or packages of components, that are most effective; devisingaccurate measures for the most meaningful outcomes; andefficiently applying these strategies in the face of limitedresources. The 26-page report, Management Strategies to Re-duce Psychiatric Readmissions, is available on the AHRQ Website (effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction5displayproduct&productID52082).

CommonwealthFund2014 surveyfindsmillionsofAmericansunderinsured:Most Americans—more than 150million people—get their health insurance through employers. Before the ACA,employer coverage was generally far more comprehensive thanindividual market coverage. However, pressures over the pastdecade have led employers to share increasing amounts oftheir health costs with workers, particularly in the form ofhigher deductibles. The latest Commonwealth Fund BiennialHealth Insurance Survey, conducted between July and De-cember 2014, categorized adults as being underinsured if they

had health insurance continuously for the prior 12 monthsbut had out-of-pocket costs or deductibles that were highrelative to their incomes. Survey findings indicate that amongadults ages 19 to 64 who were insured all year, 23%, or 31million people, were underinsured. These estimates are un-changed from2010 and 2012 but nearly double those reportedin 2003, when the measure was first introduced in the survey.The share of continuously insured adults with high deduc-tibles has tripled, rising from 3% in 2003 to 11% in 2014. Half(51%) of underinsured adults reported problemswithmedicalbills or debt, and 44% reported not getting needed care be-cause of cost. Because the survey was fielded in the latter halfof 2014, it could not assess the effects of the ACA on under-insurance because survey respondents who were insured allyear had insurance that began before the ACA’s major cover-age expansions and reformswent into effect. Respondentswhohad new marketplace or Medicaid coverage under the ACAwould not have had that coverage for a full 12 months, becauseit would have begun in January 2014 at the earliest. Similarly,people with individual market coverage who were insured allyear would have spent all or part of the period in plans that didnot yet reflect the consumer protections in the law. The20-page report, The Problem of Underinsurance and How RisingDeductiblesWillMake ItWorse: FindingsFromtheCommonwealthFund Biennial Health Insurance Survey, 2014, is available on theCommonwealthFund’sWeb site (www.commonwealthfund.org).

Kaiser Foundation report examines experiences of newlyinsured Californians under the ACA: Between October2013 and 2014, about 2.8 million people were determined eli-gible for California’s Medicaid program, which was expandedunder the ACA. During that period, roughly 1.7 million peopleapplied and were determined eligible for enrollment in a pri-vate plan through Covered California, the state-run insurancemarketplace. Low-income California adults who gainedinsurance coverage in 2014 had an easier time accessinghealth care than those who were uninsured and experiencedbetter financial protection from medical bills, according toa new Kaiser Family Foundation (KFF) report. Newly insuredCalifornians were more likely than the uninsured to have ausual source of health care (61% versus 43%) and to have usedmedical services (58% versus 45%). Although most newly in-sured adults rated their health plan as excellent or good, somereported ongoing challenges. More than a third (35%) said thatthey postponed or went without needed health care (versus29% of those who were continuously insured), and nearly half(47%) said it was somewhat or very difficult to afford theirmonthly premium. The KFF report looks at Californians whogained coverage in 2014 and those who remained uninsuredandwhy. It examines how people view their coverage and howcoverage affects financial security and access to care. Thereport, which was funded by the Blue Shield of CaliforniaFoundation, was based on findings from the California sampleof the 2014 Kaiser Survey of Low-Income Americans and theACA. The report is available on the KFF Web site (kff.org/health-reform).

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