IMPROVING ACCESS TO SPECIALTY CARE FOR MEDICAID PATIENTS: POLICY ISSUES AND OPTIONS june 2013 Laurie E. Felland, Amanda E. Lechner, and Anna Sommers The Commonwealth Fund, among the first private foundations started by a woman philanthropist—Anna M. Harkness—was established in 1918 with the broad charge to enhance the common good. The mission of The Commonwealth Fund is to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries. IMPROVING ACCESS TO SPECIALTY CARE FOR MEDICAID PATIENTS: POLICY ISSUES AND OPTIONS Laurie E. Felland, Amanda E. Lechner, and Anna Sommers June 2013 Abstract: In some states and communities, Medicaid programs, health plans, providers, and others are collaborating to improve timely access to medical and surgical specialty services for Medicaid enrollees. This report examines six models—in Connecticut, Illinois, Minnesota, New Mexico, Oregon, and Tennessee—that support innovative ways of delivering specialty care and help ensure specialty referrals for Medicaid patients are appropriate and efficient. Strategies include finding ways for specialty providers to deliver care at primary care facilities, expanding the role of primary care providers to deliver specialty care, and employing staff to communi- cate and coordinate care across providers. Although resources remain limited, participating organizations report better access to specialty care for Medicaid patients and early signs of improvements in quality and costs of care. However, sustaining, expanding, and replicating these models may require changes in Medicaid payment methods that recognize new types of interactions with patients beyond face-to-face visits. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. To learn more about new publications when they become available, visit the Fund’s website and register to receive email alerts. Commonwealth Fund pub. 1691. CONTENTS ABOUT THE AUTHORS..........................................................................................................................................6 ACKNOWLEDGMENTS...........................................................................................................................................6 EXECUTIVE SUMMARY.......................................................................................................................................... 7 INTRODUCTION: CHALLENGES ACCESSING SPECIALTY CARE...........................................................................9 ADDING SPECIALTY CARE IN CREATIVE WAYS: SELECTED MODELS...................................................................9 DIVERSE FINANCIAL SUPPORT............................................................................................................................12 VARIED MOTIVATIONS FOR PARTICIPATION......................................................................................................12 IMPLEMENTATION CHALLENGES.......................................................................................................................13 INCREMENTAL IMPACT........................................................................................................................................14 EXPANSIONS PLANNED BUT LIMITED................................................................................................................14 POLICY OPTIONS................................................................................................................................................ 16 METHODOLOGY.................................................................................................................................................. 17 NOTES...................................................................................................................................................................18 APPENDIX. DETAILS OF SELECTED MODELS AND LIST OF ADVISORY PANEL MEMBERS .............................. 20 ABOUT THE AUTHORS Laurie E. Felland, M.S., is a senior health researcher and director of qualitative research at the Center for Studying Health System Change (HSC) in Washington, D.C. With a primary interest in low-income people’s access to health care, Felland’s research has focused on the capacity and financial viability of safety-net hospitals and community health centers, issues in Medicaid and the Children’s Health Insurance Program (CHIP), and programs for uninsured people. She directs HSC’s large qualitative research projects to track the financing, organization, and delivery of health care in local markets, including a community tracking study of six California markets and research on local commercial and Medicaid insurance markets and their preparations for health reform. Felland earned a master’s degree in health policy and management from the Harvard School of Public Health. She can be emailed at LFelland@hschange.org. Amanda E. Lechner, M.P.P., is a health policy analyst at HSC and conducts policy analyses and research on a variety of topics relating to health reform. Her research interests include access to care, coverage adequacy in the private insurance market, out-of-pocket medical expenditures for people with chronic conditions, and issues related to pharmaceutical pricing and regulation. Lechner received her master’s degree in public policy from Georgetown University. Anna Sommers, Ph.D., joined the staff of the Medicaid and CHIP Payment and Access Commission in July 2012, where she directs studies of access and quality. Formerly a senior health researcher at HSC, Sommers’s research has focused on access to care, physician participation in Medicaid, and emergency department use. She previously worked as a senior research analyst at the Hilltop Institute at the University of Maryland, providing technical assistance to state Medicaid and CHIP programs. Prior to that, she worked as a research associate in the Health Policy Center at the Urban Institute, conducting studies on access to care, spending, quality, and eligibility in Medicaid and other public programs. Sommers received her doctoral degree in health services research, policy, and administration from the University of Minnesota School of Public Health and a master’s degree in public affairs from the Hubert H. Humphrey Institute of Public Affairs at the University of Minnesota. ACKNOWLEDGMENTS The authors are grateful to Pamela Riley and Melinda Abrams at The Commonwealth Fund for their support and guidance on this project. The authors also wish to acknowledge the advisory panel members who helped identify and select the models for study (see the Appendix), as well as the many health care leaders at the local level who provided their insights and perspectives on the models (see the Methodology). Editorial support was provided by Deborah Lorber. 6 Improving Access to Specialty Care for Medicaid Patients: Policy Issues and Options EXECUTIVE SUMMARY specialist appointments are appropriate and productive, freeing up specialists to treat more seriously ill patients, Many Medicaid patients face problems finding spe- and reducing use of expensive services, such as hospital cialty physicians to treat them in a timely manner. Low and emergency care. The models rely mainly on special- Medicaid payment rates typically are the main barrier, ists who already serve Medicaid patients rather than although administrative burdens, patients’ nonmedical attracting new specialists. Challenges remain, including needs and challenges keeping appointments and adher- bridging different cultures and processes among par- ing to treatment plans play a role as well. Lack of timely ticipating organizations, overcoming provider concerns specialty care can result in adverse medical outcomes about patient safety and quality of care, and taking pro- and potentially higher costs from avoidable emergency viders away from other patients or activities. department visits and hospitalizations. Safety-net While many of the models are still developing hospitals, community health centers, specialists, state and growing, participating organizations reported some Medicaid programs and Medicaid health plans are part- improvements in access to specialty care, and a few have nering to improve access to specialty care. This report measured improvements in quality and documented cost examines six such models in Connecticut, Illinois, savings; most hope to demonstrate more concrete improve­ Minnesota, New Mexico, Oregon, and Tennessee. ments through upcoming evaluations. Most models The models deploy staff members and technol- plan to expand to other specialties and patients and ogy in innovative ways, including: show promise for replication by other communities. • increasing the availability of specialty care While the models have developed under exist- through telehealth, bringing specialists ing state Medicaid policies, long-term sustainability, to primary care sites, and using physician expansion, and replication may require updates to assistants (PAs) to deliver specialty services; Medicaid payment policies that recognize and support • expanding the role of primary care providers— new types of interactions with patients. Such changes physicians and nurse practitioners (NPs)—to might include: paying providers to consult with other handle more specialized health issues through clinicians or treat patients remotely; expanding the training and electronic consultations; and scope of federally qualified health centers (FQHCs) to • enhancing communication and coordination provide more specialty services; funding the training of among patients, primary care providers, and primary care clinicians in certain types of specialty care; specialists through broad medical home models and changing the way nonclinical activities, like coordi- and staff—known as access coordinators— nating patient care, are paid and accounted for in man- dedicated to arranging specialty care. aged care contracts. The Affordable Care Act expands Medicaid While these models were selected because they coverage to millions of Americans starting in 2014 had some external funding, their available resources but does not explicitly address the likely increased did not allow them to address all types of specialties demand for specialty care stemming from the coverage or patient needs. In general, public and private grants expansion. Although the law’s temporary increase in typically help with start-up costs, particularly for big- Medicaid payments for primary care may help support ticket items like health information technology tools. components of these models that rely on a larger role Ongoing expenses, such as salaries for additional staff, by primary care clinicians, many expect the demand in many cases are supported through funding from for these providers to exceed supply. Indeed, national Medicaid programs and health plans, although partici- health reform likely will highlight and increase the need pating providers absorb many operating costs. for health care providers, plans, and policymakers to Along with improving Medicaid patients’ address problems securing timely, efficient, high-quality access to specialty care, participating organizations were specialty services for Medicaid patients. interested in improving job satisfaction, ensuring that www.commonwealthfund.org7 IMPROVING ACCESS TO SPECIALTY Medicaid patients are available through safety-net hospitals—public hospitals, academic medical centers CARE FOR MEDICAID PATIENTS: (AMCs) and other hospitals with a mission to serve POLICY ISSUES AND OPTIONS people regardless of their insurance status or ability to pay, but demand generally exceeds supply.13 INTRODUCTION: CHALLENGES ACCESSING SPECIALTY CARE Many low-income people face problems obtaining ADDING SPECIALTY CARE IN CREATIVE timely appointments with medical and surgical special- WAYS: SELECTED MODELS Safety-net hospitals, community health centers, spe- ists with expertise in such areas as cardiology, ortho- cialists, state Medicaid programs, and Medicaid health pedics, and neurology, among many others. Compared plans are partnering to improve access to specialty care. with referrals for privately insured patients, when a This report examines six such models in Connecticut, primary care physician (PCP) refers Medicaid patients Illinois, Minnesota, New Mexico, Oregon and to specialists, these referrals are less likely to result in Tennessee. The models deploy staff members and tech- appointments1,2 because of difficulty finding specialists nology in innovative ways, including: willing to accept Medicaid patients3 and long wait times for appointments.4 Lack of timely specialty care can • increasing the availability of specialty care result in adverse medical outcomes, emergency depart- through telehealth, bringing specialists ment visits and hospitalizations, and potentially higher to primary care sites, and using physician health care costs.5,6 The extent of the access problem assistants (PAs) to deliver specialty services; varies by specialty and community and is associated • expanding the role of primary care providers— with state policy and local health system characteristics, physicians and nurse practitioners (NPs)—to such as the supply and distribution of specialists.7 handle more specialized health issues through Surveys indicate that physicians’ relative training and electronic consultations; and unwillingness to serve Medicaid enrollees stems pri- • enhancing communication and coordination marily from low payment relative to Medicare and among patients, primary care providers, and commercial insurer payments and from administra- specialists through broad medical home models tive burdens.8,9 Also, compared with privately insured and staff—known as access coordinators— patients, Medicaid patients face more socioeconomic dedicated to arranging specialty care. and health issues that present challenges for specialists. For example, Medicaid patients are more likely to miss This study identified six models that arrange appointments because of lack of transportation or child for specialty care in various, systematic ways and that care and have clinical and nonclinical needs—such as obtain funding outside of regular Medicaid payments. chronic conditions, mental health issues, and language (For details on selection criteria, see the Methodology). interpretation services—that require more provider time The six models are: and resources.10,11 • ACCESS Community Health Network, partnered When Medicaid patients need specialty care, with University of Chicago Medical Center; their PCPs typically rely on existing relationships with • CareOregon, partnered with Legacy Health specialists. These often take the form of a personal favor and the Neighborhood Health Center; negotiated on behalf of each patient individually—one recent study referred to this as the “tin-cup method.”12 • Community Health Centers, Inc., partnered with However, in many communities, specialty services for Yale Medical Group and the University of Connecticut; www.commonwealthfund.org9 • Project ECHO (Extension for Community Increasing Availability of Specialty Healthcare Outcomes) at the University of Practitioners New Mexico; One key strategy used by some models is telehealth, • UnitedHealthcare Community Plan, partnered which is defined as video or other imaging technology with Tennessee Primary Care Association, that allows specialists to diagnose and treat patients Community Health Network, and Meharry remotely. Study sites use telehealth to address shortages Medical Group; and of specialists in two ways. UnitedHealthcare uses video­ conference appointments with a variety of specialists; • Health Care Homes in Minnesota. Community Health Centers, Inc. (CHCI) uses store- (For more details about each model, see the Appendix.) and-forward technology that collects images for later Each of the models represents collaboration review by an ophthalmologist to screen for early signs of across providers, with varied levels of involvement from blindness in diabetic patients. state Medicaid programs and health plans. These mod- Another strategy is to increase access to spe- els were initiated during the past decade by safety-net cialty care at primary care sites, either with specialty providers (i.e., hospitals or community health centers) physicians or midlevel providers. ACCESS contracts or Medicaid managed care plans. In some cases, the with University of Chicago Medical Center (UCMC) same types of organizations serve as partners in the specialists to treat patients at its FQHC and has added models; for example, Project ECHO is led by an AMC midlevel providers to focus on care coordination. that partners with federally qualified health centers CareOregon employs physician assistants to screen (FQHCs), a managed care plan, the state legislature, patients with orthopedic conditions and treat those who and the state Medicaid agency. do not need surgery, as well as provide pre- and postop- Some models started in response to a prob- erative care to surgical patients. lem with a particular specialty, while others took on specialty care more broadly. For instance, Project Expanding Role of Primary Care Providers ECHO began because of a hepatologist’s frustration Another approach is to expand the role of primary with patients having to wait eight month to see him care providers to handle more specialized health issues, and to travel long distances for hepatitis C treatment. reducing the need for specialty referrals. Via videocon- Generally, the targeted specialties relate to conditions ferencing, Project ECHO specialists at the University with a high prevalence, including cardiology, neurology, of New Mexico guide and train primary care providers and rheumatology. Many models added specialties over elsewhere to treat patients with certain conditions. Over time. Today, Project ECHO and the UnitedHealthcare time, the providers gain sufficient knowledge to treat Community Plan initiative both include approximately specialized problems independently. 10 specialties, while ACCESS includes more than 20. Web-based communication technology— The goal is to improve access by providing the including two tools known as eReferral or eConsults— needed specialty service, consult, or procedure more can help primary care providers secure an expert con- efficiently. This also creates the potential to reduce the sult and prevent inappropriate or premature refer- total cost of specialty care and to free up resources to rals. First developed by a physician at San Francisco care for more people. The models use one or more of General Hospital, eReferral allows specialists to review three main approaches to achieve this goal: increasing primary care providers’ requests for a referral electroni- the availability of specialty practitioners, expanding the cally—typically supported by access to electronic health role of primary care providers, and enhancing commu- records (EHRs) or other patient records.14 Similarly, nication and coordination (Exhibit 1). CHCI’s eConsults uses secure peer-to-peer electronic 10 Improving Access to Specialty Care for Medicaid Patients: Policy Issues and Options EXHIBIT 1. KEY APPROACHES USED TO IMPROVE ACCESS TO SPECIALTY CARE Increasing availability of specialty Expanding role of Enhancing communication Model practitioners primary care providers and coordination Physician assistants handle Care coordinators recruit and CareOregon routine, nonsurgical orthopedic coordinate care with orthopedic needs surgeons Nurse practitioners and medical ACCESS assistants determine severity Hospital-based specialists treat Community of condition and where patient patients at FQHC sites Health Network should be seen; support specialists’ work at FQHCs Telehealth technology allows Staff at primary care and health UnitedHealthcare Nashville-based specialists to center associations recruit and Community Plan treat patients throughout the state train physicians on telehealth and at primary care provider sites schedule appointments Project ECHO University-based specialists (Extension for remotely consult and train Community primary care providers to Healthcare treat their patients’ specialty Outcomes) needs themselves Diabetic retinopathy screening Primary care providers learn performed at FQHC sites how to treat hepatitis C and and evaluated remotely by HIV through Project ECHO ophthalmologists with store-and- Community Health clinics forward technology Centers, Inc. University-based specialists advise primary care providers on cardiology cases through eConsults Primary care providers Access coordinators serve as Minnesota Health serve as medical homes and point of contact and conduit Care Homes coordinate services beyond among patients, primary care the medical home providers, and specialty providers Note: FQHC = federally qualified health center. Source: Authors’ analysis of respondent interviews. messages to present the consult question and relevant request within two days and to see any patient needing patient notes, labs, and diagnostic images to cardiolo- an in-person visit within a week. gists at the University of Connecticut. These physicians provide the PCP with either specific guidance on how Enhancing Communication and Coordination to manage the patient or recommendations for urgent A third approach is to improve communication and care or routine specialist follow-up. coordination among the patient, primary care providers, These strategies do not represent a complete and specialists. Minnesota Health Care Homes (HCH) shift of specialty care to primary care settings. In Project broadens the medical home concept to a “medical ECHO and CHCI’s eConsults, the specialists involved neighborhood” that includes a wider team of clinicians agree to see and treat the patients deemed complex. and support staff to coordinate care and form relation- The specialist becomes familiar with the patient’s case ships and improve communication with medical and and comfortable that the patient requires follow-up surgical specialists. or is ready for a procedure. For example, cardiologists To enable better communication and coordina- working with CHCI agree to respond to an eConsults tion, most of the models have created a new clinical and www.commonwealthfund.org11 administrative position. Often called access coordina- through their own revenues, supplies, and staff time. tors, these staff members serve as a point-of-contact Many participating community health centers are for patients and facilitate communication between pri- FQHCs, which receive federal grants and enhanced mary care and specialty care providers. They also gain a Medicaid payments—that is, an all-inclusive encounter more thorough understanding of patients’ needs, which rate intended to support the broad range of services an reportedly helps secure appointments with specialists. FQHC provides. This support has been particularly One access coordinator explained the value of the new helpful in covering the general costs of providing ser- relationships formed with specialists: “It used to be a vices compared with regular Medicaid fee-for-service flat-out ‘no’ [from specialists], whereas now we have rates. 15 Additionally, ACCESS was able to modify its opened the door [to getting patients appointments].” FQHC scope-of-project designation, which determines what services can be supported with federal grant fund- ing, to include many medical specialties. Still, a respon- DIVERSE FINANCIAL SUPPORT dent discussing ACCESS reported the need for “finan- Shifting how and where specialty care is provided cial gymnastics to support the program.” requires resources, and may include implementing new Some state Medicaid agencies help fund the technology and training primary care providers and models. Although Minnesota providers must cover the other staff. The models studied in this report incur costs of obtaining Health Care Homes (HCH) certi- various capital and operational costs, such as facil- fication, the state pays an amount (through Medicaid ity expansions, health information technology (HIT), managed care plans) to certified providers for each and increased labor. HIT is typically the largest start- chronically ill patient, tied to the patient’s conditions up cost. Telehealth equipment is expensive because it and socioeconomic barriers. requires high-resolution video capabilities, among other In some cases individual Medicaid managed features. For example, respondents reported that the care plans fund up-front or ongoing components of the equipment and installation costs for each telehealth models. One of New Mexico’s four Medicaid managed unit at UnitedHealthcare was approximately $30,000 care plans pays primary care providers for their involve- to $40,000. Videoconferencing equipment for Project ment in Project ECHO, CareOregon pays a portion of ECHO and the software, portals, and interfaces with the new staff at the FQHC, and the UnitedHealthcare EHRs and other systems for eConsults were typically Community Plan paid for installation of telehealth less expensive. Maintenance and staff HIT training is equipment and reimburses specialists and providers for an ongoing cost. Employing and training primary care telehealth appointments. providers, PAs, and access coordinators are new and ongoing operational costs. Plus, there is an opportunity cost when primary care providers spend time on tasks VARIED MOTIVATIONS FOR other than billable patient visits. PARTICIPATION In models that bring specialists to the pri- Respondents reported several motivations for primary mary care site, the primary care organization receives care providers, specialists, Medicaid programs, and Medicaid payment for the services provided and pays health plans to participate. Because they serve as medi- specialists as employees or on a per-visit basis or the cal homes for Medicaid enrollees, many primary care specialist bills Medicaid directly. However, because providers want to avoid the time and frustration of a many of the models’ activities do not involve face-to- scattershot approach to specialist referrals. One primary face appointments, they are not covered by Medicaid. care respondent explained: “We need to step into our Resources tend to come from an array of responsibility of being an air traffic controller and make sources, including government, health plans, foun- referrals seamless for the patient.” Some primary care dations, and the participating providers themselves providers assumed partial responsibility for the specialty 12 Improving Access to Specialty Care for Medicaid Patients: Policy Issues and Options care problem. One said, “I will start by blaming our- referral patterns among safety-net organizations, as well selves. We don’t have robust standards for referrals. The as continued problems gaining participation from spe- first part is to create appropriate referral criteria that are cialists in private practice. Some participating safety-net shared.” Many of the models focus on reducing the need hospitals limit the participation of their own specialists for referrals to specialists and, for those patients who are for financial reasons: ACCESS would like to use more referred, reducing the time and resources the specialist UCMC specialists, but the time specialists spent in the needs to treat them. FQHC in lieu of the hospital represents a loss in rev- Indeed, specialty physicians and hospitals value enues for UCMC, particularly for higher-paid surgical the models as a way to treat low-income patients more specialists. efficiently and effectively. Specialists gained confidence Some state Medicaid programs and Medicaid that referred patients have conditions that warrant managed care plans are attracted to the potential cost consults, that patients are ready for their appointments savings the models could generate. They assume that or procedures, and that relevant information about improved coordination will reduce unnecessary patient the patient is available. For example, CareOregon and visits and, in some cases, transportation costs, and that UnitedHealthcare surveyed specialists to understand improved access to specialty care when appropriate will the specific information and tests needed to accept prevent more expensive emergency care and hospitaliza- Medicaid patients—information that varies across pro- tions. One Medicaid agency respondent said the state viders—and then created systems to meet the criteria. saw the model as a “needed expense that . . . should have In addition, the models help manage specialists’ downstream benefits.” concerns about Medicaid patients’ nonmedical needs that can waste an appointment slot or render the visit unproductive. The coordinators spend time understand- IMPLEMENTATION CHALLENGES ing patients’ barriers to getting care—for example, that a Implementation takes considerable time and trial and patient only has child care on certain days—and ensur- error, particularly to gain provider buy-in and to iron ing they can get to their appointments and adhere with out differences across providers. As one respondent said care plans. about primary care and specialty providers working Some models pay specialists for participa- together, “We have two different cultures and different tion, but it is difficult to know how much of an incen- ways of doing business.” For instance, it took ACCESS tive these payments provide. ACCESS is able to pay more than a year to ramp up because of challenges set- the UCMC specialists a negotiated payment that is ting up protocols for scheduling specialty appointments higher than what they would receive by directly bill- between the health center and UCMC. CHCI’s eCon- ing Medicaid and CHCI pays specialists a small fee for sults took several years—considerably longer than par- each telehealth and eConsults interaction. ticipants expected—to resolve information technology Primary care and specialty providers alike value and process issues. the professional growth opportunities the models pro- Also, providers reported some concerns about vide. For instance, respondents involved with Project patient safety and quality of care. Some Tennessee pri- ECHO and CHCI said that increasing PCPs’ skills and mary care providers in the UnitedHealthcare model responsibilities has boosted job satisfaction. have not used their telehealth equipment because of Still, instead of significantly expanding the quality concerns generally and are wary of working with pool of specialty physicians willing to treat Medicaid specialists they do not know. Cardiologists in the CHCI patients, the models mostly involve specialists who eConsults pilot feared PCPs would submit patients already treat a substantial number of Medicaid patients. with overly urgent and complex conditions, resulting This reflects the established working relationships and in delayed, substandard care, and potential exposure to malpractice liability. However, these problems did not www.commonwealthfund.org13 materialize, and one respondent stated that eConsults model focuses on orthopedic problems using PAs. In worked well as a “structured, electronic water-cooler contrast, respondents indicated that orthopedic issues conversation” among physicians. are more difficult to address through a telehealth model In addition, the models often hinder over- because they typically require hands-on physical exami- all productivity. A respondent reported that Project nation and assessment. The access coordination role ECHO specialists spend an estimated 15 percent or appears useful in managing chronic conditions and more of their time training and consulting with primary procedure-based specialties alike. care providers, which takes away from time to treat their Some respondents found quality of care and own patients. patient outcomes to be the same, if not better, under the models. For example, CareOregon PAs cast routine broken bones of patients released from the emergency INCREMENTAL IMPACT department within two days, while previously many Many of the models are still new, operate on a small patients could not get appointments with specialists and scale, and face ongoing challenges. For instance, at the kept their temporary splints, hindering the bones’ ability time this research was conducted, eConsults at CHCI to heal properly. Also, the PA model reportedly results were in the pilot phase, with cardiologists consulting on in many orthopedic patients receiving timely nonsurgi- approximately a dozen cases. UnitedHealthcare’s tele- cal therapy to manage joint pain, which can promote health program reportedly handles 20 medical specialty mobility and reduce further joint deterioration and the cases a month, with specialists reporting problems with need for surgery. Respondents reported that care pro- underutilization of their sessions and no-shows. vided by expanding the role of PCPs was on par with The models reportedly have improved the specialist care. A study found that patients treated for availability of specialist appointments, although respon- hepatitis C through Project ECHO had similar out- dents stressed that demand continued to exceed supply. comes as patients treated directly by UNM specialists.16 CHCI increased the percentage of diabetic patients Cost savings are difficult to estimate, but receiving retinopathy screening from 10 percent to 40 respondents noted the importance of measuring and percent. According to a respondent, waits for rheuma- demonstrating savings. CHCI published results that tology appointments at UNM declined from six months found that using telehealth for diabetic retinopathy to one month after Project ECHO’s implementation. saves approximately $28 (about 35%) per patient An access coordinator in Minnesota reported the bene- compared with a conventional exam.17 Full evaluations fits of better preparation and communication: “As far as of Project ECHO, HCH, and CHCI are under way specialists outside the clinic, health care homes’ patients or planned. seem to be prioritized. They can get in quicker than the average person not in a health care home.” Likewise, strategies that give primary care pro- EXPANSIONS PLANNED BUT LIMITED viders more responsibility for specialty care can result in Some approaches, particularly telehealth and eConsults, fewer specialist referrals. For example, a PCP trained by have been replicated in other states and communities. Project ECHO reported seeking specialty referrals for Replication typically requires well-supported, exten- only 10 percent of rheumatology cases, compared with sive safety-net capacity, with a critical mass of primary all such patients before implementation of the project. care and specialty providers already treating Medicaid Many of the models studied typically work best patients. This could take the form of a large FQHC for chronic, complex medical conditions that can be with an AMC or public hospital supplying specialty managed by a primary care physician or nonphysician care. For example, a respondent reported that it is a very clinician, although the types of specialties suitable for daunting process to achieve Minnesota HCH certifica- particular models vary. For example, the CareOregon tion and that smaller practices may not receive sufficient 14 Improving Access to Specialty Care for Medicaid Patients: Policy Issues and Options incentive payments to support ongoing costs. Larger activities could jeopardize a health plan’s ability to meet providers also tend to have existing EHRs and other the state’s medical loss ratio requirement—that is, the IT infrastructure needed to support core activities. For percentage of premiums spent on medical care com- example, the shared EHR between FQHCs and the pared with administrative costs. county hospital in Minneapolis helps access coordina- Furthermore, federal and state policies limit tors with scheduling specialty appointments and care the types of specialty services that FQHCs can add coordination. and receive payment for—this is known as the “scope Many respondents were optimistic about gain- of project.” The Health Resources and Services ing efficiencies to add more specialties, providers, and Administration (HRSA), which oversees FQHCs, patients. The models that rely heavily on HIT typically allows FQHCs only to add specialty services that are a have high up-front costs but low marginal costs, in logical extension of primary care services and that are contrast with models that depend more on additional in sufficient demand by patients. Such services com- labor. For example, by using IT, Project ECHO’s virtual monly include consultations and examinations for pul- clinics are now available to other primary care organiza- monology, cardiology, podiatry, and oncology, as well as tions beyond New Mexico, including CHCI, which has colonoscopies. After HRSA approval, a state Medicaid implemented Project ECHO for HIV and hepatitis program must approve a scope-of-service change for C, and will soon launch one for chronic pain manage- the FQHC to receive enhanced payment rates for the ment. In addition, CHCI plans to extend eConsults to added services. more specialties. In contrast, expanding CareOregon’s Many states limit the types of providers and PA model to neurology and possibly endocrinology is services eligible for enhanced Medicaid payments. For planned but will occur more slowly because of the need example, ACCESS partners with an outside provider to hire additional staff. to offer optometry services at the health center, but The lack of Medicaid payment for specialty because the Illinois Medicaid agency deems optom- services provided in new ways could limit the models’ etrists ineligible for payment at an enhanced rate, the expansion and replication. Notwithstanding the funding optometry provider bills Medicaid directly at the lower arrangements among these models, Medicaid programs rate, reportedly limiting the provider’s participation. generally are less likely to pay for strategies involving Also, state processes for acquiring scope-of-service HIT (e.g., telehealth, eConsults), staff training, access changes and payment adjustments can be complex or coordination, and other types of interactions beyond nonexistent.19 Further, the majority of state Medicaid in-person visits. While as many as 40 state Medicaid programs will not reimburse an FQHC for more than programs report covering telehealth services, many limit one medical visit per patient per day,20 requiring a coverage to real-time encounters with a patient, inpa- patient to return another day for a specialty care follow- tient or emergency services, or to certain populations, up appointment or for the FQHC to absorb additional such as children.18 cost. Medicaid programs generally do not pay for Some of these payment limitations may be providers’ ongoing education or training to provide spe- historical artifacts: when Medicaid was established in cialty care or care coordination, although some of these the 1960s, HIT used today did not exist. In addition, activities are covered by Medicaid primary care case payers are concerned about potentially duplicating pay- management programs (more common in rural areas ment, particularly if a new approach does not address in lieu of risk-based managed care plans) and disease a patient’s need and in-person treatment by a specialist management programs. In addition, state Medicaid remains necessary. programs typically consider care coordination activi- The expansion of Medicaid through the ties an administrative expense, so money spent on such Affordable Care Act could have mixed effects on www.commonwealthfund.org15 specialty care access for Medicaid enrollees. Most of specialties that need higher resolution images to diag- the states studied in this report (Connecticut, Illinois, nose and treat patients. Minnesota, New Mexico, and Oregon) plan to expand Respondents indicated that commercial health Medicaid, while Tennessee plans to opt out of the plans’ coverage of telehealth and eConsults could pave expansion, as allowed by the June 2012 U.S. Supreme the way for broader adoption for Medicaid enrollees. As Court decision. The revenues generated by previously of 2011, only 12 states required commercial insurers to uninsured patients gaining coverage and the two-year pay for telehealth services and not all require payment increase in Medicaid payment for certain primary care at rates equivalent to traditional face-to-face visits.22,23 services to Medicare levels might enable greater pro- Connecticut passed legislation in 2012 that requires vider involvement in the specialty models. At the same private insurers to cover telehealth services; respondents time, demand for specialty care is expected to rise as involved in CHCI expect this to encourage a similar more low-income people gain Medicaid coverage. If requirement for the Medicaid program. To the extent access to primary care improves, which is a key focus that private practice physicians invest in such equip- of the health care reform law,21 more clinical problems ment for privately insured patients and reap efficien- requiring specialty care may be detected. However, the cies, it could open the door for them to treat Medicaid law does not explicitly address the challenges of provid- patients in the same way. ing specialty care to Medicaid patients, and safety-net Additionally, states could consider ways to hospitals are concerned about the loss of federal sub- support clinician education and training, as well as sidies—known as disproportionate share hospital pay- care-coordination activities. As more state Medicaid ments—that help provide these and other services for programs adopt patient-centered medical home models low-income people. that pay providers extra for handling complex patients, more access coordinator positions could be supported. Also, states may want to consider care coordination a POLICY OPTIONS medical expense, rather than an administrative cost, in Federal and state policymakers wishing to improve managed care contracts. the availability of specialty care for Medicaid enrollees While FQHCs mainly focus on preventive and could consider several changes in how Medicaid dol- primary care, findings from this study show that pri- lars flow to health plans and providers. They will have mary care providers can serve as a useful bridge to cer- to weigh the benefits, in terms of improved access and tain specialty services that are difficult to obtain other- potential cost savings, against the up-front and ongoing wise. With more FQHC funding available through the costs of paying for specialty care in new ways. Affordable Care Act, HRSA might consider allowing Medicaid programs could consider paying for certain FQHCs to add specialties under their scope-of- more specialty services supported or provided through project definition. In areas where single FQHCs have telehealth and eConsults and other HIT tools. State insufficient patient volumes or capacity to support a laws could establish appropriate use and standard bill- particular specialty, providers could be encouraged to ing procedures for physician-to-physician consults share specialty services across multiple sites. For exam- and physician-to-patient encounters that may or may ple, other Portland health centers refer patients to the not require a physician be physically present with the FQHC with the CareOregon PA. patient. They also could incorporate new types of tech- For FQHCs that are adding specialties, states nology as they become available. For instance, many might consider increasing payments per encounter to Medicaid programs now reimburse for mental health FQHCs to account for the additional cost of provid- services provided through low-tech and less-expensive ing a specialty service or paying for two medical visits visual platforms like Skype, which could free up more in one day. This would allow FQHCs to optimize the complex and expensive telehealth equipment for 16 Improving Access to Specialty Care for Medicaid Patients: Policy Issues and Options convenience of colocating primary and specialty care population. These models cultivate many of the skills, services for patients. tools, and linkages needed to improve communica- One alternative to direct payments for vari- tion and collaboration across two critical and com- ous strategies is to move toward fixed payments for monly used parts of care delivery—primary and spe- patients’ overall care rather than fee-for-service arrange- cialty care—to prevent Medicaid patients from falling ments. Health care reform encourages development through the cracks and potentially needing more hospi- of accountable care organizations (ACOs) and other tal admissions and emergency department visits. new payment arrangements designed to improve both Finally, these Medicaid specialty care models the quality and efficiency of care delivery. In the ACO could be useful to a broader population. For instance, framework envisioned by many, providers take respon- although Project ECHO mainly serves low-income sibility for caring for a defined group of patients and patients, it was designed to help anyone facing barriers are rewarded financially for providing care in the least to specialists—a relatively common problem given the expensive yet appropriate setting. rural nature of New Mexico. Medicare and private The specialty models examined here could be payers also are interested in improving access to spe- important components of ACOs, structured around cialty care as a way to reduce costly emergency and inpatient and outpatient providers serving a Medicaid hospital care. METHODOLOGY Researchers at the Center for Studying Health System Change studied models focused on improving access to specialty care for Medicaid enrollees in six states or communities: Connecticut; Chicago, Illinois; Minnesota; New Mexico; Portland, Oregon; and Tennessee. Each model met five selection criteria: targets Medicaid enrollees; has a financing mechanism to support itself; exhibits strong potential for replication (i.e., not operat- ing in a unique environment); represents efforts by diverse stakeholders; and its future potential is likely linked to legislative or regulatory action. Models were selected with input from an advisory panel of 12 experts on safety-net providers and the Medicaid program. Between January and June 2012, researchers interviewed almost 40 respondents, including hospital representatives, primary care and specialty physicians, community health cen- ter executives, and Medicaid agency representatives, among others involved in the models. www.commonwealthfund.org17 NOTES 10 G. Patrick, J. Bisgaier, I. Hasham et al., “Specialty Care Referral Patterns for the Underserved: A Study 1 N. L. Cook, L. S. Hicks, J. O’Malley et al., “Access to of Community Health Centers on the South Side Specialty Care and Medical Services in Community of Chicago,” Journal of Health Care for the Poor and Health Centers,” Health Affairs, Sept. 2007 Underserved, Nov. 2011 22(4):1302–24. 26(5):1459–68. 11 P. T. Cheung, J. L. Wiler, R. A. Lowe et al., “National 2 C. B. Forrest, E. Shadmi, P. A. Nutting et al., “Specialty Study of Barriers to Timely Primary Care and Referral Completion Among Primary Care Patients: Emergency Department Utilization Among Medicaid Results from the ASPN Referral Study,” Annals of Beneficiaries,” Annals of Emergency Medicine, July 2012 Family Medicine, July/Aug. 2007 5(4):361–67. 60(1):4–10. 3 Medicaid and CHIP: Most Physicians Serve Covered 12 K. Neuhausen, K. Grumbach, A. Bazemore et al., Children But Have Difficulty Referring Them for “Integrating Community Health Centers Into Specialty Care (Washington, D.C.: U.S. Government Organized Delivery Systems Can Improve Access Accountability Office, June 2011). to Subspecialty Care,” Health Affairs, Aug. 2012, 4 31(8):1708–16. J. Resneck, Jr., M. J. Pletcher, and N. Lozano, “Medicare, Medicaid, and Access to Dermatologists: 13 M. M. Doty, M. K. Abrams, S. E. Hernandez et al., The Effect of Patient Insurance on Appointment Enhancing the Capacity of Community Health Centers Access and Wait Times,” Journal of the American to Achieve High Performance: Findings from the 2009 Academy of Dermatology, Jan. 2004 50(1):85–92. Commonwealth Fund National Survey of Federally 5“Delays Qualified Health Centers (New York: The Commonwealth in Treatment,” Sentinel Event Alert, Issue 26 Fund, May 2010). (Oakbrook Terrace, Ill.: The Joint Commission, June 17, 2002). 14 A. H. Chen, M. B. Hushel, K. Grumbach et al., “A 6 Safety-Net System Gains Efficiencies Through A. Cass, J. Cunningham, P. Snelling et al., “Late ‘eReferrals’ to Specialists,” Health Affairs, May 2010 Referral to a Nephrologist Reduces Access to Renal 29(5):969–71. Transplantation,” American Journal of Kidney Diseases, Nov. 2003 42(5):1043–49. 15 Under the Medicare, Medicaid, and SCHIP Benefits 7 Improvement and Protection Act of 2000 (BIPA), state L. E. Felland, S. Felt-Lisk and M. McHugh, Health Medicaid programs reimburse FQHCs according to Care Access for Low-Income People: Significant Safety Net a prospective payment system (PPS) based on health Gaps Remain (Washington, D.C.: Center for Studying centers’ average cost for a visit in 1999–2000, adjusted Health System Change, June 2004). annually to account for medical inflation. Under the 8 P. J. Cunningham and J. H. May, Medicaid PPS, per-visit payment rates are typically substantially Patients Increasingly Concentrated Among Physicians higher than rates paid to private physicians because (Washington, D.C.: Center for Studying Health FQHCs provide a wide range of clinical and nonclini- System Change, Aug. 2006). cal services. 16 S. Arora, K. Thornton, G. Murata, et al., “Outcomes of 9 P. J. Cunningham and A. S. O’Malley, “Do Reimburse- ment Delays Discourage Medicaid Participation by Treatment for Hepatitis C Virus Infection by Primary Physicians?” Health Affairs, Jan./Feb. 2009 28(1): Care Providers,” New England Journal of Medicine, w17–w28. June 9, 2011 364(23):2199–207. 18 Improving Access to Specialty Care for Medicaid Patients: Policy Issues and Options 17 Z. Li, C. Wu, J. N. Olayiwola et al., “Telemedicine- Based Digital Retinal Imaging vs. Standard Ophthal- mologic Evaluation for the Assessment of Diabetic Retinopathy,” Connecticut Medicine, Feb. 2012 76(2):85–90. 18 50 State Medicaid Statute Survey (Washington, D.C.: Robert J. Waters Center for Telehealth & e-Health Law, Feb. 2011). 19 D. McKinney, R. Kidney, and K. Burns, Update on the Status of the FQHC Medicaid Prospective Payment System in the States (Washington, D.C.: National Association of Community Health Centers, Nov. 2011). 20 D. McKinney, R. Kidney, C. Boselli et al., 2009 Update on the Status of the Medicaid and CHIP Prospective Payment System in the States (Bethesda, Md.: National Association of Community Health Centers, Sept. 2009). 21 M. Abrams, R. Nuzum, S. Mika et al., Realizing Health Reform’s Potential: How the Affordable Care Act Will Strengthen Primary Care and Benefit Patients, Providers, and Payers (New York: The Commonwealth Fund, Jan. 2011). 22 American Telemedicine Association, State Legislation for Telehealth-Provided Covered Services (Washington, D.C.: American Telemedicine Association, 2011). 23 American Psychological Association Practice Organization, “Reimbursement for Telehealth Services” (Washington, D.C.: American Psychological Association, March 31, 2011). www.commonwealthfund.org19 APPENDIX. DETAILS OF SELECTED MODELS AND LIST OF ADVISORY PANEL MEMBERS ACCESS Community Health Network, partnered with University of Chicago Medical Center Model ACCESS, a federally qualified health center (FQHC) operating approximately 40 community clinics across the Chicago area, focuses on providing a one-stop shop for patients for both primary and specialty care. In 2008, ACCESS partnered with University of Chicago Medical Center (UCMC), the area’s major academic medical center, to host weekly cardiology, neurology, gastroenterology, and infectious disease clinics at the main ACCESS facility. UCMC provided capital funds for ACCESS to almost double its number of exam rooms and add specialty services, although ACCESS absorbs the operating costs of the new expansion. For instance, ACCESS provides a nurse practitioner (NP) and medical assistants to support over 20 specialties and triage guidelines help determine which patients have more serious conditions and should be seen directly at the hospital. ACCESS bills Medicaid its regular prospective payment system (PPS) rate for the specialists’ time and, in turn, pays UCMC a negotiated rate to the specialists, who are employed by UCMC. ACCESS has applied for an increase in its PPS rate from the state to account for the cost of including specialty services but has not received it. ACCESS also partners with the Illinois Eye Institute (IEI) to provide optometry services at one of its sites, but because optometrists are excluded from the set of providers FQHCs in Illinois can provide and bill for, the IEI leases the space at the ACCESS site and bills Medicaid directly. CareOregon, partnered with Legacy Health and the Neighborhood Health Center CareOregon is a Medicaid managed care plan that has invested in two strategies to address the problems enrollees face in obtaining orthopedic care. About a decade ago, CareOregon partnered with Legacy Health, a hospital sys- tem in Portland, to place a physician assistant (PA) specializing in orthopedics at one of Legacy’s orthopedic clin- ics; CareOregon partially subsidizes the PA’s salary. In 2010, CareOregon expanded the model with a community clinic it previously owned, Neighborhood Health Center, an FQHC with facilities across the greater Portland area. The health center pays the salary of this additional PA. The PAs screen and triage patients to identify those who do not need or are not suitable for surgery and provide them with more basic orthopedic services or assist them with other options, such as weight loss, diabetes self-management, or physical therapy—a benefit not typically covered or paid for by the state Medicaid program, but that CareOregon is considering covering. The PAs receive payment, although less than a usual physician rate, for their services from the Medicaid health plan. CareOregon also pays the salaries of two access coordinators to locate, develop, and maintain relationships with orthopedists willing to treat patients identified by the PAs as needing surgical care. The access coordinators provide a single point of contact for specialists and patients, assisting the latter with setting up appointments and reminders, as well as educating patients on pre- and postsurgery guidelines. Community Health Centers, Inc., partnered with Yale Medical Group and the University of Connecticut Community Health Centers, Inc. (CHCI), is an FQHC operating primary care centers in 13 Connecticut cities, as well as 200 service delivery sites in schools, homeless shelters, and other community facilities throughout the state. CHCI has 130,000 active patients, a research and development center, and the country’s first postgraduate nurse practitioner residency program in primary care. CHCI has adopted three main strategies to expand specialty care 20 Improving Access to Specialty Care for Medicaid Patients: Policy Issues and Options access for patients, two-thirds of whom are Medicaid enrollees. In 2009, CHCI implemented a telehealth program to detect early signs of blindness in diabetic patients. Medical assistants at CHCI are trained to take images using retinal cameras. The images are then screened externally, through the California-based EyePACs program and read by ophthalmologists at the Yale Medical Group, to whom CHCI pays a flat rate per screening. In 2011, CHCI piloted an eConsults system with cardiologists at the University of Connecticut. CHCI pays the practice a small fee per electronic consultation, and the cardiologists agree to treat patients who need in- person appointments in their offices. CHCI plans to expand eConsults to other specialties, such as endocrinology and dermatology. CHCI started participating in Project ECHO’s hepatitis C virtual clinics in 2011. CHCI found the model very effective and replicated it across all its sites for hepatitis C, as well as HIV, and will add chronic pain manage- ment virtual clinics in 2013. CHCI largely relies on its operating margin to cover the ongoing costs of these initiatives because the state Medicaid program does not provide payment for these non-visit-based activities. CHCI has identified ways in which these efforts have improved access to specialty care and has secured research grant funds from the Connecticut Health Foundation and other foundations to conduct a formal evaluation. Health Care Homes in Minnesota Health Care Homes (HCH) is a statewide initiative in Minnesota to develop primary care medical homes for all insured patients, established by the state’s 2008 health reform law. Primary care organizations, including hospital- based outpatient departments, private physician practices, community health centers, and clinics that meet a host of criteria are certified by the state. To date, the state has certified over 200 health care homes, or almost one-third of all primary care organizations. The primary safety-net hospital in the Minneapolis area, Hennepin County Medical Center, has received certification for many of its outpatient clinics. Three of the largest FQHC organizations in the Twin Cities also are certified. Providers typically absorb the costs of making the capital and process changes to become HCHs, although some safety-net providers received grants to help cover the costs. As of July 1, 2010, health plans are mandated to pay the HCHs a monthly incentive payment to coordinate care for patients with chronic conditions, commonly asthma and diabetes. Per-member-per-month payments range from $10 to $79. Patients with multiple conditions or language or behavioral health issues will command higher payments. The state covers payments for Medicaid enrollees, while health plans absorb the cost for their privately insured enrollees. Providers commonly use the incentive payments to hire care coordinators to document a care plan for patients; discuss social needs; provide health education; schedule appointments; and facilitate communication among providers. These improvements are intended to help manage specialty care needs and reduce demand for specialty, emergency, and hospital care. Several state efforts are collecting quality and cost data on the initiative and an independent evaluation is planned for 2013 and 2015. Project ECHO (Extension for Community Healthcare Outcomes) at the University of New Mexico Project ECHO is a New Mexico videoconference-based program that allows specialty care to be provided in primary care settings. Founded in 2002 at the University of New Mexico (UNM) Health Sciences Center in Albuquerque, the state’s only academic medical center, Project ECHO began as an attempt to address significant gaps in treatment for patients with hepatitis C, particularly in the many rural and low-income areas of the state. Multidisciplinary specialty care teams designed training curricula for primary care providers—physicians and NPs— and hold 16 weekly disease-specific sessions, approximately 10 of which are for medical specialties, while others www.commonwealthfund.org21 cover mental health and substance abuse. In these “teleECHO clinics” or so-called “virtual grand rounds,” primary care providers present de-identified patient cases to the specialists, who provide advice on the treatment plans. The primary care providers gain expertise to eventually become “mini specialists.” Project ECHO has expanded over time and now trains primary care providers in other states as well. Over 1,000 primary care physicians, nurses, nurse practitioners, and physician assistants throughout the state and beyond have participated to date. Project ECHO employs over 40 people to operate the program. Project ECHO receives diverse funding, including federal and state grants and university support. In addi- tion, the state Medicaid program covers half of the administrative costs of teleECHO clinic services provided to Medicaid patients. Project ECHO services are free to primary care providers, although these providers give up their time to train and prepare, which takes them away from seeing additional patients and bringing in revenues. However, Molina Healthcare, one of the state’s four Medicaid managed care health plans, reimburses primary care providers for presenting its Medicaid enrollees to a teleECHO clinic ($150 per patient) and provides $1,500 to some primary care providers to defray the costs of their initial in-person training at UNM. UnitedHealthcare Community Plan, partnered with Tennessee Primary Care Association, Community Health Network, and Meharry Medical Group This model represents a partnership among UnitedHealthcare, one of the three health plans participating in Tennessee’s Medicaid program; the Tennessee Primary Care Association (TPCA), the state primary care association; and Community Health Network (CHN), a coalition of community health centers. In 2009, UnitedHealthcare set out to develop telehealth infrastructure to increase access primarily to behavioral health services, but also to specialty services, for Medicaid enrollees throughout much of this rural state. Through telehealth units set up at approxi- mately 40 primary care sites throughout the state, patients are treated remotely by specialists in nine medical spe- cialty areas at Meharry Medical Group, a multispecialty faculty practice at Meharry Medical College, an academic medical center in Nashville. CHN’s role is largely to install and maintain the equipment and to serve as the schedul- ing hub for telemedicine appointments across sites. TPCA trains the primary care staff and recruits new primary care sites and providers to participate. Funding to support the model flows in multiple ways. CHN had received public and private grants to install most of the telehealth units and establish the processes for using them. UnitedHealthcare paid CHN to install and maintain some additional units and reimburses the Medicaid enrollee’s primary care provider a small amount for initiating a telehealth appointment. UnitedHealthcare and the primary care providers also pay CHN for their role and UnitedHealthcare pays TPCA an annual amount and reimburses Meharry Medical Group for providing the care. Tennessee’s Medicaid program covers services delivered via telehealth. The Meharry specialists dedicate blocks of time to telehealth visits; reportedly, approximately 20 medical specialty referrals are arranged each month. Still, a number of factors have led to excess capacity in the telehealth network, including a high no-show rate, the cost to primary care providers, and primary care providers’ lack of famil- iarity with the equipment and with specialists outside their community. Some of the extra appointment slots are used by uninsured patients and the prison population. 22 Improving Access to Specialty Care for Medicaid Patients: Policy Issues and Options MEMBERS OF THE ADVISORY PANEL Linda Cummings, Director, National Public Health Roger Schwartz, Executive Branch Liaison and and Hospital Institute Associate Vice President, National Association Vice President for Research, National Association of Community Health Centers of Public Hospitals Karin Rhodes, Director, Division of Emergency Care Mario Gutierrez, Executive Director, Center for Policy and Research, Department of Emergency Connected Health Policy Medicine, University of Pennsylvania Margaret Jones, Research Associate/Senior Program Sara Rosenbaum, Professor, George Washington Manager for Evaluation Services, Group Health University, School of Public Health Research Institute, Center for Community Health and Evaluation Linda Shapiro, Vice President, Strategy, Planning and External Affairs, ACCESS Community Health Neva Kaye, Managing Director for Health System Network Performance, National Academy for State Health Policy Bobbie Wunsch, Partner, Pacific Health Consulting Group Margaret Kirkegaard, Medical Director, Illinois Health Connect Hal Yee, Chief Medical Officer, Los Angeles County Department of Health Services Meg Murray, CEO, Association for Community Affiliated Plans www.commonwealthfund.org23 One East 75th Street 1150 17th Street NW New York, NY 10021 Suite 600 Tel 212.606.3800 Washington, DC 20036 Tel 202.292.6700 www.commonwealthfund.org