News

Welcome new staff and interns

CHRT is pleased to introduce its newest hires in finance, data use, and programming. New finance team members will enhance our organization’s ability to conduct financial planning, ensure compliance, and improve operational procedures. New programmatic staff members bring expertise in health information technology, data use, public policy, mental health and substance use disorders, and more. 

Gudrun Bossman

Gudrun Bossmann is a senior financial analyst at CHRT and is responsible for financial planning. She holds a bachelor’s degree, with honors, in international business and management studies from the Hanzehogeschool, Groningen, The Netherlands.

Prior to joining CHRT, Bossmann built up the financial controlling of a media research company in Ann Arbor and managed financial operations for the premium resort sector of Thomas Cook, one of the largest travel companies in Europe.

Ayşe G. Büyüktür

Ayşe G. Büyüktür is a senior research area specialist with the University of Michigan School of Information and holds appointments at the Center for Health and Research Transformation (CHRT) and the Michigan Institute for Clinical & Health Research (MICHR).

Büyüktür first started working with CHRT in 2016 as a consultant for the Livingston – Washtenaw State Innovation Model (SIM) intervention, the predecessor to MI Community Care. She subsequently joined the intervention team in the design, implementation, and operations of the program.

Allison Fritsch 

Allison Fritsch is an intern at CHRT. She is a Master of Public Health and Master of Social Work dual-degree candidate (2022) at the University of Michigan.

Before coming to the University of Michigan in 2020, Fritsch worked in the hospitality industry.

Wendy Hawkins

Wendy Hawkins is a senior health policy analyst at CHRT. She graduated with her master’s in public policy from the University of Michigan Gerald R. Ford School of Public Policy in 2021.

Prior to joining CHRT, Hawkins worked in the harm reduction field in San Francisco and Los Angeles, providing harm reduction materials and support to people who use drugs and those experiencing housing instability. She also provided HIV/STI and Hepatitis C testing and referrals to wraparound services.

Amy Martinez

Amy Martinez is University of Michigan School of Public Health, Future Public Health Leaders Program (FPHLP) fellow, completing her field placement with CHRT. She is currently pursuing her bachelor’s degree in psychology and public health at Williams College, located in Williamstown, MA

Prior to joining CHRT, Martinez served as a public health intern in the Berkshire Area Health Education Center (AHEC) where she helped develop mental health and COVID-related programming for improving healthcare professionals’ relationships with themselves and their patients during and post-pandemic.

Augustina Nguyen

Augustina Nguyen is a University of Michigan School of Public Health’s Future Public Health Leaders Program (FPHLP) fellow. She graduated from Wheaton College in Massachusetts in 2021 with a BA in biology and business management.

Before joining CHRT, Nguyen was a public health intern at the Brigham and Women’s Hospital, doing health equity research and intervention.

Angela Palek

Angela Palek is a senior financial specialist at CHRT. She holds a master’s degree from Michigan State University in higher, adult, and lifelong education and a bachelor’s degree from Central Michigan University in administration, with an emphasis on organizational administration.

She began her career at Eastern Michigan University working for the EMU Wraparound Project which provided wrap around services for at-risk teen parents. While at EMU, she was instrumental in the development of the non-profit student food pantry.

Ivana Tullett

Ivana Tullett is compliance staff specialist at CHRT, with a focus on regulatory data compliance and data privacy. She holds a master’s degree in law from the Charles University in Prague and a master’s degree and research doctorate in law from the University of Michigan Law School.

Prior to joining CHRT, Tullet supported the University of Michigan research enterprise by negotiating data use agreements and coordinating related compliance reviews.

Luoluo Xu

Luoluo Xu is a senior accountant at CHRT, supporting the administrative and business functions. She holds a master’s degree in accounting from Eastern Michigan University.

Prior to joining CHRT, Xu worked as an accountant for MHealthy, which offers U-M faculty and staff a broad range of health and well-being programs, and the U-M Shared Services Center, which oversees a range of human resources and financial administrative functions across the University. 

New CHRT projects focus on integration, learning networks, and social determinants of health

CHRT has launched six new projects over the past few months, including designing a public health and primary care integration demonstration project, participating in a learning action network team to support integrated delivery networks, launching a new practicum and fellowship for Detroit Health Department staff members, and providing training in communicating for policy change to a national network of cancer care organizations.

Integration

Coaching members of a national learning and action network of integrated care delivery leaders

National: Institute for Healthcare Improvement (IHI)

While understanding that the social conditions in which a person lives, works, and plays is critical to health, only 24 percent of hospitals and 16 percent of physician offices report screening patients for social needs. More and more, however, health systems are recognizing the imperative of understanding the social needs of their patients and helping to resolve unmet social needs that directly impact health, well-being, and equity. 

In order to support the journey of these health care organizations, Pfizer is funding work with the national Institute for Healthcare Improvement (IHI) to create a Learning and Action Network. CHRT’s executive director will participate in a multi-disciplinary national faculty team that provides coaching and guidance to competitively selected integrated delivery networks. Read more

Integrating public health and primary care and developing sustainable funding mechanisms for both systems

National: American Board of Internal Medicine (ABIM) Foundation

The lack of connection between primary care and public health has had serious consequences during the COVID-19 pandemic. Public health messages about the measures necessary to keep people safe–masking, social distancing, the need for internal eating closures, and the like–have been highly politicized. But in many communities, it was hard for public health leaders to reach and convince their constituents.

CHRT is working with the American Board of Internal Medicine (ABIM) Foundation to Identify ways to integrate public health and primary care and to develop sustainable funding mechanisms to strengthen both systems. In the first phase of this work, CHRT will focus on key informant interviews with representatives from a range of organizations and entities such as public health and primary care professionals from states with advanced integrated systems and states identified by the National Health Security Index 2020. Read more

Expanding the Home Nutrition+ integrated infrastructure

Regional: Michigan Health Endowment Fund

Several national studies have demonstrated a return on investment for nutrition programs. Specifically, a Commonwealth Fund review identified multiple papers that provide strong evidence that medically tailored meals (MTM) improve outcomes and have a positive return on investment. Furthermore, the Commonwealth Fund found that a community-based care transition program, provided to older adults as part of a combined MTM intervention, saved $3.87 for every $1.00 spent, likely driven by a significant decrease in the 30-day readmission rate in the intervention group.

Vital Seniors Initiative grantees–five social service agencies for which CHRT provides backbone support–are forming a community integrated network with the goal of delivering MTM and coordinated service delivery to clients. The end goal: To more effectively and efficiently serve older adults and individuals with disabilities so they can remain in their community and home of choice. To do this, the network needs to develop a hub model structure, governance, and operations as well as new partnerships to expand the Home Nutrition+ program.

CHRT will provide backbone support to the community integrated network, helping network members develop strategic objectives with existing partners, develop the governance structure required to support expansion, set up the appropriate legal agreements, engage with community-based organizations beyond Washtenaw County, and develop the framework to offer Home Nutrition+ based on the “Food is Medicine” model.

During the first quarter, CHRT will identify potential geographic regions for expansion, conduct an analysis of services and gaps of MTM offerings in those regions, engage with a health plan to support the operational objectives for expansion, and conduct visioning sessions to define mission and execute delivery. During the second quarter of the grant period, CHRT will facilitate governance and geographic expansion decision making, set up legal structure and applicable agreements, and more. Read more

Public Health

Developing and delivering a fellowship and practicum for Detroit Health Department staff

Local: Detroit Health Department

In 2019, CHRT launched the Detroit Health Department Public Health Practice and Policy Engagement Fellowship, training two cohorts of DHD staff in four key areas–systems thinking, communications, policy engagement, and data analytics–so they may ultimately lead collaborative, cross-systems work, eliminating silos and addressing the social determinants of health. A shortened, supplemental virtual fellowship for alumni will continue to elevate their public health skills and professional development experience.

CHRT will lead alumni in a six-session fellowship, covering a host of current policy issues and trends. The alumni fellowship will touch on long-standing, complex issues of public health, many of which have been exacerbated by COVID-19. It will create a space to identify and discuss these dynamic problems and provide tangible ways for fellows to address them and affect change. The fellowship also includes a small-group practicum project, focused on real issues faced within DHD departments. At completion, the fellows will have a fleshed-out plan for improving processes–one that is rooted in systems thinking. Read more

Healthy Aging

Informing the development of Michigan’s statewide LTSS strategic plan

State: Michigan Department of Health and Human Services

In 2019, the Michigan Department of Health and Human Services (MDHHS) engaged in preliminary preparation for strategic planning activities around long-term services and supports (LTSS). MDHHS has now asked CHRT to facilitate a comprehensive process to inform a statewide LTSS strategic plan.

In Phase I, CHRT will review MDHHS work to date and interview key staff. CHRT will then conduct an environmental scan of federal policy and funding changes, both planned and existing, as well as examples of how states are applying these federal changes. CHRT will review best practices on equity initiatives and key LTSS options, then develop a white paper on LTSS options. CHRT will also conduct a series of internal and external key informant interviews, and complete a literature review on home- and community-based services, with high-level recommendations for the state. Read more

Communication for Policy Change

Training members of a national cancer care consortium in communicating for policy change

National: Alliance to Advance Patient-Centered Cancer Care 

The national Alliance to Advance Patient-Centered Cancer Care seeks to ensure that findings from the alliance’s six participating sites and cross-site evaluation–particularly those that demonstrate evidence-based mechanisms for advancing patient-centered care and reducing disparities–reach, inform, and inspire national decision and policy leaders.

CHRT is collaborating with the alliance around communicating for policy change. The focus: Developmental editing, as alliance staff write a policy brief to share with national policy and decision leaders, and webinar development and delivery to help alliance members in several states as they communicate their own findings to policymakers and practitioners. Read more

Special open enrollment period allows Michigan consumers to purchase 2021 health insurance on national ACA marketplace

On January 28th, President Biden signed an executive order to initiate a nationwide special enrollment period and reopen the ACA Health Insurance Marketplace. The Marketplace will reopen from February 15 – May 15, which will give consumers in Michigan (and in 35 other states that use the federal exchange) an additional opportunity to purchase 2021 health insurance coverage amidst the backdrop of the COVID-19 pandemic.

The state of Michigan experienced a 46 percent increase in the number of uninsured adults from February to May of 2020, due in large part to the pandemic.[1],[2] While over 267,000 Michiganders were able to enroll in health insurance plans during the regular 2021 open enrollment period, a 2 percent increase from the 2020 open enrollment period, thousands of Michiganders currently remain uninsured.

Governor Whitmer has announced that the state of Michigan, in tandem with this special enrollment period, will be launching outreach efforts to help uninsured Michiganders learn more about the coverage options available to them. Many uninsured individuals may find that they have subsidies that are large enough to cover the entire cost of a health insurance plan.

For more general information regarding the 2021 Health Insurance Marketplace, including an in-depth rate analysis, see CHRT’s Rate Analysis: 2021 ACA Health Insurance Marketplace for Michigan. To explore health insurance plans available through the Marketplace, visit healthcare.gov.


[1] State Leaders Applaud Biden Administration for Opening Marketplace Special Enrollment Period and Making Medicaid more accessible. (2021, January 28). Retrieved February 11, 2021, from https://www.michigan.gov/som/0,4669,7-192-29943_34759-550797–,00.html

[2] A 46% increase equates to roughly 834,000 Michiganders without health insurance coverage.

Webinar: CHRT Policy Analytics Director Robyn Rontal offers webinar on policy solutions to support family caregivers

In this hour-long webinar by Policy Analytics Director Robyn Rontal, viewers will learn about the current state of informal and family caregiving in the U.S., factors that impact caregiver stress, and a variety of policy solutions to support family caregivers.

Rontal discusses the prevalence of family caregiving and the impact of the COVID-19 pandemic on caregivers and families. She presents research showing that almost 40 percent of caregivers find their caregiving situation to be emotionally stressful, and shares examples of strategies to address these problems with policies at the local, state, and national level.

Listen to Policy solutions to support family caregivers to learn more about ways we can support unpaid caregivers in the U.S.

CHRT is growing: Join us in welcoming new staff

Several new staff members have joined the Center for Health and Research Transformation. They bring expertise in pay for success financing, evaluating case management interventions for superutilizers, recovery-oriented communities, integrative approaches to health disparities, program evaluation and improvements, and more. Please join us in welcoming them to the team.

Ryan Bartholomew is an analyst at CHRT. He manages CHRT’s Health Policy Fellowship and provides analysis of issues and trends in health policy. Prior to joining CHRT, Ryan worked as a research intern for Michigan’s Children, an independent organization that works to promote public policies in the best interest of the children and families of Michigan. He has also worked as an AmeriCorps VISTA member at the United Way of Southeastern Michigan, an Office of Presidential Correspondence intern in the White House, and as a political department intern at the Democratic National Committee. Ryan holds both bachelor’s and master’s degrees in public policy from the Gerald R. Ford School of Public Policy at the University of Michigan.

Matthew Hill is a program manager for the Center for Health and Research Transformation. He manages all Substance Use Disorder (SUD) and Mental Health related programs that fall under the Washtenaw Health Initiative (WHI). In doing so, Matthew supports the WHI Opioid Project, a community based coalition that aims to help address the opioid epidemic locally, as well as the Washtenaw County SUD System Transformation Initiative. Prior to joining CHRT, Matthew managed the Washtenaw Recovery Advocacy Project, a recovery community organization that worked to eliminate the stigma surrounding SUD, provide community education, and create a recovery oriented community in Washtenaw County. Matthew holds a bachelor’s degree in biopsychology, cognition, and neuroscience from the University of Michigan.

Samantha Iovan is a senior analyst at CHRT and will be supporting the Washtenaw Health Initiative UNITE Group and Medicaid and Marketplace Outreach and Enrollment (MMOE) Group. Prior to joining CHRT, Samantha worked as a project manager in the Department of Emergency Medicine at the University of Michigan. There, she oversaw health services research projects focused on addressing cardiac arrest outcomes in the state of Michigan and improving care coordination and patient-centered care. Before joining Michigan Medicine, Samantha managed multiple population health policy projects at the University of Michigan Ford School of Public Policy. She led data collection and analysis efforts to understand Pay for Success (PFS) financing models and interventions to address superutilizers of acute care. Samantha holds a master’s degree in public health from Wayne State University and a bachelor’s degree in philosophy from the University of Michigan.

Myra M. Tetteh is a senior analyst at CHRT. She provides project management to the Vital Seniors Initiative, a convening of multiple organizations in Washtenaw County creating actionable solutions to problems faced by seniors and their caregivers. Prior to joining CHRT, Myra worked with the Blue Cross Blue Shield of Michigan Foundation where she developed program evaluation measures for grantees, wrote and reviewed requests for proposals, and revamped multiple award programs. She also worked as a program coordinator on the translation of physical science to urban community audiences at two federally-funded research centers, Michigan Center on Lifestage Environmental Exposures and Disease (M-LEEaD) and the Michigan Center for Integrative Approaches to Health Disparities (CIAHD). In addition, Myra formerly served as the public health policy analyst at the Detroit Health Department where she coordinated multiple projects, including work on food systems and the built environment. Myra holds a doctorate in public health from the University of Michigan School of Public Health, a master’s degree in public policy from the University of Michigan-Dearborn, and a bachelor’s degree in political science and sociology from the University of Michigan-Ann Arbor.

John Tsirigotis is a healthcare analyst at CHRT.  He performs data analysis and conducts research regarding health care trends in Michigan and across the nation. Prior to joining CHRT, John worked as a survey specialist with Wolverine Pathways, a University of Michigan outreach program that serves middle school and high school students throughout Michigan that hope to attend the University. In this role, he created surveys that were used for data collection and analysis in evaluating the efficacy of the program. Before moving to Michigan to attend graduate school, John served as a middle school math teacher in New Orleans, Louisiana for three years. John holds a master’s degree in program evaluation and improvement research from the University of Michigan’s School of Education and a bachelor’s degree in philosophy, with a minor in mathematics, from Lafayette College in Easton, PA.

Nine lessons for the leaders of health and human services integration initiatives (and for the grantmakers that want them to succeed)

In Health Affairs’ GrantWatch column, Marianne Udow-Phillips, Kathryne O’Grady, and Phyllis Meadows share Nine lessons for the leaders of health and human services integration initiatives (and for the grantmakers that want them to succeed).

“Collectively addressing the environmental and social factors that influence health, a process known as health and human services integration, is not a new concept in the United States, but our understanding of the value of integration is far ahead of our implementation of integration,” they write. “Visionary leaders have shown that real integration is possible, that integration can effectively diminish health disparities, and that community life—and human lives—are better off when it can be achieved. Yet, significant barriers continue to stand in the way of integration, including isolated government departments, data systems that rarely “speak” to each other, and siloed funding sources—all of which have emerged organically over many years.”

To better understand the current state of health and human services integration across the United States, the Kresge Foundation and the Center for Healthcare Research and Transformation (CHRT) at the University of Michigan embarked on an exploration of integration efforts across the country. they tracked the goals of these initiatives; the groups, systems, and programs that had been integrated; the factors that proved critical to success; the outcomes for those who are the most vulnerable (populations such as youth at risk, seniors, and those living in poverty); and, importantly, they recorded the challenges and lessons learned along the way.

Read more at Health Affairs.

Rising Deductibles and the Underinsured

Co-authors

  • Leah Corneail, Health Policy Analyst and CHRT Policy Fellowship Program Manager
  • Josh Fangmeier, Senior Health Policy Analyst

November 1st of this year marked the beginning of the Affordable Care Act’s third marketplace open enrollment period. As consumers, health plans, and exchanges prepared for open enrollment, much of the current health policy debate shifted from reducing the number of uninsured Americans to how best to manage the growth in out-of-pocket expenses. In September, the Kaiser Family Foundation/Health Research & Education Trust 2015 Employer Health Benefits Survey found that the average deductible for covered workers increased 67 percent since 2010, significantly more than the increase in both premiums and wages. According to the Health Care Cost Institute, average out-of-pocket spending was $810 per person with employer-sponsored insurance in 2014.

These trends have prompted presidential candidates Hillary Clinton and Bernie Sanders to make cost-sharing controls a priority. Clinton recently proposed required coverage for three physician office visits per year without cost-sharing, a new limit on out-of-pocket spending on certain drugs, and tax credits for consumers with high out-of-pocket spending relative to income.

Consumers who experience large out-of-pocket costs are often considered to be “underinsured,” since their insurance coverage may not provide adequate protection from large medical expenses. The Commonwealth Fund defines the underinsured through two income thresholds: residents with health insurance in families below 200 percent of the federal poverty level (FPL) with out-of-pocket medical spending (excluding premiums) that exceed 5 percent of family income; or, 10 percent if family income is above 200 percent of FPL.

In August 2015, at the Center for Healthcare Research and Transformation (CHRT), we published an issue brief that provided baseline characteristics of Michigan’s underinsured population in 2013, just prior to the ACA’s coverage expansion. To measure underinsurance, we used the Commonwealth Fund definition and found that more Michiganders were underinsured (1.2 million) than uninsured (1 million) in 2013, and underinsurance was concentrated in certain populations, particularly low-income residents and those with certain forms of health insurance. Among those with private insurance, the underinsurance rate was nearly four times greater for those who directly purchased coverage on the individual (private, non-group) market as those enrolled in group coverage through an employer.

Challenges of Measuring Underinsurance

Compared to tracking the number of uninsured Americans, underinsurance is a difficult concept to define and measure. High levels of predictable out-of-pocket spending may be a financial burden for insured individuals, but it may not be a sign of too little insurance, since the purpose of insurance is to reduce the economic risk of catastrophic health shocks. Focusing on financial burden, people with health insurance could be considered underinsured if they require services not covered by their plan; forgo necessary care due to the co-pays and deductibles they would face; or if they experience high out-of-pocket costs for the care they do receive. The definition used by the Commonwealth Fund and CHRT only takes the last of these situations into account when measuring underinsurance. The Commonwealth Fund’s two-tiered threshold to determine underinsurance does take into account the consideration that a higher percentage of income going towards medical bills may be less burdensome for higher income individuals. However, it does not adjust for the economic risk insured individuals may face or account for individuals who forgo necessary care due to high cost-sharing.

Surveys indicate that nearly 20 million insured individuals in 2012 did not receive or delayed seeking medical care within the year due to costs. While some of this population may have also experienced large out-of-pocket spending, only measuring out-of-pocket costs relative to income leads to conservative underinsurance estimates. In addition, some insured individuals experience the combination of high out-of-pocket costs and delayed necessary care. In a 2014 survey, the Commonwealth Fund found that about one-quarter of underinsured adults reported having to change their way of life to pay medical bills, and underinsured adults were twice as likely to report not getting needed care because of cost in the past year, compared to adequately insured adults. While high medical spending can cause financial difficulties for consumers, forgone care is also an important issue to understand and measure.

Among the underinsured identified in our study, half were enrolled in employer-based coverage, but a substantial share had public insurance and were not subject to the rising deductibles of private coverage. For example, we found that almost 25 percent of Michigan residents enrolled in either Medicaid or the Children’s Health Insurance Program (CHIP) were in underinsured families in 2013. On its face, this is a surprising result, since federal Medicaid law limits beneficiary premiums and out-of-pocket spending to 5 percent of family income (effectively below the underinsured definition). While the complete explanation for this finding is not clear, there are multiple factors that likely contributed, including Medicaid benefit caps or other coverage limitations and mixed sources of coverage in low-income families.

For example, half of the Medicaid/CHIP beneficiaries who were underinsured in 2013 had at least one family member not covered by Medicaid/CHIP. This means that while one person in a family may be enrolled in Medicaid/CHIP, other family members were either uninsured or had another form of health insurance. Thus, while the Medicaid beneficiary in the family had financial protection in the form of the 5 percent cap on out-of-pocket spending, other family members may have had deductibles and other medical costs that were high enough compared to total family income that the whole family was considered underinsured. Notably, the Medicaid underinsured population we observed was before implementation of ACA’s Medicaid expansion in Michigan with its own explicit cost-sharing requirements approved through a federal waiver. Due to these circumstances, it is not clear how comparable underinsurance is for the publicly and privately insured.

Opportunities for Further Research

More than 17 million people have gained insurance since the ACA’s coverage expansions took effect in 2014. The ACA includes several provisions designed to help reduce consumer out-of-pocket spending, including cost-sharing reductions for low-income marketplace enrollees, maximum out-of-pocket spending caps on most private insurance plans, and first-dollar coverage for certain preventive services. It is too soon to understand how the ACA will affect underinsurance among both newly and previously insured individuals, but the continued growth in employer-sponsored deductibles likely means that the issue of underinsurance will not go away anytime soon.

As out-of-pocket spending continues to grow, there are certainly opportunities for researchers to develop more comprehensive and nuanced definitions of underinsurance to better examine the challenges and characteristics of this population. Not all underinsured residents are the same or experience the same degree of hardship, so it would be helpful to identify various degrees of underinsurance. This distinction could recognize how the underinsured experience can vary by source of insurance coverage and other characteristics, similar to how researchers on uninsurance developed distinctions between the short-term and long-term uninsured.