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CHRT is growing: Join us in welcoming new staff

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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)

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Diagram of a straight line vs a diagram of a tangled ball of a line

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

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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.