California is one of several states that prepared for health care reform for years before the Affordable Care Act rolled out in 2014. A new study by the UCLA Center for Health Policy Research suggests that the early rollout has had some striking results.
The state was awarded $3.3 billion in federal funding to bolster their Medicaid program, the federal health insurance program for low-income people (called Medi-Cal in California), between late 2010 and the end of 2015. The Medi-Cal funds were divided among 17 health care systems operated by either county health departments or the University of California, and used to establish new practices for better patient care. Since then, the overall mortality rate among sepsis patients at public hospitals decreased by nearly 20 percent and the stroke mortality rate by nearly 40 percent, according to data reported by the hospitals.
The hospitals and clinics that received the grant money agreed to improve their outpatient services and urgent care, redesign inpatient care delivery in at least two areas, improve the quality of care for patients with HIV or AIDS, and improve the overall health of their patients.
One of the goals of the ACA has been to move providers toward a system of value-based care – essentially providing extra incentives to ensure that patients receive better coordinated care delivery. It has done so by fostering the creation of accountable care organizations and bundled payment initiatives to reduce the costs of expensive procedures such as joint replacement surgeries, among other initiatives.
Some county departments were also able to completely revamp their delivery of outpatient primary care by assigning Medi-Cal patients in their system to a team of caregivers that included a primary care physician and staff coordinating their care.
A few of the larger providers participating in the waiver received $100 million or more annually during the five years. That inflow of cash helped marshal resources, according to Nadereh Pourat, director of research at the UCLA center and leader of the evaluation project.
“They were able to hire new staff, train new staff and get buy-in from providers,” she said. “The money made it a lot easier to get everyone motivated.”
UCSF Health, which received $110 million in federal funds, created a surveillance algorithm within its electronic medical record system that alerts both nurses and doctors if there are warning signs of sepsis in patients. The condition can cause systemic organ failure and is deadly in about 50 percent of all cases if it’s not detected in its earliest stages. The new system enabled UCSF to cut its sepsis mortality rate from 27 percent to 18 percent, a drop of one-third during the waiver, a reduction of more than one-third following the bump in funding.
Neighboring San Mateo County, which operates a 228-bed hospital, received about $70 million. The hospital cut its sepsis mortality rate in half, from 58 percent to 29 percent. According to San Mateo County Chief Medical Officer Susan Fernyak, the hospital screened every new admission and every patient in the intensive care unit to evaluate their sepsis risk. Appropriate testing and care was ordered if a patient was considered at risk for developing the condition.
San Mateo County also used a share of the funds to convert their outpatient clinics into patient-centered medical homes, ensuring coordinated care. San Mateo County placed 45,000 residents into medical homes, Fernyak said.
The Los Angeles County Department of Health Services – the largest public health system in California with four hospitals and 19 outpatient health care centers – took the medical home concept even further. It used part of the $1.1 billion it received to place 450,000 patients into medical homes. Each patient’s care is supervised by a nurse care manager, a nurse care coordinator and certified medical assistant. Communications about each patient take place within an electronic messaging platform that records any care they receive directly into the county’s EMR system.
L.A. County had “no primary care infrastructure, no EMR system, no disease registry…we didn’t have anything,” said Christina Ghaly, the system’s chief operations officer. “When you send the patients to primary care, the whole point is continuity.”
L.A. County also created a medical home specifically for patients who are HIV-positive or have AIDS. Nearly a third of those patients had formal care plans in place by the end of the evaluation period, nearly every patient was being screened for hepatitis B (about 10 percent of HIV patients also have hepatitis B), and 80 percent of patients were undergoing smoking cessation counseling (HIV/AIDS patients are at higher risk of smoking-related strokes and heart attacks than the general population).
The providers receiving additional funds also made gains in population health, but they were uneven. More than half of the patients in the public health systems were counseled on tobacco cessation by the end of the waiver, up nearly 50 percent prior to the waiver and triple the national rate. But the rates of diabetic patients whose blood was being closely monitored did not budge, nor did the rates of monitoring for hypertension.