Cost Analysis and Policy Implications of a Pediatric Palliative Care Program.

CONTEXT: In 2010, California launched Partners for Children (PFC), a pediatric palliative care pilot program offering hospice-like services for children eligible for full-scope Medicaid delivered concurrently with curative care, regardless of the child's life expectancy. OBJECTIVES: We assessed the change from before PFC enrollment to the enrolled period in 1) health care costs per enrollee per month (PEPM), 2) costs by service type and diagnosis category, and 3) health care utilization (days of inpatient care and length of hospital stay). METHODS: A pre-post analysis compared enrollees' health care costs and utilization up to 24 months before enrollment with their costs during participation in the pilot, from January 2010 through December 2012. Analyses were conducted using paid Medicaid claims and program enrollment data. RESULTS: The average PEPM health care costs of program enrollees decreased by $3331 from before their participation in PFC to the enrolled period, driven by a reduction in inpatient costs of $4897 PEPM. PFC enrollees experienced a nearly 50% reduction in the average number of inpatient days per month, from 4.2 to 2.3. Average length of stay per hospitalization dropped from an average of 16.7 days before enrollment to 6.5 days while in the program. CONCLUSION: Through the provision of home-based therapeutic services, 24/7 access to medical advice, and enhanced, personally tailored care coordination, PFC demonstrated an effective way to reduce costs for children with life-limiting conditions by moving from costly inpatient care to more coordinated and less expensive outpatient care. PFC's home-based care strategy is a cost-effective model for pediatric palliative care elsewhere.

One-stop shopping: efforts to integrate physical and behavioral health care in five California community health centers.

More than 70 percent of behavioral health conditions are first diagnosed in the primary care setting. Yet physical and behavioral health care are typically provided separately, compelling many vulnerable patients to navigate the complexities of two separate systems of care. This policy brief examines five community health centers (CHCs) in California that have taken preliminary steps toward creating "one-stop shopping" for both physical and behavioral health care. The steps taken to increase integration by the CHCs include employing behavioral health providers, using a single electronic health record that includes both physical and behavioral health data, transforming the physical space, and developing mechanisms for effective transition of patients between providers. The findings emphasize the importance of changes to Medi-Cal reimbursement policies to promote same-day visits, as well as the importance of cultural changes to integrate behavioral health. They also highlight the need for comprehensive tools to assess and promote integration and to identify solutions for the most challenging activities required to achieve full integration.

Ready for ACA? how community health centers are preparing for health care reform.

Community health centers (CHCs) are a cornerstone of the health care safety net. They are the primary source of care for many low-income populations, including both those newly insured under the Affordable Care Act (ACA) and those who were left out and will remain uninsured. The ACA provides challenges and opportunities for CHCs, which will require significant changes in infrastructure and care delivery approaches to meet those challenges. This policy brief assesses the progress made by CHCs in Los Angeles County in meeting a number of key indicators of ACA readiness in early 2014. The authors find that 39 percent of CHCs are well prepared, 23 percent have made some progress, and the rest are at the initial phases of preparation and/or lack adequate resources to meet the requirements. The latter group of CHCs require help to embark on strategic improvements in infrastructure and care delivery.

Assessing health care services used by California's undocumented immigrant population in 2010.

Undocumented immigrants were excluded from the health benefit Marketplaces created by the Affordable Care Act partly because of claims that they contribute to problems such as high costs and emergency department (ED) crowding. This article examines the likely health care use and costs of undocumented immigrants in California in 2009-10. Using data from the 2009 California Health Interview Survey (CHIS), we developed a model that estimated the state's adult and child undocumented immigrant population, since the survey does not explicitly inquire about undocumented status. The survey also provided information on insurance status, doctor visits, and ED visits in the previous year. We found that undocumented immigrants in California, and the uninsured among them, had fewer or similar numbers of doctor visits, ED visits, and preventive services use compared to US citizens and other immigrant groups. Allowing undocumented immigrants to purchase insurance in the Marketplaces and ensuring receipt of low-cost preventive services can contribute to lower premiums and reduce resource strains on safety-net providers.

Limited English proficient HMO enrollees remain vulnerable to communication barriers despite language assistance regulations.

HMO enrollees with limited English proficiency, and particularly those in poorer health, face communication barriers despite language assistance regulations. More than 1.3 million California HMO enrollees ages 18 to 64 do not speak English well enough to communicate with medical providers and may experience reduced access to high-quality health care if they do not receive appropriate language assistance services. Based on analysis of the 2007 and 2009 California Health Interview Surveys (CHIS), commercial HMO enrollees with limited English proficiency (LEP) in poorer health are more likely to have difficulty understanding their doctors, placing this already vulnerable population at even greater risk. The analysis also uses CHIS to examine the potential impact of health plan monitoring starting in 2009 (due to a 2003 amendment to the Knox-Keene Health Care Services Act) requiring health plans to provide free qualified interpretation and translation services to HMO enrollees. The authors recommend that California's health plans continue to incorporate trained interpreters into their contracted networks and delivery systems, paying special attention to enrollees in poorer health. The results may serve as a planning tool for health plans, providing a detailed snapshot of enrollee characteristics that will help design effective programs now and prepare for a likely increase in insured LEP populations in the future, as full implementation of the Affordable Care Act takes place over the next decade.