Q&A with Dr. Howell

One Year In:
A conversation with three grantees working to reduce health disparities through payment and delivery system reform.

Icahn School of Medicine at Mt. Sinai Hospital

“The mission bonds people together—from the social worker and community health worker to non-project staff, psychiatrists and others who are interested in helping this patient population.” — Elizabeth A. Howell, MD, MPP, System Vice Chair for Research in the Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine, Mount Sinai Hospital

The Mount Sinai Hospital partners with Healthfirst, a Medicaid managed care organization, to target disparities in postpartum care for low-income patients, using social workers and care coordinators who help patients get connected with care and manage their chronic conditions; financial incentives for measures like timely follow-up; and non-financial incentives including clinician education and performance feedback.

At one year in, Scott Cook, PhD, Deputy Director of Finding Answers, asked Principal Investigator Elizabeth A. Howell, MD, MPP, System Vice Chair for Research in the Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine, Mount Sinai Hospital, to take stock of the group’s progress and offer some early observations and lessons learned.

In the winter of 2015, three very different health care providers partnered with payers to take up the challenge of reducing health and healthcare disparities among their patient populations. One, based in Oregon, aimed to improve oral health in low-income children and pregnant women. Across the country in New York City, a hospital is working to increase post-partum care for low-income women to change the trajectory of their long-term health. A third, in Fairfax County, Virginia, targets the uninsured to improve patient care management for cervical cancer screening, diabetes and hypertension.

With the support of grants and technical assistance from Finding Answers, a national program of the Robert Wood Johnson Foundation, these payer and provider partners, include  private care providers, county government and a Medicaid managed care organization, are working together to create unique models tailored to their patients’ needs. 

Dr. Cook:  I have to assume that you were extremely busy before taking on the challenge of designing and implementing a new payment and delivery system to address health disparities. What drove you to take it on?

Dr. Howell: I study racial and ethnic disparities in my field, and this topic is very important because racial and ethnic minority women are more likely to have comorbidities and adverse outcomes and to develop chronic diseases. The time of pregnancy is a window when there is an opportunity to change the trajectory—it’s an underlying theme of what I do.

Dr. Cook:  You all are dealing with very different patient populations. What would you say is universal and what is distinctive about them?

Dr. Howell: We’re working with a low-income Medicaid Managed Care population, and our racial and ethnic group is quite diverse—66 percent Latina and 25 to 28 percent African American. It represents a population generalizable to other urban locations (although you have to speak English or Spanish to be in our study). New York City is unique in that the proportion of women born outside the U.S. is very high—35 to 40 percent. 

Dr. Cook: What are your specific goals? How will you measure success?

Dr. Howell: Disparities exist in receipt of postpartum care exist between women insured by Medicaid Managed Care and those who are privately insured. Nationally, about 80–85 percent of commercially insured mothers attend their postpartum visits, versus approximately 50 to 60% percent of mothers insured by Medicaid or Medicaid Managed Care. In addition, lower-income women are more likely to have postpartum complications and to develop chronic illness later in life.

The gap has social and behavioral factors, as well as health services and systems factors, and it’s difficult to quantify the contributions of each. One thing we know is that if you reduce the barriers for women to get to the doctor, you’re more likely to be successful. We’re trying to tackle it on both sides: educating women about the health risks and the importance of postpartum care and providing financial incentives to providers to do the right thing and get the patient to return for care. We’ve offered non-financial incentives like clinician education, and provided a social worker and care manager to reduce the burden of the work. Now we’re offering small financial incentives to the clinicians who see these mothers and they receive a very small bump in payment if a visit is completed. Our postpartum visit rate is up to 71 percent now. Our goal is 75 percent.

Dr. Cook: So how’s it going? What lessons have you learned from getting the project off the ground?

Dr. Howell:  We’re seeing a lot of buy-in. The mission bonds people together—from the social worker and community health worker to non-project staff, psychiatrists and others who are interested in helping this patient population. A lot of women are engaged and interested. The challenge is that there are so many competing demands for these women, both in the hospital and when they get home. They have a lot of other responsibilities. We try not to burden them and we make every effort to contact them when it is convenient for them.  It matters who’s communicating the intervention to patients—the people aspect cannot be underestimated. When you get a person who really cares, it helps you to connect with patients. A lot of our patients like having the opportunity to reflect on their care and how they’re feeling.

Also, we’re pleased with the increase in postpartum visit rates but we want to tease out the system factors that go beyond the healthcare delivery changes, such as scheduling, staffing and billing issues. For example, it was a complex process to set up protocols for implementing new procedure billing codes related to the incentive payments, and to then track the incentive payments as they came in and direct them to individual providers.  It was even more challenging because we were going through a merger at the same time.

Dr. Cook: What would be your advice to other providers and payers who want to try an integrated payment and delivery system reform program to reduce health disparities?

Dr. Howell:  One part of the project is usually easier to handle and rolls out more smoothly than the other part. Be prepared and think ahead about the challenges you might face and what you can do to prevent them. Our delivery and enrollment has gone well, but the payment reform aspect has been more challenging to figure out and make sure it gets done.

Clinicians want to do the right thing, so if you support them by giving them the tools and taking those extra steps, it’s more likely to happen. For us, the tools that were most appreciated by the clinicians were the social worker and care manager who provided education to the patients, connected patients with community resources, and called the patients to check in.