MRT Innovations in Social Determinants of Health Initiative

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NYC Department of Health and Mental Hygiene

Q1 Please provide your contact information below.

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Q2 Please describe your company or organizations overall goals and mission.

The New York City Department of Health and Mental Hygiene (NYC DOHMH) is one of the largest public health agencies in the world. We´re also one of the nation´s oldest public health agencies, with more than 200 years of leadership in the field. Our mission is to protect and promote the health of more than 8 million diverse New Yorkers. NYC DOHMH´s Bureau of Environmental Surveillance and Policy (BESP) collects and utilizes a number of local data sources to inform environmental health policy, conducts health research, and tracks and reports on environmental conditions, exposures, and related health effects in NYC. In collaboration with multiple city agencies, we also develop interventions to prevent or minimize weather–related health impacts in vulnerable communities through targeted outreach and the advancement of climate change health adaptation strategies.

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Q4 Innovation Executive Summary. Please describe the innovation, and how it addresses the social determinants of health. Please identify how the innovation addresses the 6 innovation criteria (i.e. ROI, scalability, feasibility, evidence–based support for innovation, relevance to the Medicaid population and speed to market).

An estimated 20% of people using Medicaid in New York City (NYC) do not have air conditioning (AC) (1). A subset of these individuals are at very high risk of heat–related illness (HRI) or have conditions that can be exacerbated by heat or make it difficult for the body to respond to heat, including renal disease, cardiovascular disease, diabetes, and diseases of the respiratory system; individuals who are older, have certain severe mental health conditions (such as schizophrenia), or have limitations in mobility are also at high risk of heat–related illness (2–5). The provision of AC via Medicaid is a lifesaving necessity as the climate of New York State (NYS) is warming (6).

In this innovation proposal, we are presenting the provision of AC as an innovation that can prevent hospitalizations triggered by extreme heat. More specifically, we encourage Managed Care Organizations (MCOs) and Value Based Payment (VBP) contractors to leverage their access to historical claims data to identify need of AC among Medicaid enrollees with disease profiles described by the World Health Organization (WHO) Europe in its guidance to prevent the health effects of heat (22) who have been hospitalized during previous warm seasons. The MCO or VBP contractor could ensure access to AC to these patients through assistance in obtaining the Home Energy Assistance Program (HEAP) Cooling Assistance benefit, or directly purchasing AC units for individuals not eligible for HEAP and by providing heat–sensitive patients with financial assistance to pay for the added energy costs to use air conditioning on hot days.

Providing AC through Medicaid will address the following innovation criteria, described below.

Rationale
In New York State (NYS) and across the United States, extreme heat kills more people on average than any other extreme weather event (7). In 2013, NYS ranked second nationally for the number of deaths resulting from extreme heat (8). Heat exposure can result in deaths directly via hyperthermia or indirectly through exacerbation of existing chronic conditions (9, 10). From 2002 to 2012 in NYS, ~4,600 hospitalizations and ~21,300 emergency department visits occurred for heat–related illness (11). Each year, NYC has an average of ~450 emergency department visits and 150 hospital admissions for heat–related illness, as well as 13 heat stroke deaths and 115 excess deaths from natural causes associated with extreme heat (2, 12). In addition, throughout the state, on hot days there are increases in hospitalizations for certain chronic conditions, including cardiovascular, respiratory, and renal illnesses, that are exacerbated by heat but do not have HRI codes in the claim (13, 14).

Contrary to popular belief, most heat–related deaths in NYS and NYC occur after exposure to heat inside homes without AC, rather than outside in the sun (2, 11). In fact, indoor temperatures can be several degrees hotter than the outdoor temperature without the benefit of AC (15). The New York State HEAP Cooling Component benefit provides qualifying NYS residents with assistance to purchase and install AC. This assistance, however, leaves important gaps. People receiving any type of government–subsidized housing assistance – including Medicaid beneficiaries – do not qualify for HEAP. In addition, HEAP does not provide assistance for electricity costs associated with operating AC on hot days.

We propose that VBP contractors and/or MCOs prevent emergency department (ED) visits and [re] hospitalizations by:

1. Identifying patients hospitalized in previous warm seasons (May–September) who have clinical profiles matching the WHO’s description for high risk of heat–related illness and exacerbations of diseases (22);
2. Determining those who lack home AC and whether they qualify for HEAP; and
3. If beneficiaries do qualify for HEAP, assisting them in applying for HEAP Cooling Assistance benefit; or
4. If beneficiaries do not qualify for HEAP, purchasing and installing the AC (plus providing an energy subsidy, if needed) prior to the start of the warm season (May–September).

Evidence–based support for innovation
As stated above, extreme heat kills more people on average than any other extreme weather event both in the state and across the country (7). Financial costs are major challenges to owning and operating AC (16). Poor, low–income communities of color are disproportionately at–risk for heat–related deaths and illness (17). AC use is the most effective way to prevent heat illness and heat– related exacerbations of chronic physical and mental health conditions (18, 19). Healthcare costs associated with heat–related illness can be significant, especially if the patient is admitted into the hospital (20, 21).

Evidence, including formal guidance from the WHO Europe to clinicians, shows that those with pre–existing conditions such as cardiovascular disease, respiratory conditions, renal disease, diabetes or obesity, substance use/dependency, and mental health conditions are some of the populations most at–risk for heat–related morbidity and mortality (2–5, 22). From 2008–2011, 85% of heat stroke decedents in NYC were exposed in un–air–conditioned homes (2, 12). Among decedents for whom information was available, none had working AC in their home. New Yorkers most at risk for illness and death from heat exposure are those without a working AC AND who have at least one of the following health risk factors: older adults aged 65+, chronic health conditions, serious mental illness, use of drugs or excessive alcohol use, or who are on medications that make it harder to maintain normal body temperature (2, 12).

Potential Return on Investment (ROI)
We propose AC as a cost–effective measure to prevent illness and reduce costly hospital utilization, as well as reducing preventable heat–related deaths. In the MLTC population, AC should be provided as part of the care plan as a Social and Environmental Modification benefit to any individual with the disease profile described in WHO Europe Guidance; and for those not in MLTC, we encourage VBP contractors and MCOs to include it in a VBP strategy.

Although risk is generally highest among older adults, younger adults with certain comorbidities have elevated risk as well. Preliminary analyses of NYS hospitalization billing data (NYS Statewide Planning and Research Cooperative System) for patients at highest risk of heat–related disease exacerbation and illness suggest the potential for positive Return on Investment of an AC intervention for at least one high–risk subset of individuals. Approximately 2,500 patients aged 45–64 were hospitalized during the warm months of 2012–2015 in NYC hospitals with diagnoses of mental health (MH) conditions and either chronic kidney disease (CKD) or acute renal failure (ARF).

Analyses demonstrate an increased risk of re–admission for MH and either CKD or ARF on the hottest days (defined as 90° F or higher) in warm season months (May–September). Among the universe of patients with chronic conditions known to be associated with heat – e.g., heart disease, respiratory, renal, and mental health conditions – being readmitted for the highest–risk, target conditions of MH with either CKD or ARF was 8% greater on hot (90°F+) compared to cooler days in the warm season.

In addition, data suggest that extreme heat may be influencing the re–admission rate for individuals 45–64 years old who have been hospitalized with a MH and CKD/ARF diagnoses. In NYC every day of the warm season from 2012–2015, there was an average of 6.1 hospital admissions of individuals aged 45–64 with MH and CKD/ARF diagnoses. Throughout the warm season, about 29% of these cases had a 30–day re–admission for a condition potentially associated with heat, such as cardiovascular disease (CVD), respiratory, renal or mental health conditions. The number of these 30–day re–admissions occurring on hot days (90° F or higher) was 31% greater than expected, compared to typical days in the warm season.

During the study period, the average charge was $55,200 for re–hospitalizations among those with this disease profile on hot days. Assuming a 50% cost to charge ratio and a cost of AC intervention of $600 per individual ($400 AC unit with installation and $200 energy cost subsidy), an MCO or VBP contractor could provide 46 ACs to individuals who lack an AC at home and an energy subsidy to help with an increased electricity bill for the same cost as one admission. A neutral ROI would be realized if it saves even one new hospitalization during the 30–day period or any subsequent warm season, and a positive ROI if additional hospitalizations are avoided. Furthermore, for individuals who already have an AC or who qualify to receive an AC through HEAP, the intervention cost would be much lower because it would be limited to assistance with energy costs.

Scalability
This innovation is readily scalable. Case managers and health educators can provide education to the member about the need to have AC in order to prevent heat–related exacerbation of their existing condition(s); and the delivery and installation of AC can be done using retailers such as PC Richards, Amazon, Durable Medical Equipment providers, or AC–vendors who are approved by the NYS Office of Temporary Disability and Assistance Home Energy Assistance Program (HEAP) Cooling benefit. Payers, such as Wellcare MLTC, have already established mechanisms for assessing the need and providing coverage for AC which can be used as models to scale up the project (direct communication). Self–evaporating portable AC should be considered for individuals who cannot install window ACs due to building regulations, limited space or other reasons, and subsidies for energy assistance should be provided for individuals who would be unable to afford the spike in energy bill.

Feasibility
All components of the intervention leverage existing infrastructure. WHO has issued guidance on the disease conditions and medications that place individuals’ health at high risk of heat–related illness and exacerbations of diseases (22). Health plans have access to historic claims data to proactively identify potential beneficiaries in order to prevent repeat visits/hospitalizations; they also may have health educators and case managers on staff who can outreach to members for whom an AC could result in reduced ED visits and hospitalizations during warm weather. The MLTC plans (as part of their social and environmental support benefits) and some health systems have created the infrastructure to provide and install AC to their members. The existing infrastructure of AC vendors can be leveraged to provide and install AC. This AC intervention provides an opportunity for MCOs and other VBP contractors to address their Social Determinant of Health requirement. Depending on the co–morbidities of the individuals, the AC intervention can result in a major return on investment in a relatively short period of time, as described above.

Oregon’s Coordinate Care Organizations (CCOs) provide an example of how Medicaid accountable care organizations can implement this (direct communication). In 2013 Oregon passed the "Air Conditioning Bill", which provides payments for nontraditional health services and ambulatory service centers. This bill gave the Oregon Health Authority the ability to set up codes to bill non–medical expenses (including AC) for patients on Medicaid to emphasize low–cost preventative measures that reduce overall expenditures (23). CCOs must maintain a certain "Medical Loss Ratio" of medical costs vs administrative costs. Flexible services fall under medical costs as long as they meet the Code of Federal Regulations (CFR): "Activities that improve health care quality". An analysis comparing Medicaid expenditures in Oregon and Washington (two states with similar patient demographics) found that Oregon’s reform to CCOs and a global budget were associated with a reduction in Medicaid expenditure. The 7% relative reduction across the sum of CCO services mostly came from reductions in inpatient utilization, avoidable emergency department visits and improvements in measures of appropriateness of care. The process for coverage of nontraditional services is standardized throughout the state. A provider completes a form, which is similar to that required for conventional medical expenses, and also submits medical records and a justification for the request. Once the documents have been submitted by the provider to the CCO, it is reviewed using a set of criteria by a team of physicians, nurses, social workers, and psychosocial specialists.

Relevance to the Medicaid Population
Access to AC is a matter of health equity and social justice. Medicaid is a safety net assistance program that is the primary source of health care for those living in poverty including older adults, people with disabilities, and children. Poverty strongly shapes who has access to AC and who does not. In NYC, 10% of households do not have AC, but a fifth of those with Medicaid coverage lack AC. Neighborhood–level disparities in access to AC also point to poverty as a contributor to inequitable AC access. In neighborhoods with high poverty, 18% of households do not have AC. This is three times more than low–poverty neighborhoods, where only 6% of homes do not have AC (24).

Lack of access to AC will only increase health vulnerabilities in a changing climate. Both NYC and NYS are projected to have higher average daily temperatures and more frequent, sever, and longer extreme heat events in the future. NYS Medicaid has already recognized the importance of AC for its members. In 1997, they issued guidance that "medically necessary" ACs should be provided to members, and as early as 2016, after a fair hearing, one patient was granted an AC after their plan denied the physician’s request.

Speed to market (how quickly could the strategy be launched)
The speed and process of implementation will be controlled by the MCO or VBP contractor. Some retailers can deliver an AC in as little as 2 days. MCO or VBP contractors will have to assess the need for AC and install (or arrange for installment of) an AC in the homes of members who need it.

To support providers interested in implementing this strategy, DOHMH is creating a toolkit on air conditioning as a healthcare treatment that will include a summary of adverse heat–health impacts, messaging providers can use as they communicate with patients about heat and AC, including the importance of AC, responsible AC use and energy conservation, and other resources for both patients and providers (including templates of medical necessity letters).

In addition, if an MCO/VBP contractor would like to conduct an evaluation of the strategy, DOHMH is willing to provide expertise and guidance, as requested. DOHMH can share a list of hot days in recent years so with MCOs/VBP contractors can review their historical claims data to assess use patterns on hot days. Providers interested in implementing the strategy are encouraged to contact DOHMH for additional resources and information.

References

1. New York City Department of Health and Mental Hygiene. 2007 New York City Community Health Survey. Available here. Accessed on June 8, 2018.
2. Centers for Disease Control. Heat Illness and Deaths – New York City, 2000–2011. Morbidity and Mortality Weekly 2013;62(31):617–
3. New York State Department of Health. Building Resilience Against Climate Effects (BRACE) in New York State: Climate and Health Profile (June 2015) 2015.
4. Semenza JC, McCullough JE, Flanders WD, McGeehin MA, Lumpkin JR. Excess hospital admissions during the July 1995 heat wave in Chicago. Am J Prev Med 1999;16(4):269–77.
5. Schwartz J. Who is sensitive to extremes of temperature?: A case–only analysis. Epidemiology 2005;16(1):67–72.
6. Horton R YG, Easterling W, Kates R, Ruth M, Sussman E, Whelchel A, Wolfe D, and Lipschultz F. Ch. 16: Northeast. In: Melillo JM. RT, and Yohe GW, Eds., editor. 2014: Climate Change Impacts in the United States: The Third National Climate Assessment.: U.S. Global Change Research Program; 2014.
7. National Weather Service. Office of Climate, Water, and Weather Services. Natural Hazard Statistics. Available here. Accessed on January 5, 2017
8. National Weather Service N. Natural Hazard Statistics. Available here. Accessed on August 8 2017
9. Anderson GB, Dominici F, Wang Y, McCormack MC, Bell ML, Peng RD. Heat–related emergency hospitalizations for respiratory diseases in the Medicare population. Am J Respir Crit Care Med 2013;187(10):1098–103.
10. Liu C, Yavar Z, Sun Q. Cardiovascular response to thermoregulatory challenges. Am J Physiol Heart Circ Physiol 2015;309(11):H1793–812.
11. New York State Department of Health. Environmental Health Tracking Program. Available here. Accessed on November 3, 2016
12. New York City Department of Health and Mental Hygiene. Heat–related Deaths in New York City, 2013; 2014.
13. Fletcher BA, Lin S, Fitzgerald EF, Hwang SA. Association of summer temperatures with hospital admissions for renal diseases in New York State: a case–crossover study. Am J Epidemiol 2012;175(9):907–16.
14. Lin S, Luo M, Walker RJ, Liu X, Hwang SA, Chinery R. Extreme high temperatures and hospital admissions for respiratory and cardiovascular diseases. Epidemiology 2009;20(5):738–46.
15. White–Newsome JL, Sanchez BN, Jolliet O, Zhang Z, Parker EA, Dvonch JT, et al. Climate change and health: indoor heat exposure in vulnerable populations. Environ Res 2012; 112:20–7.
16. Lane K, Wheeler K, Charles–Guzman K, Ahmed M, Blum M, Gregory K, et al. Extreme heat awareness and protective behaviors in New York City. J Urban Health 2014;91(3):403–14.
17. Madrigano J, Ito K, Johnson S, Kinney PL, Matte T. A Case–Only Study of Vulnerability to Heat Wave–Related Mortality in New York City (2000–2011). Environ Health Perspect 2015;123(7):672–8.
18. Ostro B, Rauch S, Green R, Malig B, Basu R. The effects of temperature and use of air conditioning on hospitalizations. Am J Epidemiol 2010;172(9):1053–61.
19. Naughton MP, Henderson A, Mirabelli MC, Kaiser R, Wilhelm JL, Kieszak SM, et al. Heat–related mortality during a 1999 heat wave in Chicago. Am J Prev Med 2002;22(4):221–7.
20. Merrill C MM, Steiner C. Hospital Stays Resulting from Excessive Heat and Cold Exposure Due to Weather Conditions in U.S. Community Hospitals, 2005. HCUP Statistical Brief #55 2008.
21. CostHelper. Heat Stroke Treatment Cost. Available here. Accessed on September 6, 2017
22. World Health Organization Regional Office for Europe. Public health advice on preventing health effects of heat. 2011.
23. McConnell KJ, Chang AM, Cohen DJ, Wallace N, Chernew ME, Kautz G, et al. Oregon´s Medicaid Transformation: An Innovative Approach To Holding A Health System Accountable For Spending Growth. Healthc (Amst) 2014;2(3):163–167.
24. New York City Department of Health and Mental Hygiene. Environment & Health Data Portal. In.

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