April 17, 2019 Atlanta - Dr. Claudia Vellozzi (left), medical director of Chronic Care Clinic, and Karen Sutton (center), Licensed Clinical Social Worker (LCSW), talk to Alex Harris, who is a Chronic Care Clinic program participant, at Grady Memorial Hospital's Chronic Care Clinic in Atlanta on Wednesday, April 17, 2019. The Chronic Care Clinic is unique in that it's got not just a doctor and a nurse and assistants, but community health workers who get deeply involved in the patient's situation, a social worker who hooks them up with resources, a behavioral health clinician who addresses addiction and mental health issues, and a highly credentialed pharmacist. HYOSUB SHIN / HSHIN@AJC.COM
Photo: HYOSUB SHIN / AJC
Photo: HYOSUB SHIN / AJC

Kemp could model Georgia Medicaid waiver off Grady program

There was only so much Grady Memorial Hospital’s emergency room could do for Violet Clark’s deep mental pain when she came in for crisis after crisis, sometimes so distraught she struggled to breathe.

Grady couldn’t afford it, either.

When she came in, the hospital could rack up thousands of dollars in expenses it had to swallow because she had no insurance to pay for it. And Clark wouldn’t receive the sustained care that might stop the next incident from happening.

A year later, all that has changed.

Clark entered a program that Grady invented in 2017 to lower its emergency room costs by diverting some of its most frequent ER visitors into a specialized clinic. Grady leaders believe their program could be replicated across the state, and possibly across the country, to cover more patients at a lower cost.

04/12/2019 -- Atlanta, Georgia -- Violet Clark, a graduate of the Grady Chronic Care Clinic, smiles while taking a group photo following a graduation celebration at Grady Memorial Hospital in Atlanta, Friday, April 12, 2019. The Chronic Care Clinic hosted a celebration graduation for people who had fallen out of the health system, except for going to the ER for emergencies. These patients are signed up for the Chronic Care Clinic and "surrounded" with resources including a community health worker who works with them to educate them on using resources properly, such as taking medications regularly, going to a primary care clinic for non-emergencies, and keeping up with problems before they become emergencies. (ALYSSA POINTER/ALYSSA.POINTER@AJC.COM)
Photo: Alyssa Pointer/ALYSSA POINTER/ALYSSA.POINTER@AJ

As Gov. Brian Kemp explores options for a limited expansion of Medicaid in Georgia, Grady’s program could provide one way to bring more federal health care dollars into the state to cover more people in a cost-efficient way.

Kemp recently signed legislation that allows him to ask the Trump administration for flexibility to use federal Medicaid dollars in a way that might increase the number of poor Georgians that Medicaid covers. To allow a program tailored to Georgia, the administration would have to agree to “waive” some standard requirements of the Medicaid program.

Kemp’s research into Medicaid waiver plans is just beginning. But the approach he has mentioned so far, several times, is Grady’s.

“They (the Trump administration) want us to figure out ways to innovate,” Kemp said in his most recent comments, on News 95.5 and AM 750 WSB. “Grady has a plan” to better deliver the right health care to people, he said, and the administration wants states to develop ideas that can spread across the country. “People are very excited about this, and I am as well.”

Kemp’s pursuit of a waiver instead of full Medicaid expansion would not solve the problem of covering the state’s 500,000 uninsured poor. But for Grady CEO John Haupert, it’s a positive step.

“Every state has to work through this question at its own speed, and I think he has taken a really introspective look at what this means to the state and what it means to the general health of our Georgia citizens,” Haupert told The Atlanta Journal-Constitution. “I was, to be honest, very excited.”

Grady’s experiment

An ER doctor connected Clark to Grady’s pilot project, called the Chronic Care Clinic. “Call this number. Tomorrow,” he said.

04/12/2019 -- Atlanta, Georgia -- Violet Clark becomes emotional as she talks about the Grady Chronic Care Clinic during a graduation celebration at Grady Memorial Hospital in Atlanta, Friday, April 12, 2019. The Chronic Care Clinic hosted a celebration graduation for people who had fallen out of the health system, except for going to the ER for emergencies. These patients are signed up for the Chronic Care Clinic and "surrounded" with resources including a community health worker who works with them to educate them on using resources properly, such as taking medications regularly, going to a primary care clinic for non-emergencies, and keeping up with problems before they become emergencies. (ALYSSA POINTER/ALYSSA.POINTER@AJC.COM)
Photo: Alyssa Pointer/ALYSSA POINTER/ALYSSA.POINTER@AJ

Her mental health had deteriorated. The former legal secretary lost custody of her child, title to her home, and — the breaking point — her car, which she sold to pay taxes on the house. “For a long time I didn’t know what to do,” she said, tears welling. “All I knew to do was to scream.”

She means that literally: She would stand on the sidewalk and scream until she was escorted into the ER. Or again and again, she’d call 911. She doesn’t remember how many times.

Once she was enrolled in the clinic, Grady began spending more money on Clark, but in a different way.

Suddenly at Clark’s service were the clinic’s physician, a nurse practitioner, a behavioral health clinician, a pharmacist, and one of three community health workers, plus other staff.

They did a comprehensive assessment of Clark’s ailments and her living situation. A year later, the clinicians have gotten her blood pressure medication stabilized and found an antidepressant that works.

Her community health worker, Bryna Robinson, has gone beyond that.

Robinson and two colleagues teach people how to be patients. Over time, she coaches them to show up for appointments, follow orders, take their meds, and find effective ways to raise questions and solve problems. She makes home visits and phone calls. If a clinic patient goes to the ER instead, she’ll show up in the patient’s room to ask why.

She looks for resources she can connect patients to. The home visits tell her whether patients’ surroundings are contributing to their problems.

Robinson pushed Clark to call relatives until one sent Clark money to buy a stove so she could cook. She got the patient signed up to teach crochet lessons at a library so Clark could engage with other people.

04/12/2019 -- Atlanta, Georgia -- Grady Chronic Care Clinic Community health worker Bryna Robinson (right), speaks with Nancy Carter (left), a care clinic attendee, following a graduation celebration at Grady Memorial Hospital in Atlanta, Friday, April 12, 2019. The Chronic Care Clinic hosted a celebration graduation for people who had fallen out of the health system, except for going to the ER for emergencies. These patients are signed up for the Chronic Care Clinic and "surrounded" with resources including a community health worker who works with them to educate them on using resources properly, such as taking medications regularly, going to a primary care clinic for non-emergencies, and keeping up with problems before they become emergencies. (ALYSSA POINTER/ALYSSA.POINTER@AJC.COM)
Photo: Alyssa Pointer/ALYSSA POINTER/ALYSSA.POINTER@AJ

Addressing issues such as housing “is Grady’s job because it’s at the core of their health problems,” said Dr. Claudia Vellozzi, the clinic’s medical director and a former branch chief at the U.S. Centers for Disease Control and Prevention.

Haupert, the Grady CEO, addressed the obvious criticism: “I guess some people could call it hand holding. But it’s hand holding that allows us to maintain a healthier patient population and community.”

As for Robinson, who deals face to face with the patients and sees in person how the program works, the choice is obvious. “We can either help people on the front end where we can control the cost, or we can let things fall apart and pay on the back end when it’s more expensive,” she said.

Clark agrees. “I’m sure if I had not been in this program, I would be somewhere very ill and very sick,” she said.

Instead, she graduated from the clinic in early April and now sees a regular set of medical providers, people willing to treat the uninsured. She has not been to the ER in about a year.

Promise and peril

Since the clinic started in 2017 with a $2 million private grant, it’s enrolled about 250 patients. Some fell out of the program, and others kept up with appointments but didn’t follow directions. Overall, 64 patients have graduated, moving on to regular care teams. Grady estimates the pilot project saved 44% of what the hospital would have spent on their care.

The 250 treated so far is a tiny number of people for a standard clinic.

Through Kemp’s Medicaid waiver, Grady wants to expand it to 50,000 patients.

Grady says the proposal has something for everyone on the political spectrum.

For one thing, it’s basically cost-free to the state. The program would be funded with money a public hospital already spends on health care, and the federal government would match that amount 2-to-1.

Grady would use as its match the $55 million in funding it receives from DeKalb and Fulton counties, and the feds would chip in double that amount.

For the Trump administration, which has been encouraging waiver applications, the Grady approach would advance the conservative goal of limiting federal spending. If the care for the patients enrolled in the program ends up exceeding the budget, Grady will foot the bill.

That’s not how standard Medicaid works.

April 17, 2019 Atlanta - Karen Sutton (left), Licensed Clinical Social Worker (LCSW), and Dr. Claudia Vellozzi (center), medical director Chronic Care Clinic, confer as they look medical files of Alex Harris (right), who is a Chronic Care Clinic program participant, at Grady Memorial Hospital's Chronic Care Clinic in Atlanta on Wednesday, April 17, 2019. The Chronic Care Clinic is unique in that it's got not just a doctor and a nurse and assistants, but community health workers who get deeply involved in the patient's situation, a social worker who hooks them up with resources, a behavioral health clinician who addresses addiction and mental health issues, and a highly credentialed pharmacist. HYOSUB SHIN / HSHIN@AJC.COM
Photo: HYOSUB SHIN / AJC

Grady knows its own project would need to be adapted to work at other hospitals.

Steve Gautney, the CEO of Crisp Regional Health Services in Cordele, said there’s a way it could work in his area. Crisp shaped its own project using a one-time $750,000 state grant and has been talking to Grady about the waiver idea. In spread-out Crisp, paramedics do much of the work that Grady’s clinic staff does.

“In rural Georgia, we have certainly a population that is less dense than in an urban area. But we also have a larger number of poor people or lower-income,” Gautney said. In the ER, he said, the hospital has to practice what he calls “defensive medicine” — running all manner of expensive tests that might not be helpful just because it’s a crisis and that’s what ERs do.

All ERs are legally obligated to treat whoever walks in the door, but the number of repeat visitors varies widely from hospital to hospital.

Among the avoidable ER cases there are those that are obviously not emergencies. Nationwide they may be just 3% to 6% of all visits. But that can vary a lot.

Gautney’s ER sees about 24,0o0 patients a year, and he believes a significant percentage of those visits are avoidable. Grady says that 16% of its ER visits are from patients who come six or more times a year.

If Crisp can expand its program with a hospital-based waiver program like Grady wants, he said, “Yeah I think there’s a lot of good that can be done with it.”

Grady’s waiver approach is not risk-free.

No one really knows whether Grady’s savings will bear out once it expands the target population to 50,000. With its initial group, it took cases so extreme that improvement was hard to avoid. Grady officials say they are certain of at least some cost savings from expanding the clinic, partly because of results from a similar effort tried in Cleveland, Ohio.

A cap of the federal contribution could also present a problem if the program doesn’t achieve its goals of dramatically reducing costs by intervening early in the care of the costliest patients.

That concerns Gautney. But Grady officials are rock-certain they’ll save money. And Gautney and Haupert agree on one thing: Whether Medicaid fully expands in Georgia or a more modest expansion occurs through a waiver program, the state health care system needed to be overhauled.

“Whichever one would get us there was the one I would vote for,” Haupert said.

Stay on top of what’s happening in Georgia government and politics at www.ajc.com/politics.

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