The Price We Pay for Cutting Gym

Photo via Jordan Richmond

According to a Center for Disease Control report 26 percent of New York City public school Kindergarten through 8th grade students are obese. Think about that. One in four New York City public school students are obese. With such a startling statistic you would think physical education is a top priority for the New York City Department of Education. But New York City Comptroller Scott M. Stringer's report, “Dropping the Ball: Disparities in Physical Education in New York CitySchools,” reveals a severe lack of certified physical education teachers, lack of space for physical education classes, and dismal reporting procedures implemented by the New York City Board of Education.

Specifically the report reveals:

- 41 percent of high schools have no physical fitness space

- 35 percent of middle schools have no physical fitness space

- 230,000 students lack a full-time, certified Physical Education teacher

- 91,000 students attend a school that does not have access to an outdoor school yard or nearby park

Bronx Health REACH’s school wellness program, Healthy Schools NY, works with 22 Bronx schools involving school staff, parents, and administrators to change policies and practices on nutrition and physical activity. One of the goals is to achieve the New York State-mandated 120 minutes of physical education per week. When children engage in school-day physical education, results can be seen in improved academic classroom performance such as better concentration, attentiveness and success in the classroom.

This is not the first time a New York City Department of Education audit has been conducted by the NYC Comptroller. A 2011 NYC Comptroller audit revealed that 100 percent of 31 elementary schools examined (at the time) were out of compliance with State PE regulations. A 2001 study conducted by a local non-profit group in partnership with the NYC Board of Education analyzed 391 schools (one third of the New York City public schools in the system that year) and concluded that “physical education [was] among the last areas of the New York City school system to recover from the fiscal crisis of the mid-1970s” and had been “persistently undervalued” and “sacrificed to the push for academic achievement, despite research showing that organized sports and physical fitness improve children’s performance both academically and socially.

Inset of Bronx public schools that lack a full-time certified PE teacher.

So here we are in 2015 and the problems still persist. Spaces for physical education in the schools disappeared as the Board of Education converted gyms and school yards into classrooms and parking lots, permitting athletic facilities to fall into disrepair. Lack of accountability can be traced back to the New York State Education Department failing to enforce its own regulations around physical education. When asked by the Comptroller's Office, State officials responded that they “counted on local school districts to monitor their own compliance.” Without full and complete data the Comptroller’s Office was not able to do a complete analysis of whether New York City schools are meeting New York State physical education instructional time requirements or contractually agreed-upon class size mandates.

According to Department of Education data, 2,216 full-time, licensed Physical Education teachers at general education schools are assigned to 1,072 schools leaving 506 schools citywide (over 32 percent) without a fulltime, certified PE teacher. A parent speaking to the New York Daily News stated, "All our kids are dealing with health and weight issues," said Synthia Bachman, 42, a programmer from Manhattan whose son attends the Children's Workshop School in the East Village. Kids and parents at the Children's Workshop School said the school has no gym. Students said they use an adjacent playground for exercise when the weather is good and the school's lobby for gym class in the winter." Yes, you read that correctly. The school’s lobby is being used as a gym.

Inset of Bronx public schools lacking fitness spaces.

Providing physical education to over 1 million New York City public school students can be a challenge but the New York City Board of Education must take steps to improve students’ access to physical education by implementing a system that tracks and monitors where resources are needed.

With that in mind the Comptroller recommends the following:

- Comply with state regulations requiring that all New York City public school students receive physical education instruction from, or under the supervision of, a certified physical education teacher

- Update the New York City Department of Education’s District Physical Education Plan, submit it to NYSED and post a copy on the DOE website

- Develop instruments for tracking and monitoring schools’ provision of physical education for all students

- Develop internal systems allowing the agency to track and monitor schools’ compliance with State PE regulations

- Post physical education data for every New York City school on the Department of Education website

Lack of physical education in New York City public schools over the long term wreaks economic havoc as children become adults. In New York City alone, obesity is projected to cost the City over $4 billion in health care expenses annually. Eventually we all end up paying these costs that can easily be prevented by holding those accountable and meeting physical education mandates for every school that will improve the health and well-being of all New York City children.

Images used above by NYC Dept of Education, Citizens' Committee for Children used in the Stringer report, “Dropping the Ball: Disparities in Physical Education in New York CitySchools.”

What Really Happens After Enrolling in Medicaid Managed Care?

 

Health & Disability Advocates (HDA) is monitoring the rollout of the Medicare-Medicaid Alignment Initiative (MMAI) and has heard from frustrated case managers working with consumers who are confused about the enrollment process and their rights. In response, HDA developed an enrollment timeline that explains what new enrollees can expect from Managed Care Organizations (MCOs) and plan representatives upon enrollment. To produce the timeline, HDA researched the MMAI demonstration contract developed by the State of Illinois and approved by the Center for Medicare and Medicaid Services (CMS)  HDA also solicited input from health plans on whether their on-the-ground practices were accurately reflected in the timeline.

The finished product outlines important points for case managers and their clients to consider.

One Day Changes Everything

Consumers who are enrolled in a managed care plan after the 12th day of the month will not see their coverage start until the month after next. This is relevant for consumers choosing a specific managed care plan in order to see a particular provider or specialist in that plan’s network. Submitting paperwork after the cut-off date means consumers would have to wait longer than expected for necessary treatment. Helping consumers submit required documents in a timely manner can guarantee they are connected to the medical treatment they need, which promotes continuity of care.

Stratification Sets Up Future Contact Standards

Once enrolled in a plan, all enrollees can expect to complete a Health Risk Screening within 60 days. The screen collects information on the enrollee’s physical and mental health conditions and identifies their current medical providers. This is what IlliniCare’s Health Screen looks like. Health plans use the screen to establish intensity of services and frequency of contact with Care Coordinators by stratifying the enrollee as low, moderate or high risk.

Enrollees stratified as low risk will receive annual follow-ups from their Care Coordinators while those stratified as moderate or high risk will have quarterly follow-ups. Moderate and high risk enrollees will also complete a Health Risk Assessment and create an Individualized Care Plan within 90 days. These enrollees will help form their own Interdisciplinary Care Team of healthcare providers that meets quarterly to review the Individualized Care Plan.

The Care Coordinators’ Role

Care Coordinators focus on enrollees’ healthcare needs by connecting them to necessary tests, doctors and treatment. They also facilitate information sharing among providers by leading the Interdisciplinary Care Team. Addressing enrollees’ medical needs is their priority. Care Coordinators direct less attention to linking enrollees to social supports, like housing and public benefits.

It’s also important for case managers to know that Care Coordinators must manage a substantial caseload of up to 600 enrollees. Caseloads include a blend of low, moderate and high risk enrollees, with each risk level weighted differently.

Understanding what a care coordinator can—and cannot—be expected to do is advantageous to case managers. When roles are clearly recognized, case managers know how care coordinators can be used as a resource. And in what instances an alternative referral would be more appropriate. This establishes a stronger professional relationship between case managers and care coordinators, which ultimately benefits the enrollee.

Case managers and Care Coordinators are on the front lines of healthcare reform and fostering solid working relationships between these two players will be a critical component of the success or failure of these efforts. Knowing what case managers and their clients can expect from managed care plans can lay the foundation for a strong relationship that supports the health of individuals while also furthering the goals of healthcare reform.

Bryce Marable MSW

Health Policy Analyst

Health & Disability Advocates

People With Disabilities Who Opt Out of ‘Voluntary’ Wellness Programs Will Pay the Price, and the EEOC’s Okay With That.

The following originally appeared on the American Civil Liberties Union's Speak Freely Blog.

 Voluntary wellness programs at work can provide benefits to employees, but employers are increasingly adopting “voluntary” wellness programs that unfairly burden workers with disabilities the most of all. Worse, the Equal Employment Opportunity Commission seems to think that’s okay, undermining core antidiscrimination protections it used to defend.

Here’s why.

Imagine a woman living with rheumatoid arthritis and severe depression who, under doctor’s care, has finally returned to work. Her medications — a corticosteroid and an antidepressant — have triggered weight gain. Now imagine this woman facing her employer’s “wellness activities:” She is instructed to fill out a detailed questionnaire about her medical conditions; she is weighed and pronounced overweight; she is told to lose weight. Oh, and the program is voluntary — but if she doesn’t comply, she will have to pay hundreds of dollars more in annual health care premiums. 

This imaginary example is all too real: Persons with disabilities risk discrimination and stigma if their employers gain access to their private medical information. And disabled workers are far more likely to have a condition targeted by wellness programs, such as high blood pressure, high blood glucose, or being overweight. 

Historically, the Americans with Disabilities Act has provided employees with disabilities some protections against overly intrusive and punitive wellness programs. The EEOC has maintained, sensibly, that voluntary medical examinations and inquiries cannot impose penalties on employees who decline to participate. 

Until now.

The EEOC has recently proposed new regulations and guidance language on wellness programs that would allow employers to implement wellness programs that add up to 30 percent of the cost of the employee’s health insurance to an employee’s health care bill. Based on the average annual premium, this translates to an extra cost for disabled employees of about $1,800 per year, either because they don’t want to answer questions that could expose their disability to their employer or because they cannot meet the health goal

The EEOC describes these programs as “voluntary,” but workers with disabilities are the least likely to be able to afford additional health care premiums. According to the U.S. Census Bureau, median household income for people with disabilities is less than half of household income for people without disabilities: $25,974 compared to $61,103. At the same time, there is little evidence that these programs are effective. 

If the EEOC is going to allow employers to charge workers hundreds more each year, it needs to be sure important privacy and disability protections are in place.

Three safeguards matter the most. First, the EEOC needs to provide guidance language that workers with disabilities have the right to request a reasonable accommodation waiver from a wellness program, so that their medical status can be taken into account in their ability to comply. The guidelines should also protect disabled workers’ privacy, so that their decision to join or not join the wellness program doesn’t broadcast the details of — or even the existence of — their medical condition to their employer. Finally, disabled workers should rest assured that the guidelines protect them from disability-based discrimination in the workplace, such as harassment of employees who cannot comply with “normal” health standards. 

Comments on the proposed regulations are due this Friday, June 19, 2015. Tell the EEOC not to permit employers to subject their disabled workers to a Hobson’s choice: Submit to the prescribed wellness activities, or pay hundreds more each year. The EEOC should instead insure that workers with disabilities can opt out of these programs without penalty. 

Claudia Center

Senior Staff Attorney

American Civil Liberties Union

Taking Action for Physical Education

Recent efforts to increase student access to physical education in NYC public schools and obtain data on schools compliance with state mandates for PE have been met with good news: The Department of Education has committed to spending $6.6 million to hire 50 more PE teachers and "conduct a comprehensive needs assessment to address barriers and move schools toward full PE compliance." As part of the city budget, this provision in will address school compliance with federal regulations requiring equal access to sports for girls. School wellness and physical education advocates celebrate this success as a first step to improve the quantity and quality of physical education provided to students in NYC public schools. Still, there is much more to be done in order to make significant changes.


In an effort to work toward these changes, Bronx Health REACH has collaborated with the Phys. Ed. For All Coalition, in partnership with New York Lawyers for the Public Interest, Women’s City Club of NYC, The American Heart Association, and many others to draw attention to the disparities in PE programming our city’s children currently receive, as detailed in Comptroller Scott Stringer’s recent report, “Dropping the Ball: Disparities in Physical Education in NYC Public Schools.” According to the report, more than 400,000 students in NYC public schools do not have access to either a full-time, certified PE teacher, designated gym space, or nearby park for outdoor fitness activities. The Phys. Ed. For All Coalition has been crafting legislation for Intro 644 — a reporting bill that would require the Department of Education to track and report data on which schools are adhering to state mandates for physical education, including the required amount of time and certified teachers dedicated to PE and other demographic information. While the DOE is concerned that this bill could place an undue burden on individual schools, it would bring us one step closer to being able to identify which schools require additional assistance. Such transparency would ensure that all students receive the quality PE program they are entitled to by law.


Recent highlights of this campaign have included a press conference and oversight hearing led by City Councilmembers Dromm and Crowley, and Bronx Health REACH staff members Charmaine Ruddock and Kelly Moltzen featured in the media. Our coalition is optimistic about the future of the reporting bill and the impact it would have on the health of our city’s children. Given the evidencethat high quality physical education is linked with reduced risk for obesity, enhanced focus and memory, and improved academic outcomes in children, increasing access to PE could have important implications for the overall health and success of future generations.

Redoing Redes: Strengthening Communication Procedures in the Illinois Medicaid Redetermination Project

The Illinois Medicaid Redetermination Project (IMRP) is erroneously suspending vital medical care for people who remain eligible. Since the rollout of the IMRP in early 2013, the program has been plagued by inadequate communication from the state that leaves consumers confused and ultimately without healthcare. Consumers report that they are not receiving the required notices by mail and when they call with questions, frontline state staff cannot provide answers. Because of the state’s ineffective communication protocols and inadequate employee training, rightful Medicaid beneficiaries are in the precarious situation of being unable to fill their prescriptions, go to the doctor or receive treatment. The purpose of the IMRP is to save state dollars by trimming the Medicaid program of those who are no longer eligible, not cut people who still deserve services.

Letters Lost in the Mail

Medicaid beneficiaries are cut simply because they never received their redetermination notices in the mail. For example, Health & Disability Advocates worked with a mother whose child had been dropped from Medicaid because IMRP sent the notice to a non-existent address. The fact that IRMP sent the letter to an incorrect address on the same street where the family lived suggests that it was a clerical error. In this situation, a young adult dealing with serious mental illness could not access medication and treatment, because the state, not the individual made an error. Sudden lapses in care can pose serious consequences for people who rely on these supports for their physical and mental health.

This is not an isolated instance. A survey of case managers working with older adults and people with disabilities found that the IMRP fails to adequately notify people of their redetermination responsibilities and inform them when they are bounced from the program. Many get the bad news when they attempt to fill prescription or go to the doctor and are told that they are no longer covered. People deserve clear communication from the state telling them they are no longer covered and the steps to get reinstated.

Confused and Not Covered

Even in cases where Medicaid recipients do receive notices, many consumers find the letters are hard to understand and filled with jargon. Given that the intended audience has never before been required to submit to annual redeterminations and may also have lower literacy levels, the letters must be crystal clear. Reports from case managers suggest the letters are confusing.  One case manager surveyed noted “clients do not understand what documents they need to submit with the form and whether they need to submit anything.” With the potential for people to lose their health coverage, the consequences of this confusion are severe.

IMRP’s own data reveal their communication shortcomings. According to May’s Medicaid redetermination numbers, 81% of cancellations are due to a lack of response. Being cancelled doesn’t mean a person is ineligible. In fact, a substantial portion of these clients should still be receiving services.  Of those dropped, 1/3 were reinstated within three months.  In FY 2015 alone, this translates into 238,025 people being incorrectly cut from Medicaid, and this number could be even higher. People who are less frequent healthcare users may learn of their cancellation when they attempt to schedule a doctor’s appointment. With people who deserve Medicaid cut from the program, the IMRP is not achieving its main objective of reducing state expenditures by eliminating those who no longer qualify. Cutting eligible people will actually result in higher costs. Without access to primary medical treatment, people will resort to more costly emergency room care for conditions that could have been managed or even prevented.

Matters get worse when consumers call state workers for clarification, because frontline staff members are often not fully informed themselves. In the above-mentioned case of the mother fighting for her son’s coverage to be reinstated, her interaction with the IMRP hotline was unhelpful and hurtful. The representative said there was nothing more she could do and blamed the family. Stateline workers should be fully trained to provide answers; anything less only increases confusion and frustration.

The Path Forward

The state must develop plain-language notices that explain redeterminations and their importance while outlining the specific steps to keeping coverage. This would not be a new undertaking. State officials have previously brainstormed ways to create simple, more consumer friendly forms. Unfortunately, the furor around budget deficits and service cut threats has drowned out the push for clear communication standards. Even worse, continuing to deemphasize this issue will leave many rightful Medicaid recipients suddenly without coverage. Communication protocols and state staff should support individuals in maintaining their vital connection to healthcare, not create hurdles that effectively jeopardize emotional and physical health. State officials must restart the discussions on clear notices and broaden the conversation to include improved training for frontline staff. These reforms will go a long way towards supporting the IMRP’s original objective of eliminating wasteful spending while also keeping those who still deserve coverage connected to care.

Reducing Obesity: Not Simple But Doable

Photo via k lachshand
Eating these is one way to reduce obesity.

James R. Knickman President & CEO at the New York StateHealth Foundation  asked the million dollar question in his Huffington Post piece, “What's Workingto Reduce Obesity?” In his post Mr. Knickman reveals that researchers from Drexel University studied a range of experiments aimed at reducing obesity, assessing how effective those strategies were. Researchers concluded that measures such as improving sidewalks and banning trans fats had strong impact but other approaches such as restaurants posting nutrition information had very little, to no impact.

So what does work to reduce obesity?

Mr. Knickman believes reducing obesity comes down to the following points:

- Better and more research will provide a better sense of the impact of various strategies reducing obesity in communities

- Different populations require different strategies so research can determine which approaches are most effective for high risk populations

- Seek out the economic and social benefits of interventions

- Success happens when communities and neighborhoods make it easy and affordable to be physically active and eat healthy foods, rather than one method such as banning trans fats

- All these healthy components add up to create “a neighborhood value, a point of pride” and becomes a part of the culture.

Mr. Knickman asks, “What is the best bang for your buck?” Here at the Bronx Health REACH Coalition we have launched the Towards A Healthier Bronx initiative using policy, systems and environmental improvements that increase access to healthy food, healthy beverages and opportunities for physical activity for over 75% of 675,215 residents residing in 12 high need South Bronx zip codes. Many public health campaigns rely heavily on clinical evidence, but fail to research the motivating factors relevant to that audience. To avoid this our campaign emphasizes actionable health behaviors.

Led by the Institute for Family Health, Bronx Health REACH was formed in 1999 to eliminate racial and ethnic disparities in health outcomes in diabetes and heart disease in African American and Latino communities in the southwest Bronx. Since then the Bronx Health REACH coalition has grown to include over 70 community-based organizations, 47 faith-based organizations, and health care providers. Bronx Health REACH serves as a national model of community empowerment demonstrating ways to build healthier communities by promoting healthy life-style behaviors.

The plan behind Towards A Healthier Bronx is:

- Increasing the number of bodegas and restaurants involved in incentive programs offering and promoting affordable healthy foods

- Increasing the number of farm stands making healthy food more affordable and available to the community

- Increasing the number of public and charter elementary schools emphasizing nutrition education and supporting related school policies

Partnering with bodega, deli and restaurant owners by providing them with training and education makes these initiatives not only a healthy benefit for their customers, but an economic benefit for the business owner. Encouraging chefs to attend monthly trainings on healthy food preparation results in offering patrons 2 to 3 healthier menu options. As New York City neighborhood demographics change, the restaurants and bodegas can now more easily adapt to the healthy choices their new customers are seeking resulting in those restaurant and bodega owners seeing more customers come into their stores and restaurants and gaining more revenue.

Mr. Knickman also states, “So if menu labeling isn't working for the target population--as the Drexel research and other studies suggest--we need to find and test other ways to make the healthy choice the easy choice.” Euny C. Lee, Evaluator and Policy Analyst at Bronx Health REACH agrees with Mr. Knickman citing a New York University study, “Calorie Labeling Has Barely Any Effecton Teenagers' or Parents' Food Purchases” which revealed that posting calories for food items at fast food restaurants had no impact on what consumer purchased.

Euny has moderated several focus groups with our faith-based coalition members to determine which types of messages encourage healthy behavior such as healthy eating and physical activity. Findings reveal educating the community about daily calorie intake to be important as most were not aware that you should consume no more than 2000 calories a day to maintain a healthy lifestyle.

Messaging matters as well. Signs and posters promoting a health benefit rather than a scare tactic elicit more positive behavior changes. Interventions have to be customized to a specific demographic/ethnic group so that it is culturally and linguistically understandable and appropriate. Other results include social support such as having a friend or family member who you are accountable to for your actions to reach the desired health goals.

Focus group members felt this ad was not accurate saying the soda bottle should be bigger and would be more effective if other ailments such as diabetes and heart disease that causes stroke were listed.

Focus group members felt the above ad was actually a real advertisement selling juice boxes and a better message would have been the child drinking from a water bottle.

But the question still remains. “What is doable in the fight to reduce obesity?” Bronx Health REACH can point to a few projects. A city wide campaign was created to serve only low-fat and fat-free milk rather than whole milk at New York City public schools. Bronx Health REACH educated policy makers, Coalition members and residents from the community about obesity and the benefits of reduced fat milk. This led to the New York City Public school system adopting the policy and impacting over 1.1 million children in 1,579 schools as well as a model for public schools in 15 other states.

I don't know if the day will ever arrive where the only thing one needs to do is take a miracle pill that sheds those excess pounds without any physical effort while drinking a large vanilla milkshake every day. What I do know is these healthy initiatives together will begin slowing the overweight/obesity epidemic we now face.

Harvest Home Brings Local, Farm-Fresh Produce to Soundview

 Photo by Brian Nobili

                                                               

From left to right: NY State Assemblyman Marcos A. Crespo, Harvest Home CEO Marita Owens, and NYC Council member Annabel Palma.

Soundview residents no longer have to travel outside the community for farm-fresh produce as the debut of The Soundview Farmers Market officially opened with a ribbon cutting ceremony on Saturday, June 20. New York State Assemblyman Marcos A. Crespo and New York City Council member Annabel Palma along with many from the Soundview community in attendance. This new market, located at Morrison Avenue between Harrod Place and Westchester Avenue in the Bronx, will serve more than 60,000 residents, including approximately 10,000 SNAP (Supplemental Nutrition Assistance Program/food stamp) recipients. The market will offer farm fresh fruits and vegetables from Alstede farms, a New Jersey grower.

To encourage residents to shop at the Soundview Farmers Market, Harvest Home has partnered with the Institute of Family Health through its Bronx Health REACH program to issue Fruit and Vegetable Rx to its patients at the Stevenson Health Center. Located at Morrison Avenue between Westchester Avenue and Harrod Place, the Market is open every Saturday through November 21, from 8 a.m. to 4 p.m. rain or shine. Bring your SNAP/EBT, WIC Farmer's Market and Senior Farmer Market coupons along with Health Bucks. News12 covered the event.

Having a farmers market in this area has been a long held dream of Assemblyman Marcos A. Crespo (D- Bronx, 85th AD). And, he, in conjunction with other New York State and New York City Elected Officials from the Bronx heartily welcome Harvest Home Farmers market to the Soundview community. Assemblyman Crespo noted that, “Healthy eating habits promote overall healthy lifestyles, which is why I am excited about welcoming Harvest Home Farmers Market to Soundview.” He pointed out that “Bringing in an array of healthy and organic produce to our community, in an affordable way, enhances healthier choices for both adults and children.”

Council Member Annabel Palma (D-Bronx, 18th Council District), a big supporter of the market stated, “I am excited to have a new farmers market in the Soundview section of my district; now my community will have better access to healthy food. I firmly believe that, when given the opportunities, New Yorkers want to eat healthy – they simply need to be provided the option.”

Neil S. Calman, MD, President and CEO of The Institute for Family Health stated, “I am thrilled that there is a farmers market opening in Soundview. We, at the Institute for Family Health, are deeply invested in improving the health and well-being of the residents of the Bronx and bringing fresh fruits and vegetables is a major breakthrough.”

Saturday's events included cooking demonstrations and a Bronx based disc jockey playing music. The Soundview Farmers Market can be reached by taking the 6 train to the Morrison Ave-Soundview station or the Bx4, Bx4a, Bx27 buses. Harvest Home Farmers Market will operate every Saturday rain or shine from 8 a.m. to 4 p.m. through November 21st, 2015. WIC, FMNP Coupons, Senior FMNP Coupons, Health Bucks, SNAP (EBT) and Debit/Credit Cards  will all be accepted.