Promises and Perils of Emerging Health Innovations Blog Symposium
We are pleased to present this symposium featuring commentary from participants in the Center for Health Policy and Law’s annual conference, Promises and Perils of Emerging Health Innovations, held on April 11-12, 2019 at Northeastern University School of Law. As a note, additional detailed analyses of issues discussed during the conference will be published in the 2021 Winter Issue of the Northeastern University Law Review. @NUSLHealth @nulawreview
Throughout the two-day conference, speakers and attendees discussed how innovations, including artificial intelligence, robotics, mobile technology, gene therapies, pharmaceuticals, big data analytics, tele- and virtual health care delivery, and new models of delivery, such as accountable care organizations (ACOs), retail clinics, and medical-legal partnerships (MLPs), have entered and changed the healthcare market. More dramatic innovations and market disruptions are likely in the years to come. These new technologies and market disruptions offer immense promise to advance health care quality and efficiency, as well as improve provider and patient engagement. Success will depend, however, on careful consideration of potential perils and well-planned interventions to ensure new methods ultimately further, rather than diminish, the health of patients, especially those who are the most vulnerable.
Jessica Mantel and Leah Fowler start off the Promises and Perils of Emerging Health Innovations blog symposium with a discussion about the ways in which medical-legal partnerships (MLPs) have improved quality and efficiency of care, particularly because of their innovative and interdisciplinary approach to addressing social and structural determinants of health. Mantel and Fowler, drawing on interviews with MLP professionals, highlight some of the successes existing MLPs have achieved, and share lessons learned and potential challenges for current and developing MLPs to consider.
The Promises and Perils of Medical Legal Partnerships
by Jessica Mantel & Leah Fowler
New payment models that reward improved health outcomes challenge providers to rethink how they treat patients. No longer content to simply treat patients’ underlying diseases, many providers have embraced innovative approaches that also address the social, economic, and environmental factors that affect well-being. One such innovation is medical legal partnerships (“MLPs”).
By integrating legal services into the heath care setting, MLPs address health-harming legal needs (“HHLNs”). Kate Marple, Framing Legal Care as Health Care, Nat’l Ctr. for Med. Legal P’ship (last visited Sept. 25, 2019). For example, MLP attorneys can initiate legal action against landlords whose housing code violations cause or exacerbate respiratory conditions, secure protective orders for the victims of domestic violence, or help those denied benefits under Medicaid or the Social Security Disability Income (“SSDI”) program file an appeal. MLP attorneys also train the medical partner’s clinicians and staff on how to identify patients with HHLNs and support patients exercising their legal rights, such as how to effectively navigate the SSDI application and appeals processes. Some MLPs also advocate for broad policy changes that ameliorate social determinants adverse to health.
While all MLPs share the common goal of leveraging legal services to improve individual and population health, MLPs’ operations vary greatly. In some MLPs the medical and legal sides have limited interaction beyond the initial referral of patients with HHLNs to the MLP attorney, whereas other MLPs tightly integrate their legal services with other clinical and nonclinical services offered to patients. In the latter model, the attorney works closely with clinicians and staff, often participating in rounds or interdisciplinary team meetings. MLPs also vary in other respects, such as their processes for screening for HHLNs and sharing information between medical and legal partners.
The Project
Missing from the MLP literature are empirical studies that explore the experiences of MLP professionals operating under different structures and processes. Inspired by a previous conceptual paper, we set out to fill this gap. Renee Newman Knake & Jessica Mantel, Legal and Ethical Impediments to Data Sharing and Integration Among Medical Legal Partnership Participants, 27 Annals Health L. 183 (2018). With approval from the University of Houston Institutional Review Board, we engaged 31 MLP professionals in hour-long, qualitative interviews. Our interviews explored how individuals in the MLP trenches experience and address the promises and perils of various MLP models. We discovered a range of challenges facing MLPs, with solutions as varied as the partnerships themselves. Below we highlight some key findings.
The Importance of Stakeholder Buy-In
The existing MLP literature highlights the importance of having an individual champion on the clinical side (usually a physician) who actively promotes the MLP. Nat’l Ctr. for Med. Legal P’ship, The Medical-Legal Partnership Toolkit Phase I: Laying the Groundwork 3, 10 (2015). While our research confirms the importance of having an individual champion, we also found that establishing and sustaining a successful MLP requires strong support from individuals at all levels of the provider organization, from frontline professionals to high-level administrators and in-house attorneys. Having multiple champions across the provider organization helps alleviate mistrust of the MLP attorney (including fears that they will bring malpractice claims against the provider), diminishes skepticism about the MLP’s value, and improves the quality and quantity of patient referrals to the MLP attorney.
The Need to Demonstrate Value
Securing long-term, stable funding is an ongoing challenge for MLPs. See generally Dayna Bowen Matthew, The Law as Healer: How Paying for Medical-Legal Partnerships Saves Lives and Money (2017). Because few legal organizations can fully finance an MLP, most MLPs rely on grants from philanthropic organizations or government agencies or funding from the medical partner. Outside organizations, however, often condition continued grant funding on the MLP proving its value through outcomes data. Similarly, data showing that MLPs improve patients’ health and lower providers’ costs may persuade the medical partner to finance the MLP.
Although outcomes research can help MLPs secure sustainable financing, few MLPs actually conduct such research beyond documenting their legal outcomes. This is due to a variety of factors, including privacy concerns that hinder access to the relevant data, lack of expertise on conducting outcomes research, and limited resources. As one MLP attorney lamented: “I have a public health degree. I get it, you’re supposed to track. If you track it, they’ll fund it. [But] I have a to-do list in front of me on direct client work, [so] it just doesn’t get done.”
In lieu of more robust outcomes research, many MLPs demonstrate value through patient-client anecdotes. Anecdotes, however, often carry less weight with funders than outcomes data. As one physician noted: “it’s always going to come down to a number, and the currency that we deal with in America is, in fact, currency.”
Variation in Information Practices
Sharing patient-client information between legal and medical partners can present challenges, although not necessarily for the reasons identified in the MLP literature. Contrary to conventional wisdom, our research shows that the Health Insurance Portability and Accountability Act (“HIPAA”) generally does not pose a barrier to the medical and legal partners sharing patient-client information as long as the patient gives written authorization. In contrast, concerns about protecting the confidentiality of clients’ legal information and the attorney-client privilege significantly influence MLPs’ data sharing practices. Some MLP attorneys cited these concerns as reasons why they share little, if any, client information with the medical side, whereas others saw few risks in having the MLP attorney share basic case updates with the medical partner (with client consent). Rarely, however, do MLP attorneys share client information beyond basic case updates due to concerns about client confidentiality and protecting attorney-client privilege.
Our interviews also revealed wide variation in MLPs’ use of electronic health records (“EHRs”) systems. Some MLP attorneys had full access to patient-clients’ electronic medical records, whereas others did not. In addition, MLPs varied as to whether the attorneys communicated legal information to the medical side via the EHR. Interviewees cited various factors such as shaping their MLP’s EHR practices, including convenience and efficiency, promoting greater integration of clinical and legal services, discomfort with granting attorneys access to the EHR, liability and privacy concerns, and technological challenges.
The Challenge of Patient-Client Attrition
Nearly all interviewees noted that many individuals with a HHLN fall through the cracks and do not successfully connect with the MLP attorney. Our research suggests several reasons for this patient-client attrition. In some cases, individuals fail to follow-through on a referral for legal services due to competing personal demands or misapprehension of the legal system. Instability in housing or communication technology also impedes communicating with individuals referred to MLPs. In addition, MLP attorneys may not have sufficient resources to follow-up with referred individuals in a timely manner, may lack the necessary expertise to address an individual’s specific legal needs, or may be barred from providing legal services to an individual who does not meet the applicable eligibility criteria. Our article, to be published in Volume 12, Issue 1 of the Northeastern University Law Review, discusses successful strategies that some MLPs have developed for addressing these challenges.
Conclusion
In highlighting the promises and perils of MLPs, as told by those currently operating MLPs, our forthcoming article provides a richer understanding of the different ways to structure and operate an MLP and the factors that influence choices among alternative MLP models. These findings are instructive for both existing MLPs and those forming new MLPs. In addition, our findings illuminate the debate on whether current legal and ethical rules–rules developed for a world where medical and legal professionals operate in silos–make sense for settings that integrate medical and legal services.
Bios:
Jessica Mantel is the George A. Butler Research Professor and co-director of the Health Law & Policy Institute at University of Houston Law Center.
Leah Fowler is a research assistant professor and research director for the Health Law & Policy Institute at University of Houston Law Center. @_leahrfowler
Handles: @leahrfowler