Transcript Policy Road Map for Health Equity: Outlook and

Policy Road Map for Health Equity:
Outlook and Opportunities
Minnesota Community Health Worker Alliance Statewide Meeting
Michael Scandrett, JD
Emily Zylla, MPH
Halleland Habicht Consulting
June 5, 2014
Topics for Today:
1. Health care reform & health coverage
2. New provider care delivery and payment models
3. Health equity policy developments
4. Opportunities for CHWs
2
1. Health Care Reform
& Expansion of Health Coverage
3
Background:
the American Health Care System
 More expensive than other countries
 Poorer health of the population
 Highly variable quality, effectiveness and safety
 Inadequate prevention
 Poor management of chronic disease
 Perverse financial incentives
 Unsustainable cost increases
4
Background:
the American Health Care System
5
Consequences
 Decreased worker productivity
 Rising costs contribute to government budget deficits and
divert resources from other government priorities
 Erodes health insurance coverage and benefits
 More uninsured and underinsured
 Persistent health disparities
6
Federal Reforms: 2010
Affordable Care Act (ACA)
 Medicaid Expansion
 Health Insurance Exchanges: a marketplace to buy insurance
 Regulations of Private Health Insurance
 Reforms to Provider Payment Methods
 Increased Prevention and Wellness
 And more….
7
ACA: Expands Health Coverage
Universal Coverage
Medicaid
Coverage
(Up to 133% FPL)
Exchanges
Individual
Mandate
(Subsidies for 133 – 400%
FPL)
Health Insurance
Market Reform
Employer Sponsored Coverage
8
Overall, Minnesota rate of
Uninsured Ranks #3…HOWEVER…
Uninsured Rates in “Communities of Color”
VT
WA
ND
MT
MN
OR
WY
UT
CA
AZ
CO
OH
KY
WV
AR
MS
AL
VA
CT
NJ
DE
MD
DC
NH
MA
RI
NC
TN
SC
GA
LA
FL
HI
9
IN
MO
OK
TX
AK
PA
IL
KS
NM
MI
IA
NE
NV
NY
WI
SD
ID
ME
SOURCE: KCMU/Urban Institute
analysis of 2011 and 2012 ASEC
Supplements to the CPS.
Less than 20% (14 states)
30-49% (16 states)
20- 29% (14 states)
More than 50% (7 states, including DC)
Disparities in Insurance Coverage
10
Source: MDH, Health Economics Program
MN Coverage Options
11
11
 Minnesota’s Health Insurance Marketplace
 223,000 Enrollments to Date
 126,039 in Medicaid
 46,417 in MinnesotaCare
 50,733 in Qualified Health Plans
 Navigators help consumers choose a health plan and enroll
 Many problems with MNsure’s start-tup
12
Impact of ACA on Uninsured
Estimated Uninsured in MN, With & Without ACA
13
Source: Gruber/Gorman Analysis, Prepared for Health Care Reform Task Force, MN, 2012
Preview: Access to care 5 years
after reforms enacted
14
But, the ACA has not solved the
problem of the uninsured
15
The Remaining Uninsured:201,000
16
Source: Gruber/Gorman Analysis, Prepared for Health Care Reform Task Force, MN, 2012
Reason for Coverage Gap
Affordability
Newly
Uninsured
Immigration
Status
17
• Those who pay more than 8% of income on health care
• Individuals with incomes below the tax filing threshold
($10K individual/$20K family)
• Those who lack coverage due to life transitions, largely due
to reductions in employer sponsored insurance
• Dependents ineligible for subsidized coverage in the
Exchange if an employee is offered affordable self-only
coverage by an employer
• Those who are ineligible for subsidized coverage due to
immigration status
Compared to the Insured
Population, the Uninsured are…
 Younger: almost twice as likely to be under 34 years of age





18
(54% uninsured vs. 29% insured)
Poorer: over twice as likely to have income below 200% of
poverty (56% vs. 27%)
More Diverse: almost twice as likely to be from a
community of color (32% vs. 19%)
Less educated: nearly twice as likely not to graduate from
high school (8.3% vs. 5.2%)
Single: over twice as likely to be unmarried (44% vs. 21%)
Male: a third more likely to be male (63% vs. 47%)
The Remaining Uninsured:
Undocumented Immigrants
 The largest category of the remaining low-income, uninsured
Minnesotans is people who are not eligible for MA or the
MNsure Exchange due to their immigration status
 Most uninsured immigrants seek care from safety net
providers: Community Health Centers, community dental
and mental health providers, and public hospitals and clinics
 The only State of Minnesota program for these Minnesotans
is Emergency Medical Assistance, which covers emergency
care and hospitalization
19
Uninsured Immigrants: Future
Policy Opportunities
Emergency Medical Assistance (EMA):
 A DHS Report on EMA called for expanding the coverage
and benefits for undocumented immigrants
 2014 Legislation requires a report to the 2015 Legislature on
possible improvements to the EMA program
Funding for Safety Net Providers:
 2014 Legislature provided additional grants to safety net
providers to serve uninsured patients
 2015 is a State Budget Session where funding for the
uninsured will be decided
20
Health Coverage:
Opportunities for CHWs
 MNsure outreach to communities
 MN enrollment navigation and assistance
 Advocacy on behalf of communities of color:
 MNsure advisory committees and Board
 State agencies
 MN state legislature
 Political campaigns
21
QUESTIONS
22
2. New Provider Care Delivery
and Payment Models
23
“Triple Aim” of Health Reform
 Improve the health of the patient population
 Improve the patient/consumer experience
 Improve the affordability of health care
24
Minnesota: Ahead of the Curve
2008 & 2010 Minnesota Reforms
 New Care Models: Health
Care Homes & Care
Coordination
 Quality Measurement:
for payment, consumer
information, and
accountability
 Payment Reform: Evolving
to pay for VALUE rather than
VOLUME
25
Data
Measure
Payment
New Care Models
Health Care Homes
 A primary care provider or team
 Certified by MDH
 Paid a monthly per-person care
coordination fee
 Partner with and engage the
patient/family to improve health
and manage chronic conditions
 Coordinate all needed services, with
EHR & IT
 Address non-clinical factors
affecting health
26
Accountable Care Organization
 A network of clinics and health care providers who take
responsibility for managing the health, quality and total
cost of care (TCOC) for their patients
 In Minnesota, ACOs serving patients enrolled in Medicaid
and MinnesotaCare are called “Integrated Health
Partnerships” (IHPs) and were formerly known as “Health
Care Delivery Systems” (HCDS).
27
MN ACOs:
Integrated Health Partnerships (IHPs)
 Medical Assistance/MinnesotaCare ACOs in MN
 DHS contracts directly with IHPs in a new way to serve a
specified patient population
 IHPs provide needed services for the patients attributed to
their clinics
 “Gain sharing” payments made if the IHP reduces the total
cost of care for attributed patients while maintaining quality
of care and patient satisfaction
 Nine IHP projects are underway; more are coming
28
Who is Establishing ACOs?
 Large integrated hospital-clinic organizations
 Alliances of independent clinics and hospitals
 Safety Net Providers serving low-income and underserved
populations
 County health care, social service and public health agencies
29
ACOs and Safety Net Populations
 Early models were developed by large hospital-clinic
companies working with large employers serving a
mainstream, middle-class population.
 Will ACOs work in Safety Net Settings?
 Cultural competence and socio-economic factors
 Co-occurring MI and chemical dependency
 Non-medical services needed (housing, transportation, etc.)
 Risk-adjustment for higher costs, poorer outcomes
30
IHP: Shared Savings
MA Spending per Demo
$180,000,000
$170,000,000
$160,000,000
State
$150,000,000
HCDS
$140,000,000
$130,000,000
$120,000,000
1
2
3
4
Year
31
5
6
Shared
Savings
FUHN
(FQHC Urban Health Network)
 FUHN is a “Virtual” IHP (made up of independent clinics)
 Ten FQHCs working in partnership:
 AXIS Medical Center, Cedar-Riverside Peoples Center, Community
University Health Care Center, Indian Health Board of
Minneapolis, Native American Community Clinic, Neighborhood
HealthSource, Open Cities Health Center, Southside Community
Health Services, United Family Medicine,West Side Community
Health Services
 OPTUM provides data analysis and other expertise
32
FUHN Project Goals:
 Improved Access to High Quality
Primary Care
 Improved Clinical Quality
 Improved Consumer Engagement
and Satisfaction
 Reduced Total Cost of Care
33
5/21/2013
Challenges: What will it take
for an IHP to succeed?
 Effective Team-based Primary Care services
 Robust Care Coordination
 Patients actively engaged in their care and health
 Communities actively engaged in improving population
health
 Health Information Technology (HIT) systems to support
care coordination and quality and cost management
 Health Information Exchange (HIE) systems to help provider
networks coordinate care
34
DHS Projects: The Next Wave
 More HCDS projects will coming online in 2014
 State’s goal: cover 50% of the Medicaid population in
ACO/IHPs (excluding elderly and people with disabilities)
 ACOs are expanding in the private sector, too
 Expanding to additional service: intensive mental health,
long-term care, and home and community-based services for
complex populations
 SIM Grant - Accountable Communities for Health
35
State Innovation Model (SIM) Grant
 $45 million grant from CMS
 Expansion of ACO/IHP models
 Especially small and rural providers, safety-net providers,
and providers who are not part of large integrated health
systems
 Project Goals:
 Transform care delivery
 Accelerate adoption of ACO models in Medicaid
 Ensure providers are able to securely exchange data
 Create “Accountable Communities for Health”
36
SIM Budget Allocations
 $23M for health information technology, secure
exchange of health information and data analytics
 $6.3M for practices to improve care coordination
 $2.5M for quality and performance measurement
 $10M to support up to 15 Accountable Communities
for Health
37
Accountable Communities
for Health
Expand IHP Accountable Care model beyond
traditional acute care services to include:
 Non-clinical services affecting patients’ health, including social
services, public health, housing
 Community-wide prevention efforts to improve overall health
and reduce chronic disease
 Behavioral Health, Long Term Care, and Home and
Community-based Services
 Measurable community-wide goals for improved population
health, health care and cost management
 Roles for citizens, employers, providers, health plans,
government and communities.
38
Measuring Quality
 Under the new care models and payment reforms, reducing
future costs is necessary but not sufficient
 Providers must meet also meet standards of quality and
patient satisfaction
 Standardized quality measures are measured and reported
through Minnesota Community Measurement and the
Minnesota Department of Health
39
SQRMS
 All providers measured using standardized statewide quality
measures under Minnesota’s Statewide Quality
Reporting and Measurement System (SQRMS)
 Currently SQRMS does not collect or report data by race,
ethnicity, language (REL), or socio-economic status (SES)
such as income, homelessness, and gender identity and sexual
preference
40
Healthcare Education
& Workforce
 Health professional education is lagging behind emerging
workforce trends:
 Increased reliance on primary care providers
 Multidisciplinary, team-based care
 Use of allied, mid-level and paraprofessional practitioners
 Skilled in using EHR, HIE and data to drive care delivery
 Skilled at patient and community engagement
 Cultural competency and relevance
41
Recap of Trends
1.
2.
3.
4.
5.
6.
7.
42
Care coordination of all health care services needed by a patient
Services delivered through multi-disciplinary primary care
teams.
Provider accountability for quality, health outcomes and costs
using standardized measures.
Improved patient satisfaction and engagement in their own
health and health care.
New payment methods and financial incentives for providers
to reduce the total cost of care through prevention, early management
of disease, and efficient, effective care.
Use of health information technology to improve care and
reduce costs.
New: Coordination of health care with non-health care services to
address social determinants (poverty, race/ethnicity, literacy,
homelessness, etc.) and reduce health disparities.
New Models: Opportunities for CHWs
 Member of Primary Care Team
 Improve Patient Engagement
 Improve Community Engagement
 Improve Population Health
 Address Social Determinants of Health (REL/SES)
 Advocate for Change:
 Within health care organizations
 In communities
 With government agencies
 With policymakers (MN Legislature, county boards, etc.)
43
QUESTIONS
44
3. Health Equity Policy Developments
45
Health Equity
 Increased attention to health disparities
 MDH Report – February 2014:
 “Health in All Sectors”
 Statewide Leadership – Structural Racism
 Strengthen Community Relationships
 Redesign Grant Programs
 Strengthen Data on Disparities
46
Health Care Reforms: Impact on
Health Disparities
 MA expansion improves health coverage & benefits
 Patient relationship and engagement is key to provider care
delivery and payment model reforms
 Payment reforms will allow resources to be shifted from
hospital/specialty to primary care/outpatient and to services to
address social determinants of health
 Coordination with social services & other county services will
help address social determinants of health
 Quality Measurement to track and report quality for communities
of color and other populations with health disparities.
47
2014 Legislative Session
Highlights – Health Equity
 Health Equity grants
 Funding for Interpreters
 Grants for Health Care for Uninsured Patients
 Emergency Medical Assistance Program
 Statewide Quality Reporting and Measurement System
(SQRMS) Changes
48
Data: SQRMS, REL & SES
Data on Health Disparities:
 Statewide quality measures can’t be broken down by race,
ethnicity and language (REL) or socio-economic status (SES)
 Lack of data on quality of care for communities of color and
REL/SES groups is a barrier to identifying and eliminating
health disparities
Risk Adjustment:
 Providers are accountable for quality of care
 Current measures do not adjust for REL/SES, causing harm
to providers who serve REL/SES patients
49
Data: SQRMS, REL & SES
2014 Legislation
 SQRMS: plan to measure quality of care based on
REL/SES and adjust provider quality scores based on these
factors
 MDH:
 Develop an implementation plan and budget to present to the
2015 Legislature
 Consult with stakeholders in developing the plan, including
communities of color and other groups with health disparities
 Use culturally appropriate methods of engaging communities
in the process of developing the plan
50
Health Equity Issues to Watch
 SIM Accountable Communities for Health
 Statewide community engagement Summer 2014
 RFP expected Sept. 1, 2014
 2015 Legislative Session
 State budget year
 Legislative proposals from the Health Equity Report
 Implementation plan for REL/SES quality measurement and
risk adjustment
 Emergency Medical Assistance program changes
 Coverage and access to care for the remaining uninsured
51
What’s the Role of CHWs in
Reducing Health Disparities?
 CHWs come from the communities they serve, building
trusting and vital relationships. These crucial relationships
significantly lower health disparities because CHWs:
 Facilitate access to services and coordination of care;
 Improve the quality and cultural agility of care;
 Improve chronic disease management; and
 Increase the health knowledge and self sufficiency of
underserved populations
 Increase patient and community
engagement
52
QUESTIONS
53
4. Opportunities for Community
Health Workers under Reform Trends
54
The Value of CHWs in Health Care
 Educating and engaging patients in managing their health and




55
coordinating the services they need
Bringing cultural knowledge and skills to primary care teams
Bringing cultural knowledge and skills to health care
organizations, public health agencies and other public and
private organizations
Strengthening engagement of communities of color with
health care organizations and the health care system
Identifying and addressing health disparities
Opportunities for CHWs:
Individually







56
MNsure (navigation, etc.)
Care delivery and payment models (PC, HCH, ACO/IHP,
ACH)
Public health and population health improvement
Patient and community engagement
Health equity/eliminating disparities
Community leadership
Public policy advocacy
Opportunities for CHWs:
Working Together
 Business Case for CHWs. Make the case that CHWs provide a
financial return-on-investment and add value in other areas
 CHW Workforce Models. Promote roles of CHWs with health
systems, clinics, public health agencies, and IHPs
 Community Engagement. Assist communities served by CHWs in
being engaged in policy advocacy and holding health care
organizations and the health system accountable
 Policy Advocacy: Advocate together on public policies, reforms,
programs, and funding on behalf of populations served by CHWs
57
QUESTIONS
58