Linking Community
Development & Health
Susan Dentzer
Editor-in-Chief
Health Affairs thanks
For its generous support of the
November 2011 issue and briefing
Opening Remarks
Elaine Bratic Arkin
Robert Wood Johnson Foundation
Forging New Connections
Between Community
Development and Health
How the Health and Community
Development Sectors are Combining to
Improve Health and Well-Being
Sandy Braunstein
Federal Reserve Board of Governors
We Are Working Side By Side
Source: Los Angeles County Department of Public Health
Overlapping Geographies And
Overlapping Goals
• Leading cause of premature death is not access to health
care, it is rooted in social, environmental and behavior
risks, which are often influenced by the community in
which you live.
• Community developers focused on improving
neighborhoods that struggle with poverty, overcrowded
housing, and high unemployment.
• Public health focused on combating poor health outcomes,
including high rates of obesity, asthma, and chronic
disease
• Both sectors are focused on the same communities, often
the same people, and the problems they both address are
interrelated.
How To Collaborate?
•
•
•
Started a series of conferences at Federal Reserve Banks across the
country – DC, LA, Boston, New York, Houston – on how community
development can work with the health sector to attack negative social
determinants of health.
Highlight good local examples of collaborations like in Seattle, where
public health and housing leaders reduce exposure to allergens in
low-income homes that can cause asthma in children.
Promote new national initiatives that combine both sectors: Healthy
Food Financing Initiative, HHS and HUD’s Choice Neighborhoods
program, new Federally Qualified Health Clinics as community
anchors not just medical exam rooms.
What’s Next?
• Build the infrastructure to help
foster collaboration
• Data and measurement, capital, policy
• Build the “business case” for
collaboration: bend the cost curve.
• Research and share the lessons
learned from collaboration
underway.
Conclusion
• If leaders in the community development and
public health sectors can grasp this moment in
time to capture the imagination of visionaries,
and bring expertise and considerable resources
to bear in order to align their efforts, both can be
rewarded by moving closer to our common goal
of an America where every individual has the
opportunity to live a long and fulfilling life.
Partnerships Among Community
Development, Public Health, And
Health Care Could Improve The
Well-Being Of Low-Income
People
David J. Erickson
Center for Community Development
Investments, Federal Reserve Bank of San
Francisco
Despite Obstacles, Considerable
Potential Exists For More Robust
Federal Policy On Community
Development And Health
Mariana Arcaya, Harvard School of
Public Health/Federal Reserve Bank of
Boston
Xavier de Souza Briggs, Massachusetts
Institute of Technology
Paper Aims
1. Where is community development
best positioned to shape health
outcomes?
2. A window of opportunity at the
federal level
3. Challenges to reform
4. Strategies and tools for progress
Improving Living Conditions
•
•
•
•
Structural determinants of health
Exposure to health risk factors
Vulnerability to health risk factors
Mitigation or exacerbation of health
consequences
Policy
Targeted funding
Knowledge generation and assessment
A Window Of Opportunity
• New federal “place-based” policy
– First ever White House Office of Urban
Affairs and Office of Rural Affairs
– Developing effective place-based policy:
community health and access to
opportunity
– Beyond need indicators: regionalism
and coordinated federal spending
• Implementation of the Affordable
Care Act
Challenges To Reform
• Fragmented jurisdictions of the
congressional committee system
• Budget scoring rules
• Deficit-oriented oversight
• “Wrong pocket problem”
Limited incentives for progress unless :
• Spending and savings accrue to a single agency
• Initiative under the jurisdiction of a single committee
• Evidence of probable impact is very strong.
Tools And Strategies
• Policy advocacy coalitions
– Robert Wood Johnson Foundation and
the Federal Reserve System
• Systems of innovation
– Test new models, refine approaches,
scale what works, terminate what does
not
– Health impact assessment methodology
Thank you.
Mariana Arcaya
Harvard School of Public Health
Federal Reserve Bank of Boston
Metropolitan Area Planning Council
marcaya@hsph.harvard.edu
Xavier de Souza Briggs
Massachusetts Institute of Technology
Xbriggs@mit.edu
Bringing Researchers And
Community Developers Together
To Revitalize A Public Housing
Project And Improve Health
Douglas Jutte
University of California, Berkeley, School
of Public Health
Community Health Centers And
Community Development Finance
Institutions: Joining Forces For
Healthy Communities
Ronda Kotelchuck, CEO
Primary Care Development
Corporation (PCDC)
CHCs, CDFIs Share Similar Origins,
Missions And Evolution
Community Health
Centers
•
•
•
•
•
Origins in War on Poverty/OEO
Provide affordable,
comprehensive primary and
preventive care to low income
communities
$11B industry: 1,200 CHCs
operating 8,000 sites, employing
200,000 people, serving 23M low
income Americans
Governed by consumerdominated boards
Overseen by HRSA/US Dept. of
Health and Human Services
Community Development Financial
Institutions
•
•
•
•
•
•
Origins in War on Poverty/OEO
Provide affordable financing and
TA to sustainable projects in lowincome communities
Over $23 billion in assets: 1,000
CDFIs spread across all states
and territories.
Typically invest in housing,
community facilities, day care,
charter schools, small businesses
Accountable to target markets
Overseen by CDFI Fund/ US
Treasury
CHCs Play Three Important Roles In
Community Development
1. Primary care is a crucial support for
community revitalization
2. CHCs are businesses generating
community jobs and secondary spending
3. CHCs are agents in addressing the social
determinants of health
The Health Care Paradigm Is Changing
Healthy Communities
(Nutrition, prevention, physical
fitness, healthy living,
environment)
Community Resources
(Supportive housing, social
services, eligibility programs, etc.)
Medical Neighborhood
(Specialists, ER, Inpatient, LTC +
Behavioral Health)
Medical Home
(Primary Care)
Interest In CHCs Is Growing Among CDFIs
• Two CDFIs historically involved: NCB Capital Impact, Primary
Care Development Corporation (PCDC) with partners including
JPMorgan Chase, Citibank, Bank of America and HSBC.
• New CDFI interest:
– CDFIs see a new market emerging: CHCs are sustainable businesses and
healthcare models.
– CHCs need affordable capital, especially to take advantage of federal CHC
expansion initiatives ($1.5B of capital appropriated to double CHC capacity;
$60B of capital need estimated)
• New CDFI initiatives
What Needs To Happen?
•
•
•
•
Awareness and collaboration at all levels:
– Community: Individual CHCs, CDFIs
– Region: Primary Care Associations, CDFI Coalitions
– National: National Association of CHCs, Opportunity Finance
Network
– Governmental: DHHS and Treasury
Cross exposure and training:
– CHCs – In the use of credit
– CDFIs – In the CHC business model, operations
Joint policy interests:
– CHC and CDFI program funding, expansion
– Health care payment reform
Research for policy, strategy, action: What are the…
– Most important factors in CHC and CDFI growth, effectiveness,
sustainability?
– Most powerful social determinants?
– Most effective interventions?
New Community Health, Food
Service And Environmental
Protection Workers Could Boost
Health, Jobs and Economic Growth
Nicholas Freudenberg, DrPH;
Emma Tsui, PhD
City University of New York School of Public Health
For more: nfreuden@hunter.cuny.edu
Proposal: Creating Entry-level Jobs
That Promote Health
• Community health workers
• Environmental remediation and protection
workers
• Food service workers
Jobs That Promote Health And Development
• Exist in sectors expected to grow in next
decade
• Offer long term potential to save public
money
• Help to reorient health care system
towards prevention and the control of
chronic diseases
• Should offer living wages, benefits and
career ladders
•
•
•
•
Barriers
Limited evaluation
and cost-benefit
studies
Private sector
opposition
Austerity mentality
Need for upgraded
jobs with adequate
wages
•
•
•
•
Windows Of
Opportunity
Dire jobs crisis
Existing funding
streams
Need to reduce cost
of health care
Need to align food
and health policies
Neighborhood Characteristics
And Access To Patient-centered
Medical Homes For Children
Jaya Aysola, MD, MPH
E. John Orav, PhD
John Z. Ayanian, MD, MPP
Harvard Medical School
Brigham and Women’s Hospital
Why Do We Care?
• Policy efforts to expand PatientCentered Medical Homes
– High quality primary care model
• Significant disparities in access to
medical homes exist
• Factors contributing to these
disparities are not well established
– Social determinants may play a role
Study Aim
• Examine the relationship between:
– Neighborhood characteristics:
cohesion, safety, physical environment
AND
– Whether children receive care from a
patient-centered medical home
– Nationally representative survey of
parents/guardians of children
(n=91,642)
What We Found
• 93% had access to both a personal
provider and usual source of care
• Only 58% had access to a medical
home
– Children more likely to have access:
• Non-Hispanic whites
• Higher income households
• Privately Insured
65
59.2
60
55
52.1
50
45
40
Unsafe
Medical Home Access* (%)
Medical Home Access* (%)
Place Matters For Medical Home Access
Safe
Neighborhood Safety
*Rates shown are after adjustment for several socioeconomic and
demographic variables. P<0.001
Neighborhood Characteristics
• Stronger predictors for medical
home access than income or race
– Reduced income disparity by half
• Not associated with access to a
primary care provider
• Associated with patient or family
centered care
If You Build It, Will They Come?
• Community engagement key for
expansion of medical homes
• Practice models should:
– Expand care teams to include
community health workers
– Form community partnerships with
trusted community entities
– Identify ways to build collaborative
relationships between providers and
patients/families
Acknowledgements
• Shimon Shaykevich, MS
• Ichiro Kawachi, MD, PhD
An All-Payer System:
Solution For The Alleged
Cost-Shift
Uwe Reinhardt
Princeton University
Variations In Medicare
Payments For Surgery Highlight
Opportunities And Challenges
For Bundled Payment Programs
David C. Miller, MD, MPH
Assistant Professor
Department of Urology
Center for Healthcare Outcomes & Policy
University of Michigan
Bundled Payments For Inpatient Surgery
• Surgery represents a large component of national health
care spending
• CMS and other payers are considering bundled payments
for inpatient surgery
– Lump sum payment to hospitals, physicians, and other
providers
– Aimed at improving care coordination and reducing
duplicative or unnecessary services
• Implications of bundled payments depend on extent of
true variation in current payments (payers) and patterns
of variation across procedures and specialties (hospitals)
Effects Of Price- And Case Mix Adjustment On
Variations In Medicare Payments For Surgery
CABG
1st Quintile
5th Quintile
Difference
Actual
$34,143
$57,976
$23,833 (69.8%)
Price Adjusted
$38,083
$47,863
$9,780 (25.7%)
Case mix & Price
Adjusted
$39,155
$46,590
$7,435 (19.0%)
1st Quintile
5th Quintile
Difference
Actual
$15,997
$27,676
$11,679 (73.0%)
Price Adjusted
$17,524
$24,963
$7,439 (42.5%)
Case mix & Price
Adjusted
$17,784
$24,693
$6,909 (38.9%)
Hip Replacement
Miller et al, Health Affairs, Nov 2011
Source Of Payment Variation Depends On The
Procedure
% Variation in total Medicare episode payments
Hip Replacement
AAA Repair
Colectomy
CABG
Post-discharge ancillary care
Readmissions
Physician Services
Index Hospitalization
Miller et al, Health Affairs, Nov 2011
Correlations In Medicare Payments For Surgery
Vary Across Procedures And Specialties
Miller et al, Health Affairs, Nov 2011
Implications For Bundled Payments
• Wide variation in payments imply opportunities for
substantial savings for CMS and other payers
– Depends on where payers set the payment rate and on the
procedures and services included in the “bundle”
• Probably important to include post-discharge care in the
lump sum payment
• Bundled payments could prove to be a financial “wash” for
many hospitals
– Hospitals expensive for multiple procedures (up to 30% in our
analyses) will have strong incentives to reduce costs
Kicking The Tires:
Evaluating The Road Test
Of PROMETHEUS Payment
Peter Hussey
RAND Corporation
Is The Mandate Really The
“Linch Pin” To The ACA?
John Sheils
The Lewin Group
Without The Individual Mandate,
The Affordable Care Act Would
Still Cover 23 Million; Premiums
Would Rise Less Than Predicted
John Sheils
Randall Haught
Exhibit 1: Individual Coverage Under
The Affordable Care Act With And
Without The Individual Mandate
Affordable Care Act as
Written
Exchange Status
In exchange, with subsidy
Number of
people
(millions)
Benefits
cost per
person
Affordable Care Act without the
Mandate
Number of
people
(millions)
Benefits
cost per
person
Selection
factora
22.1
$3,838
20.8
$4,135
7.7%
In exchange, no subsidy
4.0
$4,494
2.3
$6,060
34.9%
Out of exchange, no subsidy
4.6
$2,478
3.0
$3,126
26.2%
30.7
$3,721
26.2
$4,189
12.6%
Total or average
SOURCE Lewin Group estimates.
NOTE Numbers may not sum to totals because of rounding.
a The percentages are equal to average costs for covered people under the Affordable Care Act (ACA)
without the mandate over average costs under the Affordable Care Act as with the mandate.
Exhibit 2: Coverage Under The Affordable
Care Act, With And Without The Individual
Mandate And Penalty
Number of People (millions)
Coverage
before the act
Coverage
under the act
as written
Coverage under
the act without
the mandate
Employer
152.2
149.8
147.7
Nongroup
12.0
30.7
26.2
Medicaid or CHIPa
45.2
59.8
58.6
Medicare, TRICARE, or otherb
47.1
47.1
47.1
No insurance
51.6
20.7
28.5
308.1
308.1
308.1
Primary Source of Coverage
Total
SOURCE Lewin Group estimates.
NOTES These estimates assume the act is fully implemented in 2011. CHIP is the Children’s Health
Insurance Plan. TRICARE is the health care program serving Uniformed Service members, retirees
and their families.
a Does not include those eligible for both Medicaid and Medicare.
b Other includes the Indian Health Service or any other state or local sources of coverage.
Exhibit 3: Coverage Loss And Premium
Increases Under The Affordable Care Act
Without The Individual Mandate And Penalty
Source of Estimate
Loss of coverage
(millions of people) Premium increases
Congressional Budget Office
16.0
15.0–20.0%
Gruber
24.0
27.0%
Urban Institute
17.7
3.5%
7.8 (6.0 - 9.3)
12.6% (6.6%-18.0%)
The Lewin Group
SOURCES: Congressional Budget Office, Note 4 in text; Gruber, Note 5 in text; The Lewin
Group, The Lewin Group estimates.
NOTE These estimates are compared to the Affordable Care Act as written.
Projecting Medicaid
Enrollment, Costs, And
Workforce Needs Under Health
Reform: Uncertainty Behind
The Numbers
Katherine Swartz
Harvard University School
of Public Health
Health Affairs thanks
For its generous support of the
November 2011 issue and briefing