Health Enterprise Zones and
Infant Mortality in Maryland
April 9, 2014
Carlessia A. Hussein, RN, DrPH
Director
Office of Minority Health and Health Disparities
Maryland Department of Health and Mental Hygiene
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Maryland is One of the Most
Racial/Ethnic Diverse States
45% minority
4 jurisdictions
>50% minority
6 jurisdictions
>40% minority
9 jurisdictions
>33% minority
Out of 24
jurisdictions
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Disparities by Race/Ethnic Group
Selected Racial and Ethnic Health Disparities in Maryland
(Shows how many times higher the minority rate is compared to the White rate)
3
Unadjusted ED Visit Rates per
100,000 for Diabetes, by County,
Black vs. White, Maryland 2011
1600
1400
Both Place and Race Matter to this rate
1200
Black
1000
800
600
400
200
0
Maryland
White
Hospital Admission Rate
Disparities Black vs. White
• For Ambulatory Care Sensitive Conditions (or AHRQ
Prevention Quality Indicators) for Maryland:
• Kid’s Asthma: Black rate is 3.1 times higher
• Adult Asthma: Black rate is 2.7 times higher
• Adult Hypertension:
4.5 times higher
• Adult Congest Heart Fail
2.6 times higher
• Various Diabetes metrics
2.6x to 4.6 x higher
• (data from AHRQ State Snapshots as presented in the MHQCC
Health Disparities Workgroup Report)
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Cost of Disparities
in Maryland
• Minority Health Disparities cost Maryland
between 1 and 2 Billion Dollars per year of
direct medical costs.
• Excess charges from Black/White hospitalization
disparities alone were $814 Million in 2011.
– These are just the hospital charges, NOT including
physician fees for hospital care, emergency
department charges, or any outpatient costs.
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Maryland Health
Disparities Workgroup
• Convened by Maryland Health Quality and Cost Council in
2011 (Council chaired by Lt. Gov Brown and Sec Sharfstein)
• Workgroup Chaired by Dean Reece of U of MD School of
Medicine, included diverse experts on minority health
• Maryland Office of Minority Health and Health Disparities
staffed workgroup and co-drafted Final Report in 2012
• Report Recommendations:
• Health Enterprise Zones (HEZs)
• Maryland Health Innovation Prize
• Racial and Ethnic tracking of health care delivery performance
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Report Implementation
• Legislature passed Maryland Health Improvement and
Disparities Reduction Act of 2012 based on the Report
• Administration funded HEZ program with $ 4 million
per year for four years beginning in 2013
• State Health Department and the Community Health
Resources Commission oversee implementation
• Five HEZs were designated in January 2013
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Maryland Health Improvement &
Disparities Reduction Act of 2012
• Health Enterprise Zones
• Racial / ethnic data from insurers (MHCC)
• Racial / ethnic data for incentive programs:
• Hospital incentives (HSCRC)
• Patient-Centered Medical Homes (MHCC)
• Hospitals report efforts to reduce Disparities
• Health education institutions report efforts
• Cultural competency workgroup of Health
Quality and Cost Council
9
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Health Enterprise Zones:
Definition and Eligibility
• A Health Enterprise Zone was defined in law as
– A contiguous area of one or more zip codes
– Experiencing documented poor health outcomes
and health disparities
– Experiencing documented economic disadvantage
• Operationalized eligibility as
– Bottom 50% on one of two poverty metrics, AND
– Bottom 50% on one of two poor health metrics
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Health Enterprise Zones:
Provider Incentives
• HEZ enabling legislation provides various
statutory incentives for providers in the Zones:
– State income tax credits
– Hiring tax credits
– Grants for equipment purchase or lease
– Loan repayment assistance programs
• These are contingent on
– Participating in cultural competency training
– Accepting Medicaid and uninsured patients
– Participating with the Coordinating Organization 12
Health Enterprise Zones:
Community Intervention
• HEZ enabling legislation provides grants for
community-level public health interventions:
– Deploying community health workers
– Increasing availability of fresh fruits and vegetables
– Improving access to safe physical activity
– Transportation assistance programs
– Mobile crisis teams for mental health
– Providing cultural competency training
– Supporting community coalitions
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Health Enterprise Zones:
Principles for Proposals
• HEZ call for proposals contained 13 principles
that doubled as proposal review criteria.
• Several key principles were:
– Cultural, linguistic, and health literacy
competency
– Workforce diversity
– Outreach and targeting of minority populations
– Racial, ethnic & language data collection/reporting
– Addressing social determinants of health
– Balance between provider and community focus
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Health Enterprise Zones:
Progress and Future
• Five HEZs designated in January of 2013
• To date, 43 new health providers of various
types hired in the zones
• Cultural competency training assistance
• Programmatic technical assistance
• Quarterly reporting on productivity and quality
• External evaluation contract to be established
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Infant Mortality in Maryland:
DEMO Programs
• MHHD is currently funding 3 pilot Minority Health
Disparities Reduction Demonstration Grant (DEMO)
sites for minority infant mortality in FY 2014
• DEMO Programs utilize:
– Minority Perinatal Navigators, CHWs, and health
promoters;
– Community coalitions and taskforces;
– Increased community outreach and education;
– Enhancement of clinical services;
– Infrastructure for Program Sustainability;
– Inter-county collaboration.
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Infant Mortality in Maryland:
General Background
• Racial and Ethnic Breakdown of births
and infant deaths, Maryland 2012
2012
Births
% total
White
42,791
59%
174
38%
4.1
Black
24,306
33%
251
55%
10.3
Hispanic
10,201
14%
56
12%
5.5
5,430
7%
21
5%
3.9
164
0%
1
0%
6.1 **
Asian
Amer Ind
Deaths
% total Death rate *
* Infant deaths per 1000 live births, the Infant Mortality Rate
**American Indian rate varies greatly year to year due to small numbers
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Infant Mortality Reduction
in Maryland
Maryland Infant Mortality Rates, 2006-2012, by Race, Maryland Vital
Statistics Administration
25.0
Deaths per 1,000 Live Births
20.0
Black
15.0
10.0
White
5.0
0.0
2005
2006
Maryland Black
2007
2008
Maryland White
2009
2010
Linear (Maryland Black)
2011
2012
2013
Linear (Maryland White)
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Racial/Ethnic Population in
Delaware
Racial or Ethnic Minority Population,
by Jurisdiction, Delaware, 2010
33.7% minority
2 jurisdictions
>33% minority
Out of 3
jurisdictions
% Minority
New Castle
37.5%
Kent
33.4%
Sussex
23.5%
Delaware
33.7%
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Infant Mortality in Delaware:
General Background
• Racial and Ethnic Breakdown of births and infant
deaths, Delaware 5-Year Average, 2006-2011
2006-2011
Births
% total
White
7,818
68%
46
51%
5.9
Black
3,140
27%
42
46%
14.2
598
5%
3
3%
5.2
Other Race
Deaths
% total Death rate *
* Infant deaths per 1000 live births, the Infant Mortality Rate
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Infant Mortality Reduction
in Delaware
Delaware Infant Mortality Rates, 2004-2011, by Race, Delaware Vital Statistics
Administration
25.0
Deaths per 1,000 Live Births
20.0
Black
15.0
10.0
White
5.0
0.0
2003
2004
Delaware White
2005
2006
Delaware Black
2007
2008
2009
Linear (Delaware White)
2010
2011
2012
Linear (Delaware Black)
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Disparities Reduction Principles
HEZs
Community coalitions
DEMO Program
Community coalitions and taskforces
Community health workers and workforce Minority Perinatal Navigators, CHWs, and
diversity
health promoters
Outreach and targeting of minority
populations
Increased community outreach and
education
Addressing social determinants of health
Linkage to community resources
Provider Incentives (tax credits, loan
repayment)
Enhancement of clinical services
Evaluation and Sustainability
Infrastructure for Program Sustainability
Chronic Disease Utilization
Chronic Disease and Infant Mortality
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Linkages to Maryland HEZs
DEMO PROGRAMS
Shared logic model
and common
operational design
features
HEZs
Programs develop
locally-targeted
strategies for
reducing infant
mortality within a
community
Low Birth Weight is used in designation
of HEZs & HEZs may choose to target
Infant Mortality
INFANT
MORTALITY
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Recommendations
• Use HEZ/DEMO model to target infant mortality in clusters of zip codes
• Identify specific small population groups by geographic areas where
infant mortality rates and numbers are higher than the state average
• Where small groups of individuals with infant mortality that is higher
than acceptable, target communication in a culturally competent
manner
• Distribute infant mortality data trends information (rates and numbers)
by small areas within counties
• Activate a coalition of diverse interest groups ( health, citizens, elected
officials, faith-based, etc.) to focus on reducing infant mortality as a
community
• Engage in innovative communication: movie theater ads, Man/Boys
support groups, sports and entertainment personalities,
grandma/senior citizen groups, etc.
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Important Links
Health Disparities Plan
http://dhmh.maryland.gov/mhhd/Documents/Health%20Disparities%20Plan%202010.pdf
Health Disparities Workgroup Final Report
http://www.governor.maryland.gov/ltgovernorn/documents/disparitiesreport120117.pdf
Cultural Competency Workgroup Report
http://dhmh.maryland.gov/mhgcc/SiteAssets/SitePAges/meetings/Cult%20Comp%20Full%20Report%2012.13.
pdf
Maryland Chartbook of Minority Health and Minority Health
Disparities Data
http://dhmh.maryland.gov/mhhd/Documents/Maryland-API-Data-Report-2013.pdf
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Contact Information
Office of Minority Health and Health Disparities
Maryland Department of Health and Mental Hygiene
201 West Preston Street, Room 500
Baltimore, Maryland 21201
Phone: 410-767-7117
Fax: 410-333-7525
Website: www.dhmh.maryland.gov/mhhd
Facebook: www.facebook.com/Marylandmhhd
Twitter: @MarylandDHMH
Email: dhmh.healthdisparities@maryland.gov
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