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:


Health care reform & health coverage 2.

New provider care delivery and payment models 3.

Health equity policy developments 4.

Opportunities for CHWs

3 1. Health Care Reform & Expansion of Health Coverage


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


Background: the American Health Care System



     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


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….

ACA: Expands Health Coverage

Universal Coverage


Medicaid Coverage

(Up to 133% FPL)

Individual Mandate Health Insurance Market Reform Employer Sponsored Coverage Exchanges

(Subsidies for 133 – 400% FPL)

9 AK

Overall, Minnesota rate of Uninsured Ranks #3…HOWEVER…

Uninsured Rates in “Communities of Color”

CA WA OR NV HI ID AZ UT MT WY CO NM VT ND SD NE KS TX OK MN IA MO AR WI IL MS MI PA IN TN KY AL OH WV VA SC NC GA NY LA FL Less than 20% (14 states) 20- 29% (14 states) ME NJ CT DE MD NH MA RI DC 30-49% (16 states) SOURCE: KCMU/Urban Institute analysis of 2011 and 2012 ASEC Supplements to the CPS.

More than 50% (7 states, including DC)

Disparities in Insurance Coverage


Source: MDH, Health Economics Program


MN Coverage Options


12     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

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


But, the ACA has not solved the problem of the uninsured

The Remaining Uninsured:201,000


Source: Gruber/Gorman Analysis, Prepared for Health Care Reform Task Force, MN, 2012


Reason for Coverage Gap

Affordability • Those who pay more than 8% of income on health care • Individuals with incomes below the tax filing threshold ($10K individual/$20K family ) Newly Uninsured • 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 Immigration Status • 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 (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


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


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



23 2. New Provider Care Delivery and Payment Models


“Triple Aim” of Health Reform

   Improve the health of the patient population Improve the patient/consumer experience Improve the affordability of health care

Minnesota: Ahead of the Curve

2008 & 2010 Minnesota Reforms 25    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


Data Payment

New Care Models

Health Care Homes

26       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


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).


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


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


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


IHP: Shared Savings

$180,000,000 $170,000,000 $160,000,000 $150,000,000 $140,000,000 $130,000,000 $120,000,000 1 2 3


4 5 6 State HCDS

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


FUHN Project Goals:

 Improved Access to High Quality Primary Care  Improved Clinical Quality  Improved Consumer Engagement and Satisfaction  Reduced Total Cost of Care 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


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


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 ”


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


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.


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



  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


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









Recap of Trends

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.)



45 3. Health Equity Policy Developments


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

Health Care Reforms: Impact on Health Disparities

47      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.


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



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



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


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


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



54 4. Opportunities for Community Health Workers under Reform Trends


The Value of CHWs in Health Care

     Educating and engaging patients in managing their health and 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

       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