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

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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

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1. Health Care Reform
& Expansion of Health Coverage

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Background: the American Health Care System
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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

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Background: the American Health Care System

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Consequences
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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

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Federal Reforms: 2010
Affordable Care Act (ACA)
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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
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Medicaid
Coverage
(Up to 133% FPL)
Individual
Mandate
Health Insurance
Market Reform
Employer Sponsored Coverage
Exchanges
(Subsidies for 133 – 400%
FPL)

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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
Less than 20% (14 states)
20- 29% (14 states)
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
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
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Source: MDH, Health Economics Program

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MN Coverage Options
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Minnesota’s Health Insurance Marketplace
223,000 Enrollments to Date
 126,039 in Medicaid
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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

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Preview: Access to care 5 years after reforms enacted

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

The Remaining Uninsured:201,000
16 Source: Gruber/Gorman Analysis, Prepared for Health Care Reform Task Force, MN, 2012

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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

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Compared to the Insured
Population, the Uninsured are…
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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%)

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The Remaining Uninsured:
Undocumented Immigrants
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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

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Uninsured Immigrants: Future
Policy Opportunities
Emergency Medical Assistance (EMA):
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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:
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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

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Health Coverage:
Opportunities for CHWs
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MNsure outreach to communities
MN enrollment navigation and assistance
Advocacy on behalf of communities of color:
 MNsure advisory committees and Board
 State agencies
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MN state legislature
Political campaigns

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QUESTIONS

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2. New Provider Care Delivery and Payment Models

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“Triple Aim” of Health Reform
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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
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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
Measure
Data
Payment

New Care Models
Health Care Homes
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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

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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).

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MN ACOs:
Integrated Health Partnerships (IHPs)
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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

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Who is Establishing ACOs?
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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

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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
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Non-medical services needed (housing, transportation, etc.)
Risk-adjustment for higher costs, poorer outcomes

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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
Year
4 5 6
State
HCDS
Shared
Savings

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FUHN
(FQHC Urban Health Network)
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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

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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

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Challenges: What will it take for an IHP to succeed?
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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

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DHS Projects: The Next Wave
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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

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State Innovation Model (SIM) Grant
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$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
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Accelerate adoption of ACO models in Medicaid
Ensure providers are able to securely exchange data
 Create “Accountable Communities for Health ”

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SIM Budget Allocations
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$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

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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
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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.

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Measuring Quality
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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

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SQRMS
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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

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Healthcare Education
& Workforce
 Health professional education is lagging behind emerging workforce trends:
 Increased reliance on primary care providers
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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

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1.
2.
3.
4.
5.
6.
7.
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.

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New Models: Opportunities for CHWs
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Member of Primary Care Team
Improve Patient Engagement
Improve Community Engagement
Improve Population Health
Address Social Determinants of Health (REL/SES)
Advocate for Change:
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Within health care organizations
In communities
With government agencies
With policymakers (MN Legislature, county boards, etc.)

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QUESTIONS

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3. Health Equity Policy Developments

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Health Equity
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Increased attention to health disparities
MDH Report – February 2014:
 “Health in All Sectors”
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Statewide Leadership – Structural Racism
Strengthen Community Relationships
Redesign Grant Programs
Strengthen Data on Disparities

Health Care Reforms: Impact on
Health Disparities
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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.

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2014 Legislative Session
Highlights – Health Equity
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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

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Data: SQRMS, REL & SES
Data on Health Disparities:
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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:
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Providers are accountable for quality of care
Current measures do not adjust for REL/SES, causing harm to providers who serve REL/SES patients

Data: SQRMS, REL & SES
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2014 Legislation
 SQRMS: plan to measure quality of care based on
REL/SES and adjust provider quality scores based on these factors
 MDH :
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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

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Health Equity Issues to Watch
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SIM Accountable Communities for Health
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Statewide community engagement Summer 2014
RFP expected Sept. 1, 2014
2015 Legislative Session
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State budget year
Legislative proposals from the Health Equity Report
Implementation plan for REL/SES quality measurement and risk adjustment
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Emergency Medical Assistance program changes
Coverage and access to care for the remaining uninsured

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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;
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Improve chronic disease management; and
Increase the health knowledge and self sufficiency of underserved populations
Increase patient and community engagement

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QUESTIONS

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4. Opportunities for Community
Health Workers under Reform Trends

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The Value of CHWs in Health Care
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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

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Opportunities for CHWs:
Individually
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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

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Opportunities for CHWs:
Working Together
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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
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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

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QUESTIONS