Policy Road Map for Health Equity:Outlook and Opportunities

Minnesota Community Health Worker Alliance Statewide Meeting

Michael Scandrett, JDEmily 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 developments4. Opportunities for CHWs

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1. Health Care Reform& Expansion of Health

Coverage

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Background: the American Health Care

SystemMore expensive than other countriesPoorer health of the populationHighly variable quality, effectiveness and

safetyInadequate preventionPoor management of chronic diseasePerverse financial incentivesUnsustainable cost increases

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Background: the American Health Care

System

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ConsequencesDecreased worker productivityRising costs contribute to government

budget deficits and divert resources from other government priorities

Erodes health insurance coverage and benefits

More uninsured and underinsuredPersistent health disparities

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Federal Reforms: 2010Affordable Care Act (ACA)

Medicaid Expansion Health Insurance Exchanges: a marketplace

to buy insuranceRegulations of Private Health Insurance Reforms to Provider Payment MethodsIncreased Prevention and WellnessAnd more….

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ACA: Expands Health Coverage

Individual Mandate

Health Insurance

Market Reform

Medicaid Coverage

(Up to 133% FPL)

Exchanges(Subsidies for 133

– 400% FPL)

Employer Sponsored Coverage

Universal Coverage

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

9 20- 29% (14 states)Less than 20% (14 states) 30-49% (16 states)

More than 50% (7 states, including DC)

SOURCE: KCMU/Urban Institute analysis of 2011 and 2012 ASEC Supplements to the CPS.

Uninsured Rates in “Communities of Color”

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Disparities in Insurance Coverage

Source: MDH, Health Economics Program

MN Coverage Options

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Minnesota’s Health Insurance Marketplace223,000 Enrollments to Date

126,039 in Medicaid46,417 in MinnesotaCare50,733 in Qualified Health Plans

Navigators help consumers choose a health plan and enroll

Many problems with MNsure’s start-tup

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Impact of ACA on Uninsured

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

Estimated Uninsured in MN, With & Without ACA

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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

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The Remaining Uninsured:201,000

Source: Gruber/Gorman Analysis, Prepared for Health Care Reform Task Force, MN, 201216

Reason for Coverage Gap

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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%)

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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

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Uninsured Immigrants: Future Policy Opportunities Emergency Medical Assistance (EMA):A DHS Report on EMA called for expanding the coverage and benefits for undocumented immigrants2014 Legislation requires a report to the 2015 Legislature on possible improvements to the EMA programFunding for Safety Net Providers:2014 Legislature provided additional grants to safety net providers to serve uninsured patients2015 is a State Budget Session where funding for the uninsured will be decided

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Health Coverage: Opportunities for CHWs

MNsure outreach to communitiesMN enrollment navigation and assistanceAdvocacy on behalf of communities of

color:MNsure advisory committees and BoardState agenciesMN state legislaturePolitical 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 ReformImprove the health of the patient

populationImprove the patient/consumer experienceImprove the affordability of health care

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2008 & 2010 Minnesota ReformsNew 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

Minnesota: Ahead of the Curve

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New Care Models

A primary care provider or team

Certified by MDHPaid 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

Health Care Homes

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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)Medical Assistance/MinnesotaCare ACOs in MNDHS contracts directly with IHPs in a new way to

serve a specified patient populationIHPs 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?Large integrated hospital-clinic

organizationsAlliances of independent clinics and

hospitalsSafety Net Providers serving low-income

and underserved populationsCounty 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

factorsCo-occurring MI and chemical dependencyNon-medical services needed (housing,

transportation, etc.)Risk-adjustment for higher costs, poorer

outcomes30

IHP: Shared Savings

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$120,000,000

$130,000,000

$140,000,000

$150,000,000

$160,000,000

$170,000,000

$180,000,000

1 2 3 4 5 6

MA

Spen

ding

per

Dem

o

Year

State

HCDS

SharedSavings

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

FUHN Project Goals:

5/21/2013

Improved Access to High Quality Primary Care

Improved Clinical QualityImproved Consumer

Engagement and Satisfaction

Reduced Total Cost of Care

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Challenges: What will it takefor an IHP to succeed?Effective Team-based Primary Care servicesRobust Care CoordinationPatients actively engaged in their care and healthCommunities actively engaged in improving

population healthHealth 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 WaveMore HCDS projects will coming online in 2014State’s goal: cover 50% of the Medicaid

population in ACO/IHPs (excluding elderly and people with disabilities)

ACOs are expanding in the private sector, tooExpanding 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$45 million grant from CMSExpansion 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 deliveryAccelerate adoption of ACO models in MedicaidEnsure providers are able to securely

exchange dataCreate “Accountable Communities for Health”

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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

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Accountable Communitiesfor HealthExpand IHP Accountable Care model beyondtraditional 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.

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Measuring QualityUnder 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

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 & WorkforceHealth professional education is lagging

behind emerging workforce trends:Increased reliance on primary care providersMultidisciplinary, team-based careUse of allied, mid-level and paraprofessional

practitionersSkilled in using EHR, HIE and data to drive

care deliverySkilled at patient and community

engagementCultural competency and relevance41

Recap of Trends1. Care coordination of all health care services needed

by a patient 2. Services delivered through multi-disciplinary primary

care teams.3. Provider accountability for quality, health outcomes

and costs using standardized measures.4. Improved patient satisfaction and engagement in

their own health and health care.5. 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.

6. Use of health information technology to improve care and reduce costs.

7. New: Coordination of health care with non-health care services to address social determinants (poverty, race/ethnicity, literacy, homelessness, etc.) and reduce health disparities.42

New Models: Opportunities for CHWs

Member of Primary Care TeamImprove Patient EngagementImprove Community EngagementImprove Population HealthAddress Social Determinants of Health (REL/SES)Advocate for Change:

Within health care organizationsIn communitiesWith government agenciesWith 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 EquityIncreased attention to health disparities MDH Report – February 2014:

“Health in All Sectors”Statewide Leadership – Structural RacismStrengthen Community RelationshipsRedesign Grant ProgramsStrengthen Data on Disparities

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Health Care Reforms: Impact on Health Disparities

MA expansion improves health coverage & benefitsPatient relationship and engagement is key to

provider care delivery and payment model reformsPayment 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 EquityHealth Equity grants Funding for InterpretersGrants for Health Care for Uninsured

PatientsEmergency Medical Assistance ProgramStatewide Quality Reporting and

Measurement System (SQRMS) Changes

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Data: SQRMS, REL & SESData 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 disparitiesRisk Adjustment: Providers are accountable for quality of careCurrent measures do not adjust for REL/SES, causing harm to providers who serve REL/SES patients

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Data: SQRMS, REL & SES2014 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 LegislatureConsult 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 SIM Accountable Communities for Health

Statewide community engagement Summer 2014RFP expected Sept. 1, 2014

2015 Legislative SessionState budget yearLegislative proposals from the Health Equity

ReportImplementation plan for REL/SES quality

measurement and risk adjustment Emergency Medical Assistance program changesCoverage 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; Improve chronic disease management; andIncrease the health knowledge and self sufficiency of

underserved populationsIncrease 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 CareEducating 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 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

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

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QUESTIONS

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