OBJECTIVES

1. Health Policy and Health Equity:Arizona Policy PerspectivesThird Annual Latino Health Promotions Summit: Achieving Health EquityFebruary 16, 2013University of Arizona, Arizona Cancer Center, Tucson, AZ Anita C. Murcko, MD, FACP President & CEO, Cambiare, LLCClinical Associate Professor, University of Arizona Health Sciences, College of PharmacyAdjunct Faculty, Arizona State University, Biomedical Informatics

2. OBJECTIVES Define relevant health equity terms Focus on health equity-focused areas of Accountable Care Act (ACA) Provide overview of the ADHS newly-released Arizona Health Equity Stakeholder Strategies Using ACA to improve health and care in Arizona

3. Community Integrated Healthcare • Patient, Population, and Community Centered • Community Health Resource Linked • Cost , Quality, and Population Health Outcome Transparency • Community Healthy Living Choices • Community Health Integrated networks capable of addressing psycho social/economic and LTC needs • Right care, at the right time in the right setting • Population based reimbursement • Learning Organization: capable of • rapid deployment of best practices • Community Health Integrated • Community Healthy Living Oriented • Community Health Capacity Builder • Community based support developer • Shared community health responsibility • E-health and telehealth capable • Wide use of remote monitoring and telehealth and e-health management • Health E-Learning resources, social networking, health literacy tools Health System Transformation Critical Path Health System Transformation Evolution Critical Path Community Integrated Health Care System 3.0 Coordinated Seamless Health Care System 2.0 Uncoordinated Health Care System 1.0 Outcome Accountable Care Episodic Non Integrated Care • Patient/Person Centered • Transparent Cost and Quality Performance • Results oriented • Assures Access to Care • Improves Patient Experience • Accountable provider networks designed around the patient including LTC needs • Shared Financial Risk • HIT integrated • Focus on care management • and preventive care • Primary Care Medical Homes • Care management/ prevention focused • Shared Decision Making and Patient Self Management • Episodic Health Care • Sick care focus • Uncoordinated care • High Use of Emergency Care • Multiple clinical records • Fragmentation of care • Lack integrated care networks • Lack of integration between acute and long-term care settings • Lack quality & cost performance • transparency • Poorly Coordinated Chronic Care Management

4. What is Health Equity? Health Equityis achieving the highest level of health for all people—identifying and addressing avoidable inequalities, especially for the socioeconomically disadvantaged and those who have sustained historical injustices. - Source: Healthy People 2020

5. What are Health Disparities? Health Disparities are differences in health status in distinct segments of population, such as: • Gender, Race or Ethnicity • Education or Income • Disability • Living in various geographic localities

6. What are other key Health Equity factors? • Social determinants of health—examplesinclude gender, socioeconomic status, employment status, educational attainment, food security status, availability of housing and transportation, racism, and health system access and quality • Behavioral determinants of health—examplesinclude patterns of overweight and obesity; exercise norms; and use of illicit drugs, tobacco, or alcohol • Environmental determinants of health—examples include lead exposure, asthma triggers, workplace safety factors, unsafe or polluted living conditions • Biological and genetic determinants of health—examplesinclude family history of heart disease and inherited conditions such as hemophilia and cystic fibrosis

7. The moral test of government is how it treats those who are in the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadows of life, the sick, the needy and the handicapped.” -Hubert Humphrey,1977

8. Legislation and Health Equity 1. ARRA (American Recovery and Reinvestment Act) February 2009 • Health Information Technology for Economic and Clinical Health (HITECH) • Health Information Exchange (HIE) funding each state including Direct Program (secure messaging) • Regional Extension Center (REC) to accelerate electronic record adoption • Meaningful Use • Patient Centered Medical Home (PCMH) • ACA (Patient Protection and Affordable Care Act) March 2010 and upholding by Supreme Court of United States (SCOTUS) • Health Insurance Market Reform (coverage expansion, community rating, administrative cost controls (80-85%), essential health benefits, dependents to age 26; health insurance exchanges) • Healthcare delivery system reforms (ACO, PCMH, innovations) • Healthcare payment reforms (ACO, incentives for prevention and primary care, state flexibility in new model financing)

9. Strategic Aims of ACA Assuring all Americans have better care, better health, and lower costs through continuous coverage, improved health system performance, self responsibility, and patient/provider mutual accountability.

10. ACA’s Three Pillars of Reform Affordable Care Act

11. ACA’s Health Equity TOP TEN Access Prevention Non-discrimination Data HRSA expansion Health Professional Opportunity Grants Maternal / Infant Home Visitation National Health Services Corps Community Transformation Grants Community Health Workers

12. ACA Provisions that Address Health Disparities-1 Expanding coverage and access to care give millions of people and small businesses access to affordable coverage. • From 50 million now to 16 million by 2019 • Mechanisms include: • Medicaid expansion (2014) and • Health Insurance Exchanges (2014)

13. ACA Provisions that Address Health Disparities-2 Emphasis on prevention by encouraging coverage for: • Any clinical preventive service recommended with a grade A or B by the U.S. Preventive Services Task Force (USPTF); • Immunizations recommended by the Advisory Committee on Immunization Practices (ACIP).

14. Continued • Medicare beneficiaries can now receive • personalized prevention plans, • initial preventive physical examination, and • any Medicare-covered preventive service recommended (grade A or B) by the USPTF

15. ACA Provisions that Address Health Disparities-3 Nondiscrimination: • Extends existing federal civil rights laws prohibiting discrimination on the basis of race, color or national origin, gender, disability, or age to any health program or activity receiving federal financial assistance AND • Must provide information in a culturally and linguistically appropriate manner

16. ACA Provisions that Address Health Disparities-4 Data • Provisions to strengthen federal data collection efforts • Requires all federally funded programs to collect race, ethnicity, primary language, disability status, and gender.

17. ACA Provisions that Address Health Disparities-5 HRSA Community Health Center Program: Expands access to primary health care • $11 billion for HRSA Community Health Center CHC program over next five years-- doubling number of patients • 19 million patients now served • 63 percent are racial and ethnic minorities • 92 percent are below the federal poverty level

18. Continued New Access Points (NAPs) grant program. • 350 NAPs • Increase preventive and primary healthcare services for eligible public and nonprofit entities • Including tribal, faith-based and community-based organizations.

19. ACA Provisions that Address Health Disparities-6 Health Professional Opportunity Grants (HPOG): human service program grants assist organizations that serve Native American, Hispanic, and African American people. • Comprehensive healthcare-related training to low-income workers and TANF participants • Supportive services to improve success (such as transportation, dependent care, and temporary housing)

20. ACA Provisions that Address Health Disparities-7 Maternal, Infant, and Early Childhood Home Visitation Program: • Home visiting is an effective and relatively low-cost strategy • Targeted communities have more premature births, low birth-weight infants, infant mortality, poverty, crime and domestic violence, high rates of high school dropouts, substance abuse, and unemployment.

21. ACA Provisions that Address Health Disparities-8 National Health Service Corps (NHSC): • $1.5 billion over five years to expand the NHSC. • Since 1970s, NHSC funds and places health professionals in Health Professional Shortage Areas to provide healthcare services to underserved in exchange for loan repayment or scholarships, half of them in health centers. • One-third of these clinicians are minorities.

22. ACA Provisions that Address Health Disparities-9 Prevention and Public Health Funds: Community Transformation Grants • State and local governmental agencies, tribes and territories, and national and community-based organizations • Implementation, evaluation, and dissemination of evidence-based community preventive health activities to reduce chronic disease rates, prevent the development of secondary conditions, and address health disparities.

23. ACA Provisions that Address Health Disparities-10 ACA authorizes promotion of community health workers • Promotoras, peer leaders, community ambassadors, patient navigators or health advocates • Uniquely skilled in providing culturally and linguistically appropriate services, particularly in diverse, underserved areas. • Critical role in providing enrollment assistance to racial and ethnic minorities.

24. Key Disparity Measures-1

25. Key Disparity Measures-2

26. Resources

28. Arizona Health Equity Stakeholder Strategies January 2013 • Vision:Health equity for all. We envision a state where each person has equal opportunity to prevent and overcome disease and live a longer, healthier life. • Mission: to promote and protect the health and well-being of the minority and vulnerable populations of Arizona by enhancing the capacity of public health system to effectively serve minority populations and reduce health disparities. http://azdhs.gov/phs/healthdisparities/ 28

33. Key Drivers of Health Equity Shared Reward and Risk Value Based Payment Methods Accountable Care Health Systems & Medical (Health) Homes

35. Health Equity Starts with Access “My concerns about the Affordable Care Act are well-known, but it is the law of the land. With this expansion, Arizona can leverage nearly $8 billion in federal funds over four years, save or protect thousands of quality jobs and protect our critical rural and safety-net hospitals.” -Governor Brewer, 2013 State of the State

36. Covering Low Income Arizonans • $7.9 billion in federal funds over four years • $1.6 billion in the first year • Expand AHCCCS to 133 percent of the federal poverty level ($14,856 for an individual) • Add coverage for 240,000 and continue insuring 50,000 childless adults (coverage via Federal waiver expires at year’s end) • Funded by local provider fee (on hospitals)

37. We all have a Role

38. Your help is needed now • Send a clear, consistent, and powerful message to Arizona’s lawmakers that Medicaid Coverage proposal makes sense for Arizona. http://www.azahcccs.gov/publicnotices/MedicaidExpansion.aspx • Coverage expansion requires providers • Healthcare workforce including Graduate Medical Education crisis • Telemedicine and eHealth expansion • Set the stage for 2014 with your organization

39. It is time to refocus, reinforce, and repeat the message that health disparities exist and that health equity benefits everyone. --Kathleen G. Sebelius Secretary, Health & Human Services

40. Thank you!Anita C. Murcko, MD, FACP acmurcko@cambiare.uswww.cambiare.us