Policy Road Map for Health Equity: Outlook and Opportunities

1. 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

2. Topics for Today: • Health care reform & health coverage • New provider care delivery and payment models • Health equity policy developments • Opportunities for CHWs 2

3. 1. Health Care Reform& Expansion of Health Coverage

4. 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

5. Background: the American Health Care System

6. Consequences • 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

7. Federal Reforms: 2010Affordable 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…. 7

8. ACA: Expands Health Coverage Universal Coverage Individual Mandate Health Insurance Market Reform Medicaid Coverage (Up to 133% FPL) Exchanges (Subsidies for 133 – 400% FPL) Employer Sponsored Coverage 8

9. Overall, Minnesota rate of Uninsured Ranks #3…HOWEVER… VT ME WA ND MN MT Uninsured Rates in “Communities of Color” NH OR MA NY WI SD RI ID MI CT WY PA NJ IA DE OH NE NV IN IL MD CO UT WV VA CA DC KS MO KY NC TN OK SC AZ AR NM GA AL MS AK LA TX FL HI SOURCE: KCMU/Urban Institute analysis of 2011 and 2012 ASEC Supplements to the CPS. 30-49% (16 states) Less than 20% (14 states) More than 50% (7 states, including DC) 20- 29% (14 states)

10. Disparities in Insurance Coverage Source: MDH, Health Economics Program

11. MN Coverage Options 11

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

13. 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

14. Preview: Access to care 5 years after reforms enacted

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

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

17. Reason for Coverage Gap

18. 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%)

19. 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

20. 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

21. 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

22. QUESTIONS

23. 2. New Provider Care Deliveryand Payment Models

24. “Triple Aim” of Health Reform • Improve the health of the patient population • Improve the patient/consumer experience • Improve the affordability of health care 24

25. Minnesota: Ahead of the Curve 2008 & 2010 Minnesota Reforms • 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 25

26. New Care Models Health Care Homes • A primary careprovider 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 26

27. 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). 27

28. 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 28

29. 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 29

30. 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 30

31. IHP: Shared Savings Shared Savings

32. 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

33. FUHN Project Goals: • Improved Access to High Quality Primary Care • Improved Clinical Quality • Improved Consumer Engagement and Satisfaction • Reduced Total Cost of Care

34. Challenges: What will it takefor 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

35. 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 35

36. 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” 36

37. 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 37

38. Accountable Communitiesfor 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. 38

39. 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

40. 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

41. 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

42. Recap of Trends • Care coordination of all health care services needed by a patient • Services delivered through multi-disciplinary primary care teams. • Provider accountabilityfor quality, health outcomes and costs using standardized measures. • Improved patient satisfaction and engagementin 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 technologyto 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. 42

43. 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.)

44. QUESTIONS

45. 3. Health Equity Policy Developments

46. 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

47. Health Care Reforms: Impact on Health Disparities • 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. 47

48. 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

49. Data: SQRMS, REL & SES 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

50. Data: SQRMS, REL & SES 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