Health Homes, Equity, and the ACA: Working to Leverage Opportunity in a Changing Health Care Landscape

Health Homes

Health Equity

A

C

A

Dennis P. Andrulis, PhD, MPHSenior Research Scientist, Texas Health InstituteAssociate Professor, University of Texas School of Public Health

Institute of Medicine Roundtable on the Promotion of Health Equity and the Elimination of Health DisparitiesApril 22, 2013Hartford, CT

Overview

� Our ACA & Health Equity Series

� Advancing Equity through Health Homes

� Explicit health home & equity provisions

� Other opportunities in the ACA

� Challenges to Addressing Equity in an Era of

Health Care Reform

� Moving Forward: Key Areas to Monitor

ACA & Health Equity Series

� Utilizing a “health equity lens” to monitor 60+ ACA provisions

� Focus is on specific provisions and others with implications for racial/ethnic health equity across five areas:

� Health Insurance Exchanges – Final Report released in March 2013

� Health Care Safety Net – Draft Report, Final in May 2013

� Workforce Support and Diversity – Draft Report, Final in May 2013

� Data, Research, and Quality – Forthcoming, June/July 2013

� Public Health and Prevention – Forthcoming, June/July 2013

� Issuing reports for each of the five areas

Health Homes & Equity in the ACA

Priority Provision

Fair/Good

Progress

Diversity

Focus

State Action Health Home State Option √ √

Primary Care Residency & Physician Asst. Support √ √

10 provisions in the ACA with explicit mention of “health homes” or “medical

homes” of which 6 also specify priorities for advancing racial/ethnic equity.

Workforce

& Delivery

Primary Care Residency & Physician Asst. Support √ √

Primary Care Extension Program* √ √

Community Health Teams √

Community-Based Collaborative Care Network

Research &

Innovation

CMS Innovation Center √

Patient-Centered Outcomes Research Institute √ √

Payment &

Insurance

Quality & Disparities Incentives in Exchanges √

Quality Reporting Amendments for Plans

Primary Care Medical Home Plan as QHP √

Framework

� Following slides present:

� ACA’s provisions specific to health homes & equity

� Other opportunities embedded in the ACA

� Opportunities are Organized by 4 Priorities:� Opportunities are Organized by 4 Priorities:

� State Action

� Workforce & Delivery

� Research & Innovation

� Payment & Insurance

State ActionACA's Provisions Specific to Health Homes & Equity

� ACA created a state option to provide health homes for Medicaid enrollees with chronic conditions to improve health outcomes.

� 10 States with approved health home plans.Missouri Iowa New York Oregon Rhode Island

� Current equity activities in state health homes:� Culturally & linguistically appropriate patient communication

� Culturally & linguistically appropriate individual & family support

� Use of evidence-based culturally sensitive wellness and prevention

� Patient health assessment to include measures of language/culture

Missouri

Idaho

Iowa

Maine

New York

Ohio

Oregon

N. Carolina

Rhode Island

Wisconsin

State ActionOther Opportunities in the ACA for Health Homes & Equity

� States with Medicaid 1115 Waivers that explicitly focus on health system restructuring may consider using matching funds to test health homes for diverse patient populations.

� Some states using 1115 Waivers to support other initiatives—such as health workers—to support health homes & advance equity.

Workforce & Delivery ACA's Provisions Specific to Health Homes & Equity

� HRSA funded primary care residency and physician assistant training, curricula development, & continuing education.

� Placements & programs in medical home settings;

� Priority for underserved minorities & cultural competence.

� “Health extension agents” in 4 states (NC, PA, NM, OK) to assist � “Health extension agents” in 4 states (NC, PA, NM, OK) to assist in adopting medical homes with patient language and cultural competence as priority.

� Areas to Monitor Related to Equity:� Evaluate training curricula– e.g., how is cultural competence, language,

health literacy addressed in training in health homes across professions?

� Identify supportive best practices —e.g., other actions to support equity in health homes such as use of HIT & interpreters?

� Measure equity-focused process and outcomes –e.g. Patient satisfaction? Quality? Disease Management? Adherence?

Workforce & DeliveryOther Opportunities in the ACA for Health Homes & Equity

� Expanding health home and equity programs to other practice settings supported by the ACA

� Teaching health centers

� Nurse-managed clinics

� School-based health centersSchool-based health centers

� Addressing “Scope of Practice” in health homes

� Role of Advance Practice Nurses & Physician Assistants

� Community Health Workers as part of care team

Research & InnovationACA's Provisions Specific to Health Homes & Equity

� Patient Centered Outcomes Research Institute

� 1 of 5 research priorities on health disparities

� Some testing outcomes associated with medical home model, such as patient preferences, satisfaction, and quality.

� CMS Innovation Center� CMS Innovation Center

� Innovations Awards on primary care, payment, & delivery reform, but few explicitly address racial/ethnic equity

� FQHC Advanced Primary Care Practice Demonstration

� Points for Consideration:

� Assessing disparities in health home outcomes

� Metrics on specific diversity and equity interventions in health homes

� Measurable, short-term outcomes in addition to long-term

Research & InnovationOther Opportunities in the ACA for Health Homes & Equity

� Draw on other broader, funded ACA community initiatives to address and integrate health homes and equity.

� Community Transformation Grants

� Non-Profit Community Health Needs Assessment

Insurance & PaymentACA's Provisions Specific to Health Homes & Equity

� Little or no federal guidance to date, but the ACA:

� Encourages health plans offered in the exchanges to incentivize providers for improving health outcomes by adopting health homes and/or activities to reduce disparities.

� Expected to provide rules on quality reporting in health plans reimbursing providers for use of medical homes.

� Key Observations:

� Focus is more on start up & meeting deadlines for broader reforms—e.g., Exchanges & Medicaid

Insurance & Payment Other Opportunities in the ACA for Health Homes & Equity

� Integrate & align key features of medical homes with exchanges and active purchasing to advance equity.

� Exchanges opting to be “active purchasers” may require health plans to implement quality improvement to include quality reporting, features of health homes, and disparities actions to address disparities.actions to address disparities.

� Encourage pilot payment programs to test new-patient centered models of care, including health homes which disproportionately serve diverse patients.

Challenges to Addressing Equity in an Era of Reform

� Not a Priority: “[areas] not a priority, like cultural competency, get put on at the very end…it’s not in the ‘urgent’ category.” Therefore, many such provisions are left unfunded.

� Complex Nature of ACA: “There’s no discussion around diversity and cultural competency because they’re still struggling with what broader change means.”diversity and cultural competency because they’re still struggling with what broader change means.”

� Deadlines & Insufficient Guidance: “Many challenges may be summarized in three ways—imperfect information, demanding deadlines, and dependencies beyond…control.”

� Competition. “Some providers [health centers] are in competitive mode versus collaborative mode.” AND “The biggest challenge is how do [providers] navigate this new system while keeping their souls intact?”

Moving Forward: Key Areas to Monitor

Policy & Advocacy

• State-level uptake in health homes & integration of equity

Research & Innovation

• Integration of equity in FOAs, outcomes research, and metrics on health

Workforce & Delivery

• Cultural competence training & diversity in health homes.

Payment & Exchanges

• Market-based incentives for health homes & disparities reduction.

of equity objectives.

• Federal guidance and rules for health homes & integration of equity.

metrics on health homes.

• Inclusion of health home metrics by race/ethnicity—e.g., continuity of care; access; quality; disease management; adherence.

health homes.

• Impact of Scope of Practice laws in states on health homes & access for diverse patients.

reduction.

• State active purchasing requirements & inclusion of health homes and equity.

Thank YouACA & Health Equity Team at Texas Health Institute

Dennis P. Andrulis, PhD, MPHSenior Research Scientist, Texas Health Institute

Associate Professor, University of Texas School of Public Health

Nadia J. Siddiqui, MPHSenior Health Policy Analyst, Texas Health Institute Senior Health Policy Analyst, Texas Health Institute

Maria Rascati Cooper, MAHealth Policy Analyst, Texas Health Institute

Lauren R. Jahnke, MPAffConsultant, LRJ Research & Consulting

For questions, feedback, or to be added to our mailing list, please e-mail:

nsiddiqui@texashealthinstitute.org.

Website: http://www.texashealthinstitute.org/health-care-reform.html