Health Homes, Equity, and the ACA: Working to Leverage Opportunity in a Changing Health Care Landscape
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1 Health Homes A C A Health Equity Health Homes, Equity, and the ACA: Working to Leverage Opportunity in a Changing Health Care Landscape Dennis P. Andrulis, PhD, MPH Senior Research Scientist, Texas Health Institute Associate Professor, University of Texas School of Public Health Institute of Medicine Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities April 22, 2013 Hartford, CT
2 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
3 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
4 Health Homes & Equity in the ACA 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. Priority Provision Fair/Good Progress Diversity Focus State Action Health Home State Option Workforce & Delivery Research & Innovation Payment& Insurance Primary Care Residency & Physician Asst. Support Primary Care Extension Program* Community Health Teams Community-Based Collaborative Care Network CMSInnovation Center Patient-Centered Outcomes Research Institute Quality & Disparities Incentives in Exchanges Quality Reporting Amendments for Plans Primary Care Medical Home Plan as QHP
5 Framework Following slides present: ACA s provisions specific to health homes & equity Other opportunities embedded in the ACA Opportunities are Organized by 4 Priorities: State Action Workforce & Delivery Research & Innovation Payment & Insurance
6 State Action ACA'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 Idaho Iowa Maine New York Ohio Oregon N. Carolina Rhode Island Wisconsin 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
7 State Action Other 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.
8 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 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?
9 Workforce & Delivery Other 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 centers Addressing Scope of Practice in health homes Role of Advance Practice Nurses & Physician Assistants Community Health Workers as part of care team
10 Research & Innovation ACA'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 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
11 Research & Innovation Other 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
12 Insurance & Payment ACA'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
13 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. Encourage pilot payment programs to test new-patient centered models of care, including health homes which disproportionately serve diverse patients.
14 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. 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?
15 Moving Forward: Key Areas to Monitor Policy & Advocacy Research & Innovation Workforce & Delivery Payment & Exchanges State-level uptake in health homes & integration of equity objectives. Federal guidance and rules for health homes & integration of equity. Integration of equity in FOAs, outcomes research, and metrics on health homes. Inclusion of health home metrics by race/ethnicity e.g., continuity of care; access; quality; disease management; adherence. Cultural competence training & diversity in health homes. Impact of Scope of Practice laws in states on health homes & access for diverse patients. Market-based incentives for health homes & disparities reduction. State active purchasing requirements & inclusion of health homes and equity.
16 Thank You ACA & Health Equity Team at Texas Health Institute Dennis P. Andrulis, PhD, MPH Senior Research Scientist, Texas Health Institute Associate Professor, University of Texas School of Public Health Nadia J. Siddiqui, MPH Senior Health Policy Analyst, Texas Health Institute Maria Rascati Cooper, MA Health Policy Analyst, Texas Health Institute Lauren R. Jahnke, MPAff Consultant, LRJ Research & Consulting For questions, feedback, or to be added to our mailing list, please Website:
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