Objectives Envisioning Women Centered Care in a Changing Health Care Landscape Erin N. Saleeby, MD, MPH Medical Director - California Family Health Council Director, Women s Health Programs and Innovation Los Angeles County Department of Health Services Department of Obstetrics and Gynecology Harbor UCLA Medical Center At the end of the talk participants will be able to: List 3 components of the health care reform which will directly impact women's health List 3 levers for organizational change that can support women and families over the life course List 3 essential tenets of a medical home Acknowledgments Health Care Reform is a Woman s Issue Thanks to Michael Policar for sharing slide sets. Market Reforms Individual + Small Group Problem Example Solution When Recession Gender Rating If costly disease, insurance revoked retroactively Women charged more than men for the same coverage Prohibited 9/2010 Prohibited 1/2014 More is not always better Exclusion of pregnancy coverage Pre-existing condition exclusions Only 13% of individuals now include pregnancy coverage 38% women denied coverage Prior pregnancy Prior caesarean section Domestic Violence Guaranteed maternity coverage 1/2014 Prohibited 1/2014 What will guide this expansion in coverage? 1
Triple Aim Levers For Change 1. Improving the patient experience of care (including quality and satisfaction) 2. Improving the health of populations 3. Reducing the per capita cost of health care Payment Access & Service Coverage Quality Assistance For Uninsured Women Under Health Reform Other 3% Type of Assistance Potentially Available in 2014 No Subsidies > 400% Follow The $Money$ Employer 59% 19.1 million Uninsured Tax Credits 139-399% 20% Medicaid 12% Medicaid <138% Individual 6% 96.2 million women ages 18-64 Other includes programs such as Medicare and military-related coverage. The federal poverty level for a family of four in 2009 was $22,050. SOURCE: KFF/Urban Institute analysis of 2010 ASEC Supplement to the Current Population Survey, U.S. Census Bureau. Payment structures Using $$ to change structure of care Capitated rate Fee-For-Service Categorical funds Block grants MORE STUFF MORE $$$ CMS Innovations awards: The Physician Group Practice Demonstration Strong Start for Mothers and Newborns Bundled Payments for Care Improvement Medicare Accountable Care Organizations (ACOs) - Medicare Shared Savings Program Commercial ACOs 2
Why innovations center projects? Broad field testing of care models Allows for ROI calculations Can investigate implementation in special populations Why Bundle? Focus on: Disease management Quality Episode rather than visit.. Not Volume of Visits.. Not Life Course either Why ACOs? Promote wellness Emphasize screening Anticipatory counseling Manage disease Life Course Perspective What Tools are needed? Patient identification Analytics for performance measurement Risk stratification Workflow applications: create and manage care plans, track events and scheduling Patient engagement tools Select The Services What do women need for care over the life of the course? Women s Services & Health Reform Direct Access to Ob-Gyns Ends pre-existing coverage exclusions Maternity & Newborn Care are EHBs STIs/HIV Teen Pregnancy Prevention Abortion Coverage Excluded. 3
Promoting Prevention through the Affordable Care Act Howard K. Koh, M.D., M.P.H. and Kathleen G. Sebelius, M.P.A. Specified preventive services must be covered with no cost-sharing (no out-of-pocket costs) Applied to private and public programs (New) Private insurance policies 2010 Medicare, Medicaid 2011 State insurance exchanges 2014 Promoting Prevention through the Affordable Care Act Howard K. Koh, M.D., M.P.H. and Kathleen G. Sebelius, M.P.A. Preventive services include all services USPSTF grade [A] or [B] recommendations AAP Bright Futures recommendations for adolescents CDC ACIP vaccination recommendations IOM recommendations to close the gaps Preventive Screening Services Institute of Medicine Lifestyle/Healthy Behaviors U.S. Preventive Taskforce A + B Level Recommendations Cancer STI/STDs Chronic Conditions Preganancy Alcohol Screening Colorectal HIV Hypertension Tobacco Depression Screening Health Diet Counseling Tobacco Breast Screening Gonorrhea Diabetes Rh Incompatibility Screening Breast Chemoprevention Breast/Ovarian High Risk/BRCA Chlamydia Obesity Screening Hepatitis B Screening Syphilis Osteoporosis Iron Deficiency Anemia Screening Immunizations Cervical Cancer Lipid Disorders Bacteriurea Screening Committee on Preventive Services for Women Closing the Gaps released July 20, 2011 16 member panel 8 additional preventive services recommended U.S.P.S.T.F. A and B Recommendations No Cost Sharing Medicare, Medicaid, Qualified Health Plans Reproductive Health STI and HIV counseling ; all sexually active F) Ct, GC, Syphilis screening HIV screening (adults at HR; all sexually active F) Cancer Breast Cancer Mammography Healthy Behaviors Alcohol S&C Pregnancy related Alcohol S&C Genetic S&C Tobacco C&I Tobacco C&I Preventive medication counseling Diet counseling if CVD risk Folic acid supplement Immunizations TdaP, Td booster, MMR, varicella Influenza Hepatitis A, B Meningococcal Chronic conditions CV: HTN, lipids T2DM screen Depression screen Contraception Cervix: Interpersonal GDM HPV Osteo- (women w/repro Capacity) Cytology HPV + cytology and DV S&C screen Rh screen Anemia screen (women 19 26) porosis screen Women s Preventive Services HHS Guide for Insurance Coverage Frequency All FDA approved contraceptive methods, As sterilization procedures and patient education prescribed + counseling for women with reproductive capacity Colorectal: Well woman FOBT, visits Colonoscopy, Sigmoid STI screen Bacteruria screen Pneumococcal Zoster Obesity screen; C&I if obese Lactation Supports S&C: screening and counseling C&I: counseling and interventions 4
Can Plans Limit Coverage Without Cost-Sharing? Plans must cover all of the FDA-approved methods Reasonable medical management techniques are allowed Cost-sharing for brand-name drugs Cost-sharing for out-of-network services Prescription for over-the-counter methods The Waiver Process Allows women to access medically appropriate method without cost-sharing if plan typically imposes cost-sharing Usually done through pharmacy pre-authorization Contraception as a Preventive Service Exempt employers (mainly churches) Exists for the purpose of Inculcating religious values Primarily employs & serves persons who share religious tenets Meets certain provisions i of the tax code Accommodation (mainly hospitals, universities) Religiously-affiliated employers who do not meet exemption but who have a religious objection Insurer offers rates that excludes contraceptives, but health plan covers contraceptive benefit Quality Standards The Quality construct How will we measure success? Department of Health and Human Services Agency Health Research & Quality (AHRQ) National Quality Strategy National Quality Forum (NQF) Quality Positioning System (QPS) National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey Quality Process Professional organizations (AMA, ACOG, APA) Research Consensus conferences & expert groups Guideline clearing houses (USPSTF) Advocates IOM aims for quality improvement Safe Effective Patient-Centered Efficient Timely Equitable 5
Ensuring Quality over the Life Course Tracking both process and outcomes metrics RLPs Regular Health Assessments/Screenings Patient education Using a standard set of metrics Evidence-based Valid and Reliable Review: 3 levers to guide change Payment Structures Service Coverage Quality Constructs Now what? Applying these levers to service delivery Models Of Care Woman-Centered Models of Care: Direct Access Wrap-around, integrated services: Primary Care + Sexual & Reproductive Health A Life Course Perspective How can we integrate primary care and high quality sexual and reproductive health? 6
What is Sexual + Reproductive Health? Birth control and sexually transmitted disease (STD) prevention Sexual behaviors and STD risks Sexual orientation and gender identity Pregnancy history and intentions or goals Pregnancy and preconception care Sexual function, issues, concerns Why Integrate? New ACA rules specific to SRH as preventative care Continuity of care in the PCMH Increase patient satisfaction Increase services provided Decrease malpractice Expand services to hard to reach populations Sexual and relationship satisfaction and health Why Integrate? Providing Services for Young Invincibles 18-34 y/o 19 mil lack basic health insurance Transitioning from adolescence to adulthood Unintended Pregnancies in the Unite States Unintended 49% Reproductive and contraceptive needs 90% having sex Highest birth rate High rates of risky behavior National Survey of Family Growth Finer LB, et al. Persp Sex Reprod Health. 2006 Women of Reproductive Age: Prevalence of Chronic Diseases Women of Reproductive Age: 7
Decision-Making over the Life Course Begins before pregnancy Strong family planning and preconception care Pregnancy intentions assessments Evidence-based counseling Pregnancy options Prenatal screening algorithms Labor and Delivery options Support for women s choices Care Coordination over the Life Course Team-based care Women Primary Care Providers Women s Health Providers Maternity Care Providers Reproductive Life Planning Support during adolescence Transitions of care from Pediatrics to Adult Medicine Client-centered coordination of pregnancy timing during optimized control of chronic disease Single Provider Model Single Provider Model Woman-Centered Preventive/ Chronic Care OB & GYN care Appropriately delivered by?? Family Medicine OBGYN or CNM if appropriate patient panel: Young AND/OR Few chronic conditions Dual Provider Model Dual Provider Model Discuss: 1. Family planning + preconception / interconception care 2. Risk factors impacting pregnancy (h/o cervical procedures, infectious disease, etc) 3. Management of chronic disease in pregnancy Chronic Care & GYN: Family Med. Obstetrics: OBGYN CNM Appropriately delivered by?? Pediatrics/Adolescent Medicine (+) OBGYN or CNM or Family Med Family Medicine (+) OBGYN or CNM Internal Medicine providers with Women s Health expertise (+) OBGYN or CNM or Family Med 8
Three Provider Team Model Three Provider Team Model Discuss: 1. Management of chronic disease in pregnancy 2. Preconception / interconception care Obstetrics: OBGYN Family Med CNM Chronic Care Non-GYN: Internal Med Family Med Discuss: 1. Family planning + preconception/ interconception care 2. Risk factors impacting pregnancy (h/o cervical procedures, infectious disease, etc). GYN provider: OBGYN GYN NP (JWCH) Discuss: 1. Family planning/ chronic conditions as relates to contraceptive/ pregnancy risk 2. Preventive health screenings (pap, STI, osteoporosis, breast, colon, etc) Appropriately delivered by?? Pediatrics/Adolescent medicine Family medicine Internal medicine All above: + OBGYN or CNM or Family Medicine + Women s health specialist: Internal med/fam Med MDS, GYN NP or Family planning specialist Considerations Cons Lost in translation Primary/ Specialty balance Pros Enhanced subject knowledge Improved screening rates Key components of a medical home 1. Primary care-access 2. Continuity 3. Comprehensiveness 4. Coordination of care PCMH: The Care Team in Action Medical Director Clinicians Medical Assistant RN/LVN Health Educator Outreach Worker Clinic Manager Front Desk Staff Referral Coordinator Pharmacist/Dispensary Coordinator Social S i l Worker Phlebotomist Biller Team-Based Sexual + Reproductive Health Integration How does each team member contribute to a patient s positive experience? Professionalism Cultural competence Environment Patients need to be able to talk about their sexual and reproductive needs in the primary care setting 9
Women in Medical Homes In order to assure communication and accountability, care teams will need to have formalized relationships Concerns: referral to women s health specialists for primary care activities relinquishes primary care provider s responsibility for holistic view of their patient s health Woman Centered Care Models Developing care pathways and discrete relationships between providers on a team will help realize: patient-centered care shared decision-making i direct access These pathways will also lead to improve patient experience, improve quality, reduce waste and add value Thank You Necessity is the mother of invention Envision woman-centered care for the new millennium Find opportunities in the chaos!! CMS Innovation Award Strong Start Initiative Boots on the ground Innovative models of care 10
Innovation Center Goals Goals: Reduce preterm birth Reduce low birthweight births Test new models of care: Group prenatal Birth Center based care Maternity Medical homes Awardees 27 nationwide 32 states 87,000 women 182 health care facilities 15 group care 22 birth centers 14 medical homes MAMA S Neighborhood Maternity Assessment Management Access and Service synergy throughout the Neighborhood for health Model Mother centered policies MAMA S Neighbor hood Family and community Mother Current OB practice at DHS Basic OB, limited ancillary services Includes high risk only as MFM care Few psychosocial resources Limitationsit ti Not comprehensive Not coordinated Not patient centered Not cost conscious Definition of care/health system focused What s missing Assessment - Risk Stratification Supportive services Team based care Management Population Individual 11
What else is needed Service Synergy - Community Engagement Expands services Contextualizes care Changes care paradigm from system focus to partnership focus Innovation Service provision by care teams Patient-centered case management services for high-risk women Health Information Technology (HIT) utilization for population management Continuous quality improvement processes to track process and outcome measures, and support rapidcycle improvement Care Domains 1. Substance Use Issues of smoking, alcohol and drug use 2. Social Insecurity Issues of food and housing scarcity 3. Mental Health Instability Issues of depression, anxiety, intimate partner violence 4. Biomedical Risk Issues of non-empanelment, MFM accessibility, non-risk stratification, non-team based care Mother-Centered Medical Home Care is Our mothers register with DHS as their maternity home. We systematically assess our mothers with a standardized comprehensive clinical and social care assessment that identifies strengths and areas of improvement needed. A multi-disciplinary team of clinical and social care professionals coordinate internal and external referrals that are tailored to mothers individual needs based on risk level. We actively engage and connect a multi-disciplinary Neighborhood Network of Care comprised of health and social care providers which LINK together pathways of care for the mother. We utilize evidence-based measures and quality indicators to aid in continuous quality improvement activities that support better perinatal clinical and psychosocial outcomes. We utilize electronic health records and empanel mothers to support continuity of care and identification of strengths and gaps in care. We offer and track a diverse menu of tests, consultations, specialty care and follow-up utilized during perinatal care to support seamless and informed care. We offer a proactive clinical and social care team that honors the perinatal period as a critical window for intervention and improvement, and special time for mothers. MAMA S Neighborhood Maternity Assessment Management Access and Service synergy Neighborhood for health throughout the 12