Session B1 This presenter has nothing to disclose Ensuring Equity in the Health Care Workforce: Beyond the Affordable Care Act Brian D. Smedley, Ph.D. Joint Center for Political and Economic Studies www.jointcenter.org/hpi Session Objectives Describe how diversity in the heathcare workforce is beneficial for healthcare systems and patients Explain how healthcare quality, safety and patientcenteredness can be improved by greater healthcare workforce diversity Identify the institutional policies and strategies that are promising to increase the diversity of the U.S. healthcare workforce 1
Examples of Racial/Ethnic Health Inequalities Many racial and ethnic minority groups particularly American Indians, African Americans, Pacific Islanders, and some Asian Americans and Latinos have higher rates of disease and disability than national averages African Americans and American Indians have high rates of infant mortality, even when socioeconomic differences are taken into account African Americans, American Indians, and other experience high rates of premature mortality Number and Proportion of Quality Measures for Which Selected Groups Received Better, Same, or Worse Quality of Care Compared with Reference AHRQ, National Healthcare Disparities Report, 2011 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 74 82 26 Black vs. White 38 31 74 36 Asian vs. White 65 67 11 AI/AN vs White 67 37 Hispanic vs. NH White 46 46 6 Poor vs. High Income Worse Same Better 2
Examples of Health Care Quality Gaps AHRQ, National Healthcare Disparities Report, 2008 African Americans have higher rates of hospital admissions for lower extremity amputations than whites Asian Americans are less likely than Whites to get care for an injury or illness as soon as wanted American Indian and Alaska Native women are twice as likely as whites to lack prenatal care Parents of Hispanic children are twice as likely as whites to report problems communicating with health care providers The Economic Burden of Health Inequalities in the United States (www.jointcenter.org/hpi) Direct medical costs of health inequalities Indirect costs of health inequalities Costs of premature death 3
The Economic Burden of Health Inequalities in the United States Between 2003 and 2006, 30.6% of direct medical care expenditures for African Americans, Asians, and Hispanics were excess costs due to health inequalities. Eliminating health inequalities for minorities would have reduced direct medical care expenditures by $229.4 billion for the years 2003-2006. Between 2003 and 2006 the combined costs of health inequalities and premature death were $1.24 trillion. Patient Protection and Affordable Care Act of 2010: Addressing Health Equity for Racially and Ethnically Diverse Populations www.jointcenter.org/hpi 4
Implications of PPACA for Addressing Health Inequalities in the United States Insurance coverage expansions Expand Medicaid income eligibility to 133% of FPL (some states have set eligibility well below 20% of FPL). Employers with 50 or more employees must offer coverage or pay a penalty for FTEs receiving tax credit to purchase insurance. Small employers with fewer than 25 employees are eligible for tax credit to purchase insurance (among workers in small firms, 57% of Hispanics, 40% of African Americans, 40% of American Indians, and 36% of Asian Americans are uninsured). Implications of PPACA for Addressing Health Inequalities in the United States (continued) Improving Access to Health Care: Doubles funding to expand Community Health Centers. Funds to expand oral and behavioral health care services in CHCs. Expands funding for National Health Service Corps. Increases Medicaid payments for primary care services to 100% of Medicare payment rates for 2013 and 2014. Authorizes funds for school-based health centers, nursemanaged health clinics, and Community Health Teams to support medical homes 5
Implications of PPACA for Addressing Health Inequalities in the United States (continued) Data Collection and Reporting Require that population surveys collect and report data on race, ethnicity and primary language Collect and report disparities in Medicaid and CHIP Monitor health disparities trends in federally-funded programs Implications of PPACA for Addressing Health Inequalities in the United States (continued) Other Important Provisions: Reauthorizes Titles VII and VIII, health workforce programs to increase diversity and improve the distribution of providers Authorizes cultural competence education and organizational support Increases investments in health disparities research Establishes Prevention and Public Health Fund 6
More Needs to Be Done: Despite the Important Provisions in PPACA, Public Health and Health Systems in Partnership with Communities Can Take Steps to Promote Diversity and Excellence in the Health Care Workforce In the Nation s Compelling Interest: Ensuring Diversity in the Health-Care Workforce National Academies Press, 2004 7
In the Nation s Compelling Interest Increasing racial and ethnic diversity among health professionals is important because evidence indicates that diversity is associated with: improved access to care for racial and ethnic minority patients, greater patient choice and satisfaction, and Better educational experiences for health professions students, among many other benefits. In the Nation s Compelling Interest Many groups including health professions educational institutions (HPEIs), private foundations, and state and federal government agencies have worked to increase the preparation and motivation of underrepresented minority (URM) students to enter health professions careers. Less attention, however, has been focused on strategies to reduce institutional- and policy-level barriers to URM participation in health professions training. 8
In the Nation s Compelling Interest Recommendations for HPEIs: Improve admissions policies and reduce barriers to URM admission by developing a clear statement of mission that recognizes the value of diversity in health professions education Base admissions policies on a comprehensive review of each applicant, including an assessment of applicants attributes that best support the mission of the institution (e.g., background, experience, multilingual abilities) Admissions models should balance quantitative data (i.e., prior grades and standardized test scores) with these qualitative characteristics In the Nation s Compelling Interest Recommendations for HPEIs: Develop and regularly evaluate comprehensive strategies to improve the institutional climate for diversity. Proactively and regularly engage and train students, house staff, and faculty regarding institutional diversityrelated policies and expectations and the importance of diversity to the long-term institutional mission. 9
In the Nation s Compelling Interest Recommendations for HPEIs: HPEI governing bodies should develop institutional objectives consistent with community benefit principles that support the goal of increasing health-care workforce diversity, including efforts to ease financial and nonfinancial obstacles to URM participation Increase involvement of diverse local stakeholders in key decision-making processes, and undertake initiatives that are responsive to local, regional and societal imperatives. These objectives are best assessed and enforced via the accreditation process. In the Nation s Compelling Interest Public and Private Strategies to Expand Diversity Congress should provide increased funding for programs shown to be effective in enhancing diversity. State and local entities should increase support for diversity efforts through programs such as loan forgiveness, tuition reimbursement, loan repayment, and other efforts. Private entities should be encouraged to collaborate through business partnerships with HPEIs to support the goal of developing a more diverse health-care workforce. 10
In the Nation s Compelling Interest Public and Private Strategies to Expand Diversity The U.S. Department of Education should strongly encourage accreditation bodies to be more aggressive in formulating and enforcing standards that result in a critical mass of URMs throughout the health professions. Health professions education accreditation bodies should develop explicit policies articulating the value and importance of diversity among health professionals, and monitor the progress of member institutions toward achieving these goals. Given these challenges, what can hospital and health system leaders do? Connect programs and outreach with community-based efforts to address social, economic, and environmental conditions Educate policymakers about segregation and its role as a root cause of health inequities Support community benefit strategies that require robust community needs assessments, and identify how your institution can help address upstream determinants Carefully monitor and examine patient care data for health care disparities, and aggressively address them 11
Why Does Leadership for Health Equity Matter? Equity must be a key goal of any healthcare reform effort Equity is a concern for ALL of us Given demographic shifts, the future success and viability of healthcare institutions requites that they aggressively promote equitable care Characteristics of Leaders of Equitable, High-Performing Healthcare Organizations Willing to scrutinize all policies and practices of their organizations, and insist that equity be a key focus of quality improvement efforts Willing to monitor healthcare access and quality and make course corrections as necessary Willing to advocate for social justice Welcoming conversations about tough issues, such as racism in all its forms 12
Leader Behaviors Which Create a Culture of Excellence for Advancing Health Equity Attend to workforce diversity and the institutional climate for diversity Foster community trust and engagement Identify and help support sources of community strength and resilience Openness to feedback and change [I]nequities in health [and] avoidable health inequalities arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. The conditions in which people live and die are, in turn, shaped by political, social, and economic forces. World Health Organization Commission on the Social Determinants of Health (2008) 13