National Health Policy Forum on Safety Net Integration: Tackling Fragmentation While Improving Access to Care and Efficiency An Overview of Integration Among Safety Net Providers Katherine Neuhausen, MD Robert Wood Johnson Foundation Clinical Scholar Clinical Scholar, Department of Family Medicine University of California, Los Angeles December 7, 2012 1
Key Points 1. The challenges in the U.S. health care system are compounded in the safety net 2. Medical neighborhoods in the safety net should coordinate social services and behavioral health services with medical care 3. Isolated federal funding streams in separate agencies are the greatest policy barrier to integrated care in the safety net 2
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IOM Definition of the Health Care Safety Net Providers that organize and deliver a significant level of health care and other related services to uninsured, Medicaid, and other vulnerable patients Core safety net providers have 2 features: 1. Either by legal mandate or explicitly adopted mission they maintain an open door, offering access to services for patients regardless of their ability to pay 2. A substantial share of their case mix is uninsured, Medicaid, and other vulnerable patients 6 Source: Institute of Medicine. America's Health Care Safety Net: Intact but Endangered. 2000.
Core Safety Net Providers Community Health Centers Public Hospitals Local Health Departments Special service providers such as HIV/AIDS Clinics and School-Based Clinics 7 Source: Institute of Medicine. America's Health Care Safety Net: Intact but Endangered. 2000.
Safety Net Population Present: 48.6 million uninsured 62.5 million Medicaid beneficiaries If all states expand Medicaid in 2014: 84 million Medicaid beneficiaries with 21 million individuals gaining Medicaid Over 1 in 4 Americans could have Medicaid after implementation of health care reform 8 Sources: Kaiser Commission Medicaid and the Uninsured. The Medicaid Program At A Glance. September 2012 and Holahan J, Buettgens M, Carroll C, Dorn S. The Cost and Coverage Implications of the ACA Medicaid Expansion: National and State-by-State Analysis
Integrated Care Definition Safety net medical neighborhood is the full constellation of coordinated services required to provide comprehensive care to patients including: Primary care Specialty care Inpatient care Behavioral health (mental health and substance abuse treatment) Social services 9 Source: Fisher E. Building a medical neighborhood for the medical home. N Engl J Med 2008; 359:1202-1205
Continuum of Integrated Care 10 Source: Institute of Medicine. Primary Care and Public Health: Exploring Integration to Improve Population Health. March 2012.
Importance of Safety Net Integration Improve Care and Improve Health Decrease avoidable deaths Improve chronic disease outcomes Improve treatment of mental health conditions and substance abuse disorders Decrease Costs Reduce costly readmissions Reduce preventable admissions for chronic disease Increase appropriate care 11
Policy Barriers to Safety Net Integration Isolated Federal Funding Streams Federal funding streams and programs for community health centers, public hospitals, behavioral health services, and social services are not aligned Inadequate Delivery System Infrastructure Many providers lack health information technology and care coordination infrastructure Limited Financial Resources Many providers require up-front funding/seed capital Providers have limited ability to take on financial risk 12
Major Policy Levers IOM Report on Primary Care and Public Health Integration Identify opportunities to coordinate funding streams in selected programs and convene joint staff groups to develop grants, requests for proposals, and metrics for evaluations. Coordinate federal funding streams for safety-net providers New funding or reauthorization of existing funding should require collaboration between agencies Align Medicaid DSH, Section 330 funds, and other funding streams around common incentives 13 Source: Institute of Medicine. Primary Care and Public Health: Exploring Integration to Improve Population Health. March 2012.
Major Policy Levers Programs authorized by PPACA but not funded that could promote integration: Community-Based Collaborative Care Networks (Section 10333) would fund community consortia of at least one hospital and all FQHCs in the community Primary Care Extension Program (Section 5405) would help primary care practices increase care integration 14
Conclusions 1. The challenges in the U.S. health care system are compounded in the safety net 2. Medical neighborhoods in the safety net should coordinate primary care, specialty care, inpatient care, behavioral health services, and social services 3. Coordinating isolated federal funding streams for safety net providers is the strongest lever to drive safety net integration 15