Achieving health equity: leveraging health reforms to align resources with needs within thesafety net Kevin Fiscella, MD, MPH Professor Family Medicine Public Health Sciences University of Rochester School of Medicine Associate Director, Center for Communication and Disparities Research
Outline The challenge The plan The definition The safety net The 11 recommendations
The Challenge Access and disparities are not improving -9th National Healthcare Disparities Report, AHRQ
The Plan (HHS Action Plan) 1. Assess and heighten the impact of all HHS policies, programs, processes,and resource decisions to reduce health disparities. 2. Increase the availability, quality, and use of data to improve the health of minority populations. 3. Measure and provide incentives for better healthcare quality for minority populations. 4. Monitor and evaluate the Department s success in implementing the HHS Disparities Action Plan.
The Definition Racial or ethnic differences in the quality of health care that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention. -Unequal Treatment, 2002
The Definition Racial or ethnic differences in the quality of health care that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention. -Unequal Treatment, 2002
Limitations of the definition Artifact of the congressional charge to the IOM to examine role of racial and ethnic bias without regard to access factors It neglects other dimensions of social disadvantage beyond race and ethnicity It doesn t explicitly require adverse impact
New definition Recommendation 1. Adopt the National Quality Forum s (NQF) definition for health care disparities. NQFdefines healthcare disparities as differences in health care quality, access, and outcomes adversely affecting members of racial and ethnic minority groups and other socially disadvantaged populations. -NQF, Healthcare Disparities and Cultural Competency Consensus Standards, Technical Report, September 2012
Why focus on the safety net? Federally qualified health centers (FQHCs) and correctional facilities (jails, prisons, and detention facilities) are the key providers for primary care to the most socially disadvantaged patients Both are under-resourced relative to patient needs Major opportunities for promoting equity
FQHCs Largest provider of primary care to socially disadvantaged patients nationally 22.3 million Patient-operated and culturally diverse Mission driven with services based on documented community needs assessment Offer comprehensive services - outreach, language, case management Provide high quality, efficient care positioned to implement to Patient Centered Medical Homes (PCMHs)
What are the key levers for equity? Payment reform Leveraging Health Information Technology through Meaningful Use standards (MU) Support for care delivery transformation from provider-centered to team-based, patient-centered, care
Limited resources Payment to FQHCs through the prospective payment system (PPS) has kept FQHCs afloat over time PPS is visit-based - meaning that it does not pay for most aspects of the PCMH (which occur outside of face-to-face clinician visits) PCMH and MU payments have helped, but are likely temporary
Adopt PPS + global payments for FQHCs Recommendation 2. Adopt blended payments for FQHCs, e.g. PPS in addition to global payments through affiliations with Accountable Care Organizations (ACOs). Rationale. Preserves PPS and FQHC governing autonomy while providing FQHCs with the resources to support essential features for PCMHs while enhancing access to specialty care through the ACO.
Health Information Technology When optimized, it potentially enables: Planning and needs assessment Accountability Care processes that promote equity Efficiency
Meaningful use standards stage 2 (MU-2) Requires the collection of key structured data elements: Demographics (age, sex, race, ethnicity, and language income based on Medicaid i.e. < 133% FPL) Risk factors: smoking, BMI, BP, laboratory values
Expand structured data elements in MU Recommendation 3. Expand required structured data elements in MU to key measures relevant to safety net patients, e.g. cancer screening and other evidence-based procedures, along with hospitalizations and ED use. Rationale. This will enable creation of dynamic equity report cards at various levels of aggregation for planning and accountability. It could reduce costs and error associated with manual data entry and foster effective FQHC population management and clinical decision support.
Online Patient Health Records MU-2 provides payments to physicians and hospitals for patient use of online Personal Health Records (PHRs). In the absence of mitigation, this initiative will worsen health care disparities due to the digital divide, i.e. disparities in web access and ehealthliteracy.
Mitigate disparities in ehealth Recommendation 4. Larger payments to providers for online PHR use by patients needing more assistance, i.e. patients with Medicaid. Rationale. This will better align resources with need and encourage safety net providers to support poor and minority patients in accessing their online PHRs.
Team-based care Creation of genuine PCMHs requires a fundamental transformation in practice design and work flow. This requires not only payment reformand MU, but also a paradigm shift from clinician-centered care to teambased, patient-centered care. To date, the science of teams has not been widely applied to primary care, much less to safety net providers.
Implement team training Recommendation 5. Implement team training using principles from team science with adaptation to the primary care safety net. This will require support for infrastructures for such training. Rationale. This paradigm shift to teams is critical to achieving health care equity and value.
Correctional health care 2.2 million largely poor and minority persons are in prison or jail High physical and mental health needs Most inmates lack any health insurance Electronic health records adoptions lags Poor coordination of care entry/release Health care in corrections is off the grid
Require accreditation of health care facilities in corrections Recommendation 6. Require accreditation of all health care provided in correctional facilities. Rationale. There is not systematic system for accountability of health care quality in corrections. Requiring accreditation represents an important step towards ensuring appropriate health care in corrections.
Insurance enrollment and continuity Recommendation 7. Promote insurance enrollment and continuity in jails and prisons Enroll patients in Medicaid/Exchanges pre-release Leverage insurance navigators to offset costs Rationale. Most inmates are uninsured insurance coverage is critical to post-release care coordination and future health care access.
Promote participation by corrections in Meaningful Use incentives Recommendation 8. States and localities should actively promote correctional physician eligibility in federal Meaningful Use programs by suspending rather than terminating inmate s Medicaid eligibility. Rationale. This will help correctional facilities qualify for MU payments. Funding could fuel adoption of EHRs in corrections and foster participation In health information exchanges.
Applied research infrastructure Successful health care systems such as the VA, Kaiser and Group Health have an infrastructure for applied R &D (research and development). Safety net practices have few venues to support such infrastructure. HRSA s fledgling CHARN and Connecticut s Department of Corrections partnership with the University of Connecticut represent notable, worthy exceptions.
Applied research infrastructure Recommendation 9. Create dedicated program announcements among existing federal funding agencies to establish and maintain research infrastructure necessary to inform best practices for care within the safety net. Rationale. R &D is critical to creating high equity/high value health care systems.
Bias in health care There is ample evidence from social psychology that perpetuation of two-tiered systems of care, i.e. practices comprised of clinic patients (often poor, minority, Medicaid or uninsured) and private patients creates a culture among health care trainees, clinicians and staff that perpetuates unconscious bias. Dual systems of care also undermine care continuity for socially disadvantaged patients who are disproportionately cared for by trainees who come and go.
Proscribe segregation of health care by payer Recommendation 10. States and the federal government prohibit this practice. This proscription could be linked to receipt of federal (Medicare/Medicaid) or state (Medicaid) payments. Rationale. Separate, but equal failed in education and has failed in health care. The creation of integrated systems of care offers potential for reducing bias and promoting equity in care continuity and improved access.
Workforce diversity ACAand the HHSAction Plan promote workforce diversity, but successful strategies are in short supply.
Promote cultural competency though health care career ladders Recommendation 11. Foster natural health care career ladders for low-income and minority health care workers as a means for promoting work force diversity and team-based cultural competency. Rationale. The health care work force at FQHCs, corrections and hospitals is diverse, but gets Whiter as pay grades rise. Why not foster the natural career progression of minority/low income workers along a health care path based on FQHC/hospitalcommunity-educational partnerships, tuition assistance, flexibility in hours, and mentoring? High need health care jobs could be given priority.
Thank-You