Achieving Health Equity After the ACA: Implications for cost, quality and access Michelle Cabrera, Research Director SEIU State Council April 23, 2015
SEIU California 700,000 Members Majority people of color 70% women Majority low-wage workers
SEIU on Health Care Broad spectrum of health care workforce Workers bargaining for health benefits Beneficiaries of health care services Policy advocates
Health Care Pre- and Post-ACA Pre-ACA Fee-for-Service (FFS) / volume-based care Inpatient, hospital -based care Serious data gaps Physician and hospital-driven health care Post-ACA Value-based care and payment reforms Population health & outpatient, ambulatory care settings Federal incentives for electronic health records Non-traditional providers and upstream, prevention-related interventions
Post-ACA Payment Reforms Ambitious goals set forward by HHS Secretary Burwell in January 2015: Tie 30% of fee-for-service Medicare payments to quality or value through alternative payment models by the end of 2016 Tie 50% of payments to these models by the end of 2018 Tie 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018
Implications for the Safety Net Analysis of Medicare payment reforms on California safety-net hospitals : More likely to be penalized under the value-based purchasing program, readmissions penalties, and the electronic health record meaningful-use program; Thirty-day risk-adjusted mortality outcomes in safety-net hospitals were better than those in other hospitals for patients with acute myocardial infarction, heart failure, or pneumonia; and, Cost was virtually identical at safety-net and non-safety-net hospitals. Source: Gilman M, Adams EK, Hockenberry JM, Wilson IB, Milstein AS, Becker ER. California Safety-Net Hospitals Likely To Be Penalized By ACA Value, Readmission, And Meaningful-Use Programs. Health Affairs. August 2014. 33:81314-1322.
Safety Net at a Crossroads Taken together, these results indicate that safety-net hospitals provided better health outcomes than other hospitals at a similar cost level yet were more likely to be penalized under programs that are intended to improve and reward high performance. Health Affairs, August 2014 Impact on low-income communities of color in California: Safety net providers receive higher penalties even if patient outcomes are superior Already face very low operating margins (can t afford to lose more) Score lower on patient experience and process outcomes Outside factors like access to primary care or housing not considered Impacts of income, race, ethnicity, language, or other demographic factors not considered
2013 National Healthcare Quality Report Overview Tracks >200 process outcome, and access measures Analyzed national health care data from 2000-2011 Goal: Create a baseline to track improvement over time Quality Rated as Fair Improving Access Rated as Fair Getting worse Disparities Rated as Poor No change over time
2014 National Healthcare Quality & Disparities Report First annual update Data complete through 2012 Released April 2015 Findings: Quality improved for most of National Quality Strategy (NQS) priorities Few disparities were eliminated, most disparities persisted Living in poverty = less access and poorer quality. Some disparities related to hospice care and chronic disease management grew larger. More data is needed to understand disparities among smaller groups such as Native Hawaiians, mixed race, and LGBT populations Eliminating disparities is possible: several racial and ethnic disparities in rates of childhood immunization and rates of adverse events associated with procedures were eliminated.
From Triple Aims* to Quadruple Aims** Lower Cost Improved Quality Population Health Equity *Don Berwick, Institute for Healthcare Improvement s Triple Aim **Dr. Bob Ross, The California Endowment
Post-ACA Medi-Cal 12 million lives or 1/3 of all Californians 80% in managed care
P4P to Reduce Disparities SEIU, CPEHN, Health Access Proposal to pay-for-improvements (reductions) in significant health disparities impacting people of color on Medi-Cal Proposal: Identification and development of incentive payments for improvements to reduce disparities by health plan within six target areas of known racial or ethnic-related disparities Diabetes care (address racial disparities related to amputations) Child and maternal health (address mortality rates) Asthma (address avoidable ER visits) Hypertension and congestive heart failure (reduce avoidable admissions) Behavioral Health (address lags in screening) Readmissions (eliminate disparities in avoidable readmissions and hospital acquired infections)
Advancing Quality, Cost and Equity through Workforce Non-Traditional Providers Community Health Workers, Navigators, Promotoras, advanced IHSS worker, Peer Counselor Expands Access to Care Increases panel size by offloading appropriate tasks to workers, freeing up more time for provider visits/exams Teach newly covered or assigned patients how to use their coverage or navigate health system Conduct home visits and provide frequent follow up and support Attend clinical visits with the patient, and understand and reinforce care plan Improves culturally and linguistically competent care Workforce hired from within communities served
Workforce Investment Opportunities January Budget Proposal: California 1115 Waiver Renewal $15 million for apprenticeships AB 1797 (Rodriguez) of 2014 Earn and Learn
Policy Recommendations Health Justice as a Priority Bring a disparities and equity focus to a broader cross-section of policy discussions, e.g. Triple Aims, payment reforms, data collection and reporting, quality monitoring, etc. E.g. California s 1115 Waiver Renewal Improved Transparency Around Disparities Require more robust data collection more standardized, more complete, more accountable, and more public E.g. Require payers (e.g. DHCS, Covered California), plans and providers to collect SDS data Data stratified by sociodemographic factors Data adjusted for SDS when appropriate Require DHCS and Covered California to develop a plan and mechanisms to target the identification and elimination of addressable disparities
Policy Recommendations Do No Harm to the Safety Net Monitor the impact of payment reforms on the safety net and adjust policies to avoid unintended consequences like adverse selection ( cherry picking ) and worsening disparities Support greater investment in the safety net so that low-income communities of color can access care in their own communities Future goal: adjust for sociodemographic factors when there is a nexus Expand Access to More Appropriate Care Support greater investment in a culturally and linguistically appropriate workforce (from physicians to non-licensed providers)
Advocacy Efforts March Joint Senate and Assembly Informational Hearing on Disparities Speakers included: CPEHN, California Black Health Network, Latino Coalition for a Healthy California, Southeast Asia Resource Action Center, the Williams Institute, DHCS, Covered California, CDPH Office of Health Equity, Partnership Heath Plan, Safety Net Institute Building momentum for data collection and reporting: National Quality Forum Convened an expert panel and approved a two-year trial period to adjust quality measures for sociodemographic status factors California Senate Bill 26 (Hernandez), which would create a health care costs and quality database 1115 Waiver Renewal (Medi-Cal and remaining uninsred)
Questions? mcabrera@seiucal.org