Achieving Health Equity After the ACA: Implications for cost, quality and access

Michelle Cabrera, Research Director SEIU State Council

April 23, 2015

700,000 Members

Majority people of

color

70% women

Majority low-wage workers

SEIU California

Broad spectrum of health care workforce

Workers bargaining for health benefits

Beneficiaries of health care services

Policy advocates

SEIU on Health Care

•Fee-for-Service (FFS) /”volume-based” care •Inpatient, hospital -based care •Serious data gaps •Physician and hospital-driven health care

Pre-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

Health Care Pre- and Post-ACA

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

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.

Implications for the Safety Net

“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

Safety Net at a Crossroads

2013 National Healthcare Quality Report

•Tracks >200 process outcome, and access measures •Analyzed national health care data from 2000-2011 •Goal: Create a baseline to track improvement over time

Overview

•Rated as Fair •Improving

Quality

•Rated as Fair •Getting worse

Access

•Rated as Poor •No change over time

Disparities

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.

2014 National Healthcare Quality & Disparities Report

Lower Cost

Improved Quality

Population Health Equity

From Triple Aims* to Quadruple Aims**

*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

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)

P4P to Reduce Disparities

•Community Health Workers, Navigators, Promotoras, advanced IHSS worker, Peer Counselor

Non-Traditional Providers

• 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

Expands Access to Care

•Workforce hired from within communities served

Improves culturally and linguistically competent care

Advancing Quality, Cost and Equity through Workforce

Workforce Investment Opportunities

California 1115 Waiver Renewal

AB 1797 (Rodriguez) of 2014 “Earn and

Learn”

January Budget Proposal:

$15 million for apprenticeships

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)

Policy Recommendations

• 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)

Advocacy Efforts

Questions?

mcabrera@seiucal.org