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Advancing Health Equity through
        Health Reform Implementation




                   Thursday, July 21, 2011
          This webcast will begin at 2:00 P.M. EDT
          Please hold until we start the conference.
The audio portion of this webcast can be accessed by dialing:
                         800.757.7641
Agenda
n    Welcome and Introductions
      ¡    Diane Justice, MA, Senior Program Director, National Academy for State
            Health Policy (NASHP)
      ¡    Dr. Anne C. Beal, MD, MPH, President, Aetna Foundation

n    National Healthcare Quality and Disparities Reports and State
      Disparities
      ¡    Dr. Ernest Moy, MD, MPH, Medical Officer, Center for Quality
            Improvement and Patient Safety, Agency for Healthcare Research and
            Quality (AHRQ)

n    State Obligation and Opportunity in Health Care Reform:
      Implementing the Affordable Care Act to Advance Health Equity
      for Racially and Ethnically Diverse Populations
      ¡    Dr. Dennis P. Andrulis, Ph.D., MPH, Senior Research Scientist, Texas
            Health Institute; Associate Professor, University of Texas School of Public
            Health
Agenda (cont.)
n    ACA Implementation and Health Equity: Experiences from
      Maryland
      ¡    Dr. Carlessia A. Hussein, Dr.PH, RN, Director, Office of
            Minority Health and Health Disparities, Maryland Department of
            Health and Mental Hygiene

n    State Health Equity Learning Collaborative:
      Request for Applications for Technical Assistance
      ¡    Diane Justice, MA, Senior Program Director, NASHP

n    Questions and Answers
About NASHP

n    22 year old non-profit, non-partisan organization
n    Academy members
      ¡    Peer-selected group of state health policy leaders
      ¡    Commitment to identifying state needs and guiding our
            work
n    Working together across states, branches, and
      agencies to advance, accelerate, and implement
      workable policy solutions that address major health
      issues
Advancing Equity through State
Implementation of Health Reform
n    Supported by the Aetna Foundation
n    Project goals include:
      ¡    Supporting state leadership for eliminating disparities and
            advancing health equity through health care reform
            implementation
      ¡    Establishing a State Health Equity Learning Collaborative
      ¡    Facilitating a National Invitational Health Equity Summit
      ¡    Publishing a State Policymakers Action Agenda for
            Achieving Health Equity through Health Reform
National Healthcare Quality and Disparities
      Reports and State Disparities



                  Ernest Moy
              Ernest.moy@ahrq.hhs.gov
                      301-427-1329
            www.ahrq.gov/qual/qrdr10.htm
            http://statesnapshots.ahrq.gov
National Healthcare Reports
   Annual reports to Congress from Secretary since 2003
   mandated by 1999 Healthcare Research and Quality Act

   Unified team, Interagency Work Group, framework, data,
                  methods, quality measures

       Quality Report                 Disparities Report
Snapshot & trends in quality of   Snapshot & trends in
health care in America            disparities in health care

Effectiveness, safety, timeliness,
                                   Differences across race,
patient centeredness, care
                                   ethnicity, & socioeconomic
coordination, efficiency, health
                                   status
system infrastructure, access
Variation across states           Variation across populations
State Snapshots: Overall Health Care
        Quality for California
State Snapshots: California
Dashboard Compared to All States
Racial/Ethnic Diversity
    Across States
Hispanic-White Disparity in Colorectal
                     Cancer Screening across States

30                                        Worst States

25                            All State
                              Average
20

15
          Best States
10

 5

 0     B e st

      S ta te s
                                                          Wo rst

                                                         S ta te s




 -5

-10

-15
Black-White Disparity in Colorectal
                   Cancer Screening across States

30                                                 Worst States

25

20

15                           All State
                             Average
10

 5

 0     B e st

      S ta te s
                                A ll	
   S ta te

                                A v e ra g e
                                                               Wo rst

                                                              S ta te s




 -5

-10
        Best States
-15
Weak Relationship between Overall Receipt of Colorectal
  Cancer Screening and Hispanic-White Differences
Weak Negative Relationship between Overall Receipt of
Colorectal Cancer Screening and Black-White Differences
Mountain   West North Central                                    New
                                                                          England
                                               East North


                                                                                                    Poorer Overall Quality
                                                Central




                                                                                                    of Preventive Care
                                                                                 Middle
                                                                                 Atlantic



                                                                                    DC

                                                                                    PR

                                                                                    VI




Pacific


                                                                       South
                                                                      Atlantic

                                              East
                                             South
                                    West     Central
                                   South
                                   Central

                                                                                         Mountain     West North Central                          New
                                                                                                                                                 England
                                                                                                                                East North
                                                                                                                                 Central




                                                                                                                                                        Middle
                                                                                                                                                        Atlantic



                                                                                                                                                           DC

                                                                                                                                                           PR

                                                                                                                                                           VI




                                                            Pacific



Larger Racial or Ethnic                                                                                                        East
                                                                                                                                              South
                                                                                                                                             Atlantic




         Disparities in                                                                                              West
                                                                                                                    South
                                                                                                                    Central
                                                                                                                              South
                                                                                                                              Central




       Preventive Care
State Snapshots:
California Focus on Disparities
Conclusions
n  State need to address
   disparities
   –  Different populations
   –  Different disparities
n  Disparities can help States
   –  Identify strategies
   –  Target populations and
      services
n  States are succeeding at
   reducing disparities
Click to edit Master title style



 Dennis	
  P.	
  Andrulis,	
  PhD,	
  MPH	
  
 Senior	
  Research	
  Scien-st,	
  Texas	
  Health	
  Ins-tute	
  
 Associate	
  Professor,	
  University	
  of	
  Texas	
  School	
  of	
  Public	
  Health	
  
 	
  
 	
  
Background Master title
Click to edit and Purposestyle
•  With	
  support	
  from	
  the	
  Joint	
  Center	
  for	
  Poli3cal	
  and	
  
   Economic	
  Studies,	
  we	
  conducted	
  a	
  comprehensive	
  review	
  
   of	
  the	
  Pa3ent	
  Protec3on	
  and	
  Affordable	
  Care	
  Act	
  of	
  2010:	
  
     –  To	
  iden3fy	
  and	
  describe	
  provisions	
  specific	
  to	
  race,	
  ethnicity	
  and	
  
        language;	
  and	
  general	
  provisions	
  likely	
  to	
  have	
  a	
  significant	
  affect	
  on	
  
        diverse	
  popula3ons.	
  

     –  To	
  assess	
  status,	
  challenges	
  and	
  opportuni3es	
  of	
  health	
  care	
  reform	
  
        provisions	
  for	
  improving	
  the	
  health	
  and	
  health	
  care	
  of	
  racially	
  and	
  
        ethnically	
  diverse	
  popula3ons.	
  

•  We	
  have	
  also	
  tracked	
  implementa3on	
  status	
  and	
  progress	
  
   for	
  provisions	
  with	
  explicit	
  requirements	
  for	
  linguis3c	
  and	
  
   cultural	
  competence.	
  

     	
  
Click to edit Master title style
Cultural Competence & Workforce
Diversity
Click to edit Master title style
•  Cultural	
  Competence	
  
    –  Model	
  cultural	
  competence	
  curricula.	
  
    –  Cultural	
  competence	
  training	
  for	
  health	
  professionals.	
  
    –  Culturally	
  appropriate	
  pa3ent	
  decision	
  aids.	
  
    –  Culturally	
  appropriate	
  personal	
  responsibility	
  educa3on	
  for	
  teen	
  
       pregnancy	
  preven3on.	
  
    –  Culturally	
  appropriate	
  na3onal	
  oral	
  health	
  campaign.	
  
    	
  
•  Workforce	
  Diversity	
  
    –      Increase	
  diversity	
  among	
  health	
  professionals.	
  
    –      Health	
  professions	
  training	
  preference	
  for	
  cultural	
  competence.	
  
    –      Investment	
  in	
  HBCUs	
  &	
  minority-­‐serving	
  ins3tu3ons.	
  
    –      Collect	
  &	
  report	
  workforce	
  diversity	
  data.	
  
Data Collection & Disparities
Click to edit Master title style Research
•  Data	
  Collec3on	
  &	
  Repor3ng	
  
    –  Collect	
  racial/ethnic	
  sub	
  group	
  data	
  in	
  popula3on	
  surveys.	
  
    –  Collect/report	
  dispari3es	
  data	
  in	
  Medicaid	
  &	
  CHIP.	
  
    –  Monitor	
  dispari3es	
  trends	
  in	
  federally	
  funded	
  programs.	
  


•  Health	
  Dispari3es	
  Research	
  
    –  Examining	
  dispari3es	
  through	
  compara3ve	
  effec3veness	
  
       research.	
  
    –  Suppor3ng	
  research	
  on	
  topics	
  of	
  cultural	
  competence	
  and	
  
       health	
  dispari3es.	
  
Click to edit Master title style
General Provisions
Click to edit Master title style
•      Expansion	
  of	
  Medicaid	
  eligibility	
  to	
  133%	
  FPL	
  
•      Reauthoriza3on	
  of	
  CHIP	
  
•      Small	
  business	
  (<25	
  employees)	
  tax	
  credits	
  
•      State-­‐based	
  Insurance	
  Exchanges	
  
•      Community	
  Health	
  Center	
  support	
  
•      Demonstra3on	
  programs	
  for	
  na3onal	
  
       priori3es	
  
	
  
General Provisions
Click to edit Master title style
•  Expanding	
  and	
  building	
  a	
  diverse	
  workforce	
  
•  Requiring	
  non-­‐profit	
  hospital	
  community	
  
   needs	
  assessments	
  
•  Expanding	
  the	
  focus	
  on	
  quality	
  through	
  linking	
  
   Medicare	
  payments	
  to	
  outcomes,	
  quality	
  
   measures	
  development,	
  a	
  na3onal	
  strategy	
  
   for	
  quality	
  improvement	
  and	
  other	
  efforts	
  
Click to edit Master title style
Highlights
Click to edit Master title style
•  Great	
  breadth	
  of	
  opportuni3es	
  in	
  ACA	
  to	
  reduce	
  dispari3es	
  and	
  
   improve	
  health	
  equity.	
  

•  Federal	
  agencies,	
  generally	
  assigned	
  leading	
  responsibility	
  for	
  
   advancing	
  and	
  implemen3ng	
  	
  disparity	
  and	
  cultural	
  competence	
  
   provisions.	
  

•  Many	
  provisions	
  with	
  requirements	
  related	
  to	
  equity,	
  cultural	
  
   competence	
  and	
  language	
  assistance	
  have	
  received	
  appropria3ons	
  
   and	
  offer	
  opportuni3es	
  for	
  states	
  and	
  state	
  agencies	
  to	
  pursue	
  
   funding.	
  

•  Other	
  important	
  race/culture/language	
  provisions,	
  however,	
  have	
  
   not	
  received	
  appropria3ons	
  as	
  yet.	
  	
  	
  
Funded Opportunities:
Health edit Master title
Click toInsurance Programs style
•  State	
  Health	
  Insurance	
  Exchanges	
  
    –  State	
  planning	
  and	
  establishment	
  grants,	
  with	
  requirements	
  for	
  
       cultural	
  &	
  linguis3c	
  competence	
  in	
  benefit	
  summaries,	
  appeals	
  
       processes,	
  and	
  other	
  provisions	
  related	
  to	
  health	
  plans.	
  
          •    Non-­‐discrimina3on	
  in	
  health	
  insurance	
  exchanges.	
  
          •    Culturally	
  &	
  linguis3cally	
  appropriate	
  summary	
  of	
  benefits.	
  
          •    Culturally	
  &	
  linguis3cally	
  appropriate	
  claims	
  appeal	
  process.	
  
          •    Navigator	
  to	
  provide	
  culturally	
  &	
  linguis3cally	
  appropriate	
  informa3on.	
  
          •    Incen3ve	
  payments	
  for	
  cultural	
  competence	
  &	
  reducing	
  dispari3es.	
  


•  State	
  Office	
  of	
  Consumer	
  Health	
  Assistance	
  
    –  Federal	
  grants	
  to	
  states	
  to	
  establish	
  an	
  Office	
  of	
  Health	
  Insurance	
  
       Consumer	
  Assistance	
  or	
  an	
  Ombudsman	
  Program.	
  
Funded Opportunities:
Community Health and Prevention
Click to edit Master title style
•  Community	
  TransformaBon	
  Grants	
  
    –  Over	
  $100	
  million	
  for	
  75	
  grants	
  to	
  help	
  communi3es	
  implement	
  projects	
  proven	
  
       to	
  reduce	
  chronic	
  diseases	
  as	
  well	
  as	
  health	
  dispari3es.	
  	
  

•  Personal	
  Responsibility	
  EducaBon	
  	
  
    –  $75	
  million	
  for	
  states	
  in	
  2011	
  to	
  educate	
  youth	
  in	
  culturally/linguis3cally	
  
       appropriate	
  ways	
  to	
  prevent	
  teen	
  pregnancy	
  and	
  sexually	
  transmifed	
  infec3ons.	
  
    	
  	
  


•  CHIP	
  Childhood	
  Obesity	
  DemonstraBon	
  
    –  $25	
  million	
  in	
  FY	
  2011	
  to	
  develop	
  a	
  model	
  for	
  reducing	
  childhood	
  obesity.	
  

•  Medicaid	
  PrevenBon	
  and	
  Wellness	
  IniBaBves	
  
    –  State	
  grants	
  to	
  provide	
  incen3ves	
  for	
  Medicaid	
  beneficiaries	
  to	
  par3cipate	
  in	
  
         evidence-­‐based	
  programs	
  to	
  prevent/manage	
  chronic	
  disease.	
  $100	
  million	
  for	
  
         5-­‐year	
  period	
  from	
  FY	
  2011-­‐2016.	
  
    	
  
Funded Opportunities:
Improving Quality and Efficiency
Click to edit Master title style
•  Medicaid	
  Integrated	
  Care	
  HospitalizaBon	
  DemonstraBon	
  
    –  Up	
  to	
  8	
  states	
  to	
  use	
  bundled	
  payments	
  to	
  promote	
  integrated	
  care.	
  


•  Pediatric	
  Accountable	
  Care	
  OrganizaBon	
  DemonstraBon	
  
    –  Allow	
  pediatric	
  providers	
  to	
  organize	
  as	
  ACOs	
  and	
  share	
  in	
  federal	
  and	
  state	
  
       cost	
  savings	
  generated	
  under	
  Medicaid.	
  
Funded Opportunities:
Access to Health Care & Support for Safety
Net
Click to edit Master title style
•  Grants	
  for	
  Trauma	
  Care	
  Centers	
  
       –  Grants	
  to	
  states	
  to	
  support	
  universal	
  access	
  to	
  trauma	
  care	
  services.	
  $100	
  
          million	
  per	
  FY	
  2010-­‐2015.	
  	
  States	
  must	
  award	
  at	
  least	
  40%	
  to	
  safety	
  net	
  
          ins3tu3ons.	
  

•  Primary	
  Care	
  Extension	
  Program	
  
       –  $120	
  million	
  in	
  2011	
  to	
  establish	
  program	
  to	
  support	
  and	
  assist	
  primary	
  care	
  
          providers	
  to	
  improve	
  community	
  health.	
  	
  

•  State	
  Health	
  Care	
  Workforce	
  Development	
  Grants	
  
       –  Up	
  to	
  $150,000	
  per	
  state	
  partnership	
  for	
  carrying	
  out	
  planning	
  and	
  
          implementa3on	
  of	
  health	
  care	
  workforce	
  development.	
  
       –  25	
  states	
  received	
  planning	
  grants	
  and	
  1	
  with	
  an	
  implementa3on	
  grant	
  in	
  2010.	
  

•  Maternal,	
  Infant	
  and	
  Early	
  Child	
  Home	
  VisiBng	
  Programs	
  
       –  $1.5	
  billion	
  for	
  FY	
  2010-­‐2014,	
  for	
  home	
  visi3ng	
  programs	
  for	
  at-­‐risk	
  popula3ons.	
  

	
  
Caution!
Click to edit Master title style
Notwithstanding	
  these	
  access	
  and	
  safety	
  net	
  
ini3a3ves:	
  
	
  


•  $18	
  billion	
  reduc3on	
  in	
  Medicaid	
  Dispropor3onate	
  
   Share	
  payments	
  over	
  7	
  years	
  creates	
  great	
  
   uncertainty	
  for	
  the	
  future	
  of	
  safety	
  net	
  hospitals.	
  
                                                                            	
  




•  State	
  budget	
  deficits	
  may	
  undermine	
  efforts	
  to	
  
   sustain	
  the	
  safety	
  net	
  and	
  improve	
  access.	
  
       	
  	
  
	
  
Unfunded Opportunities:
Click to edit Master title style
Community Health & Prevention
•  Community-­‐Based	
  PrevenBon	
  and	
  Wellness	
  Programs	
  	
  
    –  Grants	
  to	
  state/local	
  health	
  depts.	
  to	
  carry	
  out	
  5-­‐year	
  pilot	
  programs	
  
       for	
  Medicare	
  beneficiaries.	
  
    	
  

•  Community	
  Health	
  Teams	
  (CHTs)	
  
    –  As	
  states	
  adopt	
  medical	
  home	
  models,	
  more	
  low	
  income	
  &	
  diverse	
  
       individuals	
  with	
  chronic	
  illness	
  will	
  be	
  able	
  to	
  turn	
  to	
  a	
  CHT	
  to	
  help	
  
       them	
  link	
  with	
  a	
  full	
  range	
  of	
  health	
  and	
  social	
  services	
  they	
  may	
  need.	
  

•  Community	
  Health	
  Workers	
  (CHWs)	
  
    –  Use	
  of	
  CHWs	
  in	
  health	
  interven3on	
  programs	
  associated	
  with	
  
       improved	
  access,	
  prenatal	
  care,	
  pregnancy	
  and	
  birth	
  outcomes,	
  health	
  
       status,	
  screening	
  behaviors	
  &	
  reduced	
  health	
  care	
  costs.	
  	
  

•  ImmunizaBon	
  DemonstraBon	
  Program	
  
    –  Grants	
  for	
  immuniza3on	
  programs	
  for	
  at-­‐risk	
  popula3ons.	
  
Unfunded Opportunities:
Cultural Competence
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•  Model	
  Curricula	
  for	
  Cultural	
  Competency	
  
     –  Opportunity	
  to	
  test	
  impact	
  of	
  a	
  range	
  of	
  cultural	
  competency	
  training	
  
        programs	
  	
  on	
  health	
  outcomes	
  and	
  to	
  iden3fy	
  efficacy	
  &	
  effec3veness.	
  


•  FacilitaBng	
  Shared	
  Decision	
  Making	
  
     –  Pa3ent	
  decision	
  aids	
  are	
  required	
  to	
  present	
  up-­‐to-­‐date	
  clinical	
  
        evidence	
  about	
  risks	
  and	
  benefits	
  of	
  treatment	
  op3ons	
  to	
  meet	
  
        cultural	
  &	
  health	
  literacy	
  requirements	
  of	
  popula3ons.	
  
Click to edit Master title style
Advancing the Health of Communities
Click to edit Master title style
 1.  Leveraging	
  support	
  for	
  community-­‐based	
  strategies	
  
     and	
  engagement	
  in	
  reducing	
  dispariBes.	
  	
  	
  
     •  Communi3es	
  must	
  be	
  ac3ve	
  and	
  involved	
  par3cipants	
  in	
  sekng	
  
        overall	
  objec3ves,	
  specific	
  goals	
  and	
  strategies	
  for	
  achieving	
  them.	
  

 2.	
  	
  	
  PromoBng	
  integrated	
  strategies	
  across	
  health	
  and	
  
               social	
  services	
  to	
  improve	
  the	
  health	
  of	
  diverse	
  
               communiBes.	
  	
  
     •  Need	
  for	
  direct,	
  concerted	
  research,	
  policy	
  and	
  programs	
  that	
  seek	
  to	
  
        alter	
  significantly	
  the	
  nega3ve	
  influence	
  of	
  social	
  determinants	
  in	
  
        diverse	
  communi3es.	
  
Health Care Organization-Based
Initiatives
Click to edit Master title style
1.	
  	
  	
  Developing	
  and	
  tesBng	
  model	
  programs	
  that	
  link	
  specific	
  
              organizaBonal	
  efforts	
  to	
  reducing	
  dispariBes	
  and	
  improving	
  
              quality	
  of	
  care.	
  
       •  Organiza3ons	
  must	
  be	
  commifed	
  to	
  support	
  prac33oners	
  through	
  more	
  
          comprehensive	
  and	
  ac3ve	
  engagement	
  in	
  caring	
  for	
  diverse	
  pa3ents.	
  	
  

2.	
  	
  	
  DocumenBng	
  and	
  linking	
  non-­‐profit	
  community	
  needs	
  
              assessment/benefit	
  requirements	
  to	
  health	
  care	
  reform	
  
              incenBves	
  to	
  address	
  dispariBes.	
  	
  	
  
       •  Need	
  to	
  reach	
  beyond	
  demonstra3ons	
  and	
  funding	
  opportuni3es.	
  
       •  Require	
  provider	
  organiza3ons	
  to	
  show	
  evidence	
  of	
  working	
  to	
  reduce	
  
          dispari3es—e.g.	
  through	
  educa3on	
  &	
  community	
  outreach	
  
3.	
  	
  	
  Preserving	
  and	
  transiBoning	
  the	
  health	
  care	
  safety	
  net.	
  
       •  Providing	
  direct	
  support	
  for	
  safety	
  net	
  hospitals,	
  par3cularly	
  in	
  regions	
  with	
  
          large	
  uninsured	
  and	
  undocumented	
  popula3ons.	
  
       •  Guidance	
  for	
  philanthropic	
  organiza3ons	
  on	
  ways	
  to	
  support	
  safety	
  net.	
  
Individual Level Initiatives
Click to edit Master title style
 1.  Developing	
  effecBve	
  care/disease	
  management	
  and	
  self	
  
     management	
  intervenBons	
  and	
  protocols	
  for	
  diverse	
  
     paBents.	
  	
  
        •  New	
  programs	
  will	
  need	
  to	
  address	
  how	
  and	
  to	
  what	
  extent	
  
           inafen3on	
  to	
  race-­‐	
  and	
  culture-­‐specific	
  and	
  language/literacy	
  
           concerns	
  may	
  create	
  impediments	
  to	
  care	
  management	
  and	
  self	
  
           management.	
  	
  
 	
  
 2.  MiBgaBng	
  the	
  effects	
  of	
  overweight/obesity	
  and	
  negaBve	
  	
  	
  	
  
     environmental	
  factors	
  that	
  may	
  impede	
  progress	
  on	
  
     reducing	
  dispariBes.	
  	
  
        •  Greater	
  health	
  care	
  provider	
  awareness	
  of	
  culture	
  and	
  challenges	
  
           faced	
  by	
  diverse	
  popula3ons	
  will	
  be	
  important	
  for	
  reducing	
  
           dispari3es	
  in	
  care	
  and	
  adherence	
  to	
  treatment.	
  
Next Steps
Click to edit Master title style
•  Educa3on	
  around	
  specific	
  ACA	
  language	
  for	
  priority	
  areas.	
  

•  Work	
  with	
  representa3ve	
  associa3ons/organiza3ons	
  to	
  
   educate	
  and	
  discuss	
  strategies	
  for	
  pursuing	
  priority	
  areas.	
  

•  Advocate	
  for	
  state,	
  county	
  and	
  community	
  innova3on	
  in	
  
   health	
  equity	
  and	
  reducing	
  dispari3es.	
  
	
  


•  Appropria3ons,	
  appropria3ons,	
  appropria3ons—assuring	
  
   adequate	
  funding	
  for	
  provisions.	
  
	
  


•  Communicate	
  with	
  agencies	
  likely	
  to	
  oversee	
  iden3fied	
  
   priority	
  areas	
  about	
  status	
  and	
  progress	
  in	
  adding	
  content	
  to	
  
   these	
  areas.	
  
Click to edit Master title style
              Dennis P. Andrulis, PhD, MPH
                 Senior Research Scientist, Texas Health Institute
         Associate Professor, University of Texas School of Public Health
                             dpandrulis@gmail.com

                           Nadia J. Siddiqui, MPH
               Senior Health Policy Analyst, Texas Health Institute
                       nsiddiqui@texashealthinstitute.org

                       Jonathan P. Purtle, MPH, MSc
          Program Manager, Drexel University School of Public Health
                           jpp46@drexel.edu

                           Lisa Duchon, PhD, MPA
                         Health Management Associates
                        lduchon@healthmanagement.com

                            *Download publication here*
ACA Implementation and Health
Equity: Experiences from Maryland


 Dr. Carlessia A. Hussein, Dr.PH, RN, Director
  Office of Minority Health and Health Disparities
Maryland Department of Health and Mental Hygiene
State Health Equity Learning
Collaborative: Request for Applications
for Technical Assistance



               Diane Justice, MA
             Senior Program Director
 National Academy for State Health Policy (NASHP)
What is it?
n    Opportunity for states to
      advance health equity agendas
      while engaging in critical health
      care reform implementation
      activities
n    Structured peer-learning
      opportunity to integrate health
      equity initiatives across state
      agencies – specifically
      Medicaid, Public Health and
      Minority Health Offices
n    Collaborative will consist of
      seven competitively selected
      states working in key policy
      areas:
      ¡    Health insurance coverage
      ¡    Delivery system reform
      ¡    Public health
What s in it for States?
n    Participating states will:
      ¡    Receive a customized State Health Equity
            Profile developed by NASHP
      ¡    Work across state teams to develop a state
            health equity work plan
      ¡    Collaborate with peer states through an online
            community portal
      ¡    Receive technical assistance from national
            health equity experts
      ¡    Opportunity to attend and present at a National
            Invitational Health Equity Summit
State Requirements
n    Maintain a core team of at least three
      members from state agencies
n    Develop a state health equity work plan
n    Participate in all TA activities
n    Achieve reasonable implementation of state
      work plan
n    Review NASHP products as requested
n    Update work plan at end of 8-month TA
      period
Process: Request for Applications
July 21, 2011       Issue Requests for Applications
                    Accessible at www.nashp.org

August 9, 2011      Prospective Applicant Call
3:00 pm EDT         Call-in: 866-640-1260, Passcode: 3938541

August 23, 2011     Applications Due to NASHP

September 9, 2011   Selected States are Notified

October 7, 2011     Work Plan Due to NASHP

March 2012          National Summit in Washington, DC

May 2012            Final Report Due: State Work Plan Update

Ongoing             Participation in Technical Assistance Activities
n    Statereforum.org is a space for:
      ¡    Peer-to-peer learning and discussion
      ¡    Exchanging reform ideas
      ¡    Posting, organizing, and sharing useful state
            documents
      ¡    Announcing off-line events and activities
      ¡    Spotlighting the keys to successful
            implementation
      ¡    Mapping states progress in implementing
            health reform
Questions and Answers?
Contact Information

n    Dr. Ernest Moy
      ¡    ernest.moy@ahrq.hhs.gov
n    Dr. Dennis Andrulis
      ¡    dpandrulis@gmail.com
n    Dr. Carlessia A. Hussein
      ¡    husseinc@dhmh.state.md.us
n    Diane Justice
      ¡    djustice@nashp.org
Thank You!


For more information, please visit:
        www.nashp.org
    www.aetna-foundation.org
     www.statereforum.org

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Advancing Health Equity through State Implementation of Health Reform

  • 1. Advancing Health Equity through Health Reform Implementation Thursday, July 21, 2011 This webcast will begin at 2:00 P.M. EDT Please hold until we start the conference. The audio portion of this webcast can be accessed by dialing: 800.757.7641
  • 2. Agenda n  Welcome and Introductions ¡  Diane Justice, MA, Senior Program Director, National Academy for State Health Policy (NASHP) ¡  Dr. Anne C. Beal, MD, MPH, President, Aetna Foundation n  National Healthcare Quality and Disparities Reports and State Disparities ¡  Dr. Ernest Moy, MD, MPH, Medical Officer, Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality (AHRQ) n  State Obligation and Opportunity in Health Care Reform: Implementing the Affordable Care Act to Advance Health Equity for Racially and Ethnically Diverse Populations ¡  Dr. Dennis P. Andrulis, Ph.D., MPH, Senior Research Scientist, Texas Health Institute; Associate Professor, University of Texas School of Public Health
  • 3. Agenda (cont.) n  ACA Implementation and Health Equity: Experiences from Maryland ¡  Dr. Carlessia A. Hussein, Dr.PH, RN, Director, Office of Minority Health and Health Disparities, Maryland Department of Health and Mental Hygiene n  State Health Equity Learning Collaborative: Request for Applications for Technical Assistance ¡  Diane Justice, MA, Senior Program Director, NASHP n  Questions and Answers
  • 4. About NASHP n  22 year old non-profit, non-partisan organization n  Academy members ¡  Peer-selected group of state health policy leaders ¡  Commitment to identifying state needs and guiding our work n  Working together across states, branches, and agencies to advance, accelerate, and implement workable policy solutions that address major health issues
  • 5. Advancing Equity through State Implementation of Health Reform n  Supported by the Aetna Foundation n  Project goals include: ¡  Supporting state leadership for eliminating disparities and advancing health equity through health care reform implementation ¡  Establishing a State Health Equity Learning Collaborative ¡  Facilitating a National Invitational Health Equity Summit ¡  Publishing a State Policymakers Action Agenda for Achieving Health Equity through Health Reform
  • 6. National Healthcare Quality and Disparities Reports and State Disparities Ernest Moy Ernest.moy@ahrq.hhs.gov 301-427-1329 www.ahrq.gov/qual/qrdr10.htm http://statesnapshots.ahrq.gov
  • 7. National Healthcare Reports Annual reports to Congress from Secretary since 2003 mandated by 1999 Healthcare Research and Quality Act Unified team, Interagency Work Group, framework, data, methods, quality measures Quality Report Disparities Report Snapshot & trends in quality of Snapshot & trends in health care in America disparities in health care Effectiveness, safety, timeliness, Differences across race, patient centeredness, care ethnicity, & socioeconomic coordination, efficiency, health status system infrastructure, access Variation across states Variation across populations
  • 8. State Snapshots: Overall Health Care Quality for California
  • 9. State Snapshots: California Dashboard Compared to All States
  • 10. Racial/Ethnic Diversity Across States
  • 11. Hispanic-White Disparity in Colorectal Cancer Screening across States 30 Worst States 25 All State Average 20 15 Best States 10 5 0 B e st S ta te s Wo rst S ta te s -5 -10 -15
  • 12. Black-White Disparity in Colorectal Cancer Screening across States 30 Worst States 25 20 15 All State Average 10 5 0 B e st S ta te s A ll   S ta te A v e ra g e Wo rst S ta te s -5 -10 Best States -15
  • 13. Weak Relationship between Overall Receipt of Colorectal Cancer Screening and Hispanic-White Differences
  • 14. Weak Negative Relationship between Overall Receipt of Colorectal Cancer Screening and Black-White Differences
  • 15. Mountain West North Central New England East North Poorer Overall Quality Central of Preventive Care Middle Atlantic DC PR VI Pacific South Atlantic East South West Central South Central Mountain West North Central New England East North Central Middle Atlantic DC PR VI Pacific Larger Racial or Ethnic East South Atlantic Disparities in West South Central South Central Preventive Care
  • 17. Conclusions n  State need to address disparities –  Different populations –  Different disparities n  Disparities can help States –  Identify strategies –  Target populations and services n  States are succeeding at reducing disparities
  • 18. Click to edit Master title style Dennis  P.  Andrulis,  PhD,  MPH   Senior  Research  Scien-st,  Texas  Health  Ins-tute   Associate  Professor,  University  of  Texas  School  of  Public  Health      
  • 19. Background Master title Click to edit and Purposestyle •  With  support  from  the  Joint  Center  for  Poli3cal  and   Economic  Studies,  we  conducted  a  comprehensive  review   of  the  Pa3ent  Protec3on  and  Affordable  Care  Act  of  2010:   –  To  iden3fy  and  describe  provisions  specific  to  race,  ethnicity  and   language;  and  general  provisions  likely  to  have  a  significant  affect  on   diverse  popula3ons.   –  To  assess  status,  challenges  and  opportuni3es  of  health  care  reform   provisions  for  improving  the  health  and  health  care  of  racially  and   ethnically  diverse  popula3ons.   •  We  have  also  tracked  implementa3on  status  and  progress   for  provisions  with  explicit  requirements  for  linguis3c  and   cultural  competence.    
  • 20. Click to edit Master title style
  • 21. Cultural Competence & Workforce Diversity Click to edit Master title style •  Cultural  Competence   –  Model  cultural  competence  curricula.   –  Cultural  competence  training  for  health  professionals.   –  Culturally  appropriate  pa3ent  decision  aids.   –  Culturally  appropriate  personal  responsibility  educa3on  for  teen   pregnancy  preven3on.   –  Culturally  appropriate  na3onal  oral  health  campaign.     •  Workforce  Diversity   –  Increase  diversity  among  health  professionals.   –  Health  professions  training  preference  for  cultural  competence.   –  Investment  in  HBCUs  &  minority-­‐serving  ins3tu3ons.   –  Collect  &  report  workforce  diversity  data.  
  • 22. Data Collection & Disparities Click to edit Master title style Research •  Data  Collec3on  &  Repor3ng   –  Collect  racial/ethnic  sub  group  data  in  popula3on  surveys.   –  Collect/report  dispari3es  data  in  Medicaid  &  CHIP.   –  Monitor  dispari3es  trends  in  federally  funded  programs.   •  Health  Dispari3es  Research   –  Examining  dispari3es  through  compara3ve  effec3veness   research.   –  Suppor3ng  research  on  topics  of  cultural  competence  and   health  dispari3es.  
  • 23. Click to edit Master title style
  • 24. General Provisions Click to edit Master title style •  Expansion  of  Medicaid  eligibility  to  133%  FPL   •  Reauthoriza3on  of  CHIP   •  Small  business  (<25  employees)  tax  credits   •  State-­‐based  Insurance  Exchanges   •  Community  Health  Center  support   •  Demonstra3on  programs  for  na3onal   priori3es    
  • 25. General Provisions Click to edit Master title style •  Expanding  and  building  a  diverse  workforce   •  Requiring  non-­‐profit  hospital  community   needs  assessments   •  Expanding  the  focus  on  quality  through  linking   Medicare  payments  to  outcomes,  quality   measures  development,  a  na3onal  strategy   for  quality  improvement  and  other  efforts  
  • 26. Click to edit Master title style
  • 27. Highlights Click to edit Master title style •  Great  breadth  of  opportuni3es  in  ACA  to  reduce  dispari3es  and   improve  health  equity.   •  Federal  agencies,  generally  assigned  leading  responsibility  for   advancing  and  implemen3ng    disparity  and  cultural  competence   provisions.   •  Many  provisions  with  requirements  related  to  equity,  cultural   competence  and  language  assistance  have  received  appropria3ons   and  offer  opportuni3es  for  states  and  state  agencies  to  pursue   funding.   •  Other  important  race/culture/language  provisions,  however,  have   not  received  appropria3ons  as  yet.      
  • 28. Funded Opportunities: Health edit Master title Click toInsurance Programs style •  State  Health  Insurance  Exchanges   –  State  planning  and  establishment  grants,  with  requirements  for   cultural  &  linguis3c  competence  in  benefit  summaries,  appeals   processes,  and  other  provisions  related  to  health  plans.   •  Non-­‐discrimina3on  in  health  insurance  exchanges.   •  Culturally  &  linguis3cally  appropriate  summary  of  benefits.   •  Culturally  &  linguis3cally  appropriate  claims  appeal  process.   •  Navigator  to  provide  culturally  &  linguis3cally  appropriate  informa3on.   •  Incen3ve  payments  for  cultural  competence  &  reducing  dispari3es.   •  State  Office  of  Consumer  Health  Assistance   –  Federal  grants  to  states  to  establish  an  Office  of  Health  Insurance   Consumer  Assistance  or  an  Ombudsman  Program.  
  • 29. Funded Opportunities: Community Health and Prevention Click to edit Master title style •  Community  TransformaBon  Grants   –  Over  $100  million  for  75  grants  to  help  communi3es  implement  projects  proven   to  reduce  chronic  diseases  as  well  as  health  dispari3es.     •  Personal  Responsibility  EducaBon     –  $75  million  for  states  in  2011  to  educate  youth  in  culturally/linguis3cally   appropriate  ways  to  prevent  teen  pregnancy  and  sexually  transmifed  infec3ons.       •  CHIP  Childhood  Obesity  DemonstraBon   –  $25  million  in  FY  2011  to  develop  a  model  for  reducing  childhood  obesity.   •  Medicaid  PrevenBon  and  Wellness  IniBaBves   –  State  grants  to  provide  incen3ves  for  Medicaid  beneficiaries  to  par3cipate  in   evidence-­‐based  programs  to  prevent/manage  chronic  disease.  $100  million  for   5-­‐year  period  from  FY  2011-­‐2016.    
  • 30. Funded Opportunities: Improving Quality and Efficiency Click to edit Master title style •  Medicaid  Integrated  Care  HospitalizaBon  DemonstraBon   –  Up  to  8  states  to  use  bundled  payments  to  promote  integrated  care.   •  Pediatric  Accountable  Care  OrganizaBon  DemonstraBon   –  Allow  pediatric  providers  to  organize  as  ACOs  and  share  in  federal  and  state   cost  savings  generated  under  Medicaid.  
  • 31. Funded Opportunities: Access to Health Care & Support for Safety Net Click to edit Master title style •  Grants  for  Trauma  Care  Centers   –  Grants  to  states  to  support  universal  access  to  trauma  care  services.  $100   million  per  FY  2010-­‐2015.    States  must  award  at  least  40%  to  safety  net   ins3tu3ons.   •  Primary  Care  Extension  Program   –  $120  million  in  2011  to  establish  program  to  support  and  assist  primary  care   providers  to  improve  community  health.     •  State  Health  Care  Workforce  Development  Grants   –  Up  to  $150,000  per  state  partnership  for  carrying  out  planning  and   implementa3on  of  health  care  workforce  development.   –  25  states  received  planning  grants  and  1  with  an  implementa3on  grant  in  2010.   •  Maternal,  Infant  and  Early  Child  Home  VisiBng  Programs   –  $1.5  billion  for  FY  2010-­‐2014,  for  home  visi3ng  programs  for  at-­‐risk  popula3ons.    
  • 32. Caution! Click to edit Master title style Notwithstanding  these  access  and  safety  net   ini3a3ves:     •  $18  billion  reduc3on  in  Medicaid  Dispropor3onate   Share  payments  over  7  years  creates  great   uncertainty  for  the  future  of  safety  net  hospitals.     •  State  budget  deficits  may  undermine  efforts  to   sustain  the  safety  net  and  improve  access.        
  • 33. Unfunded Opportunities: Click to edit Master title style Community Health & Prevention •  Community-­‐Based  PrevenBon  and  Wellness  Programs     –  Grants  to  state/local  health  depts.  to  carry  out  5-­‐year  pilot  programs   for  Medicare  beneficiaries.     •  Community  Health  Teams  (CHTs)   –  As  states  adopt  medical  home  models,  more  low  income  &  diverse   individuals  with  chronic  illness  will  be  able  to  turn  to  a  CHT  to  help   them  link  with  a  full  range  of  health  and  social  services  they  may  need.   •  Community  Health  Workers  (CHWs)   –  Use  of  CHWs  in  health  interven3on  programs  associated  with   improved  access,  prenatal  care,  pregnancy  and  birth  outcomes,  health   status,  screening  behaviors  &  reduced  health  care  costs.     •  ImmunizaBon  DemonstraBon  Program   –  Grants  for  immuniza3on  programs  for  at-­‐risk  popula3ons.  
  • 34. Unfunded Opportunities: Cultural Competence Click to edit Master title style •  Model  Curricula  for  Cultural  Competency   –  Opportunity  to  test  impact  of  a  range  of  cultural  competency  training   programs    on  health  outcomes  and  to  iden3fy  efficacy  &  effec3veness.   •  FacilitaBng  Shared  Decision  Making   –  Pa3ent  decision  aids  are  required  to  present  up-­‐to-­‐date  clinical   evidence  about  risks  and  benefits  of  treatment  op3ons  to  meet   cultural  &  health  literacy  requirements  of  popula3ons.  
  • 35. Click to edit Master title style
  • 36. Advancing the Health of Communities Click to edit Master title style 1.  Leveraging  support  for  community-­‐based  strategies   and  engagement  in  reducing  dispariBes.       •  Communi3es  must  be  ac3ve  and  involved  par3cipants  in  sekng   overall  objec3ves,  specific  goals  and  strategies  for  achieving  them.   2.      PromoBng  integrated  strategies  across  health  and   social  services  to  improve  the  health  of  diverse   communiBes.     •  Need  for  direct,  concerted  research,  policy  and  programs  that  seek  to   alter  significantly  the  nega3ve  influence  of  social  determinants  in   diverse  communi3es.  
  • 37. Health Care Organization-Based Initiatives Click to edit Master title style 1.      Developing  and  tesBng  model  programs  that  link  specific   organizaBonal  efforts  to  reducing  dispariBes  and  improving   quality  of  care.   •  Organiza3ons  must  be  commifed  to  support  prac33oners  through  more   comprehensive  and  ac3ve  engagement  in  caring  for  diverse  pa3ents.     2.      DocumenBng  and  linking  non-­‐profit  community  needs   assessment/benefit  requirements  to  health  care  reform   incenBves  to  address  dispariBes.       •  Need  to  reach  beyond  demonstra3ons  and  funding  opportuni3es.   •  Require  provider  organiza3ons  to  show  evidence  of  working  to  reduce   dispari3es—e.g.  through  educa3on  &  community  outreach   3.      Preserving  and  transiBoning  the  health  care  safety  net.   •  Providing  direct  support  for  safety  net  hospitals,  par3cularly  in  regions  with   large  uninsured  and  undocumented  popula3ons.   •  Guidance  for  philanthropic  organiza3ons  on  ways  to  support  safety  net.  
  • 38. Individual Level Initiatives Click to edit Master title style 1.  Developing  effecBve  care/disease  management  and  self   management  intervenBons  and  protocols  for  diverse   paBents.     •  New  programs  will  need  to  address  how  and  to  what  extent   inafen3on  to  race-­‐  and  culture-­‐specific  and  language/literacy   concerns  may  create  impediments  to  care  management  and  self   management.       2.  MiBgaBng  the  effects  of  overweight/obesity  and  negaBve         environmental  factors  that  may  impede  progress  on   reducing  dispariBes.     •  Greater  health  care  provider  awareness  of  culture  and  challenges   faced  by  diverse  popula3ons  will  be  important  for  reducing   dispari3es  in  care  and  adherence  to  treatment.  
  • 39. Next Steps Click to edit Master title style •  Educa3on  around  specific  ACA  language  for  priority  areas.   •  Work  with  representa3ve  associa3ons/organiza3ons  to   educate  and  discuss  strategies  for  pursuing  priority  areas.   •  Advocate  for  state,  county  and  community  innova3on  in   health  equity  and  reducing  dispari3es.     •  Appropria3ons,  appropria3ons,  appropria3ons—assuring   adequate  funding  for  provisions.     •  Communicate  with  agencies  likely  to  oversee  iden3fied   priority  areas  about  status  and  progress  in  adding  content  to   these  areas.  
  • 40. Click to edit Master title style Dennis P. Andrulis, PhD, MPH Senior Research Scientist, Texas Health Institute Associate Professor, University of Texas School of Public Health dpandrulis@gmail.com Nadia J. Siddiqui, MPH Senior Health Policy Analyst, Texas Health Institute nsiddiqui@texashealthinstitute.org Jonathan P. Purtle, MPH, MSc Program Manager, Drexel University School of Public Health jpp46@drexel.edu Lisa Duchon, PhD, MPA Health Management Associates lduchon@healthmanagement.com *Download publication here*
  • 41. ACA Implementation and Health Equity: Experiences from Maryland Dr. Carlessia A. Hussein, Dr.PH, RN, Director Office of Minority Health and Health Disparities Maryland Department of Health and Mental Hygiene
  • 42. State Health Equity Learning Collaborative: Request for Applications for Technical Assistance Diane Justice, MA Senior Program Director National Academy for State Health Policy (NASHP)
  • 43. What is it? n  Opportunity for states to advance health equity agendas while engaging in critical health care reform implementation activities n  Structured peer-learning opportunity to integrate health equity initiatives across state agencies – specifically Medicaid, Public Health and Minority Health Offices n  Collaborative will consist of seven competitively selected states working in key policy areas: ¡  Health insurance coverage ¡  Delivery system reform ¡  Public health
  • 44. What s in it for States? n  Participating states will: ¡  Receive a customized State Health Equity Profile developed by NASHP ¡  Work across state teams to develop a state health equity work plan ¡  Collaborate with peer states through an online community portal ¡  Receive technical assistance from national health equity experts ¡  Opportunity to attend and present at a National Invitational Health Equity Summit
  • 45. State Requirements n  Maintain a core team of at least three members from state agencies n  Develop a state health equity work plan n  Participate in all TA activities n  Achieve reasonable implementation of state work plan n  Review NASHP products as requested n  Update work plan at end of 8-month TA period
  • 46. Process: Request for Applications July 21, 2011 Issue Requests for Applications Accessible at www.nashp.org August 9, 2011 Prospective Applicant Call 3:00 pm EDT Call-in: 866-640-1260, Passcode: 3938541 August 23, 2011 Applications Due to NASHP September 9, 2011 Selected States are Notified October 7, 2011 Work Plan Due to NASHP March 2012 National Summit in Washington, DC May 2012 Final Report Due: State Work Plan Update Ongoing Participation in Technical Assistance Activities
  • 47. n  Statereforum.org is a space for: ¡  Peer-to-peer learning and discussion ¡  Exchanging reform ideas ¡  Posting, organizing, and sharing useful state documents ¡  Announcing off-line events and activities ¡  Spotlighting the keys to successful implementation ¡  Mapping states progress in implementing health reform
  • 49. Contact Information n  Dr. Ernest Moy ¡  ernest.moy@ahrq.hhs.gov n  Dr. Dennis Andrulis ¡  dpandrulis@gmail.com n  Dr. Carlessia A. Hussein ¡  husseinc@dhmh.state.md.us n  Diane Justice ¡  djustice@nashp.org
  • 50. Thank You! For more information, please visit: www.nashp.org www.aetna-foundation.org www.statereforum.org