Advancing Health Equity: The Essential Role Of Primary Care

Advancing Health Equity:The Essential Role of Primary Care2021 Leadership and Faculty Development Program ConferenceMay 4, 2021Judith Steinberg, MD, MPHChief Medical OfficerOffice of Infectious Disease and HIV/AIDS Policy

Agenda Health, health equity, disparitiesPrimary care and advanced primary care modelsWhat’s the data?Barriers and facilitatorsWhat’s needed?Current landscapeKey takeaways

HealthCummings Graduate Institute for Behavioral Health StudiesHealthy People 2030

Health Equity: Attaining The Highest Level Of Health For All PeopleHealth inequities:Systematic differences in the opportunitiesgroups have to achieve optimal health,leading to unfair and avoidable differencesin health outcomesRoot Cause: Structural InequitiesEqualityEquityGraphic: NASTAD.org Interpersonal, institutional,and systemic biases inpolicies and practicesBraveman. Public Health Reports 2014Braveman, 2006WHO, 2011Communities in Action: Pathways to Health Equity, NASEM 2017

The COVID-19 Pandemic Has Exposed And Highlighted HealthInequities In Our NationCOVID-19 Cases by Race/EthnicityCOVID Tracking Project

Higher Social Vulnerability Index Predicts COVID 19 Hotspot AreasDasgupta, et al. MMWR October, 2020

Primary Care: The Basics Founded on ongoing trusting relationshipbetween patient and provider Entry point of health care system Prevention, screening and wellbeing Diagnosis and treatment of acute disease Chronic disease: diagnosis, ongoingmanagement Referral to specialty carePhoto: Phinney Neighborhood Association

Primary Care Improves Health Outcomes 1978 Alma Alta Declaration First Person or familycenteredness Community orientationPlus: Cultural competence1. Shi, Scientifica 20122. Basu et al. Jama Int Med 2020Better primary care is associated with more equitable distribution ofhealth1Stronger primary care systems are generally associated with betterpopulation health outcomes:1 Lower mortality rate Lower rates of premature death and hospitalizations for ambulatory caresensitive conditions Higher infant birth weight Greater life expectancy Higher satisfaction with the healthcare system.Larger primary care workforce is associated with better healthoutcomes2 Increased life expectancy; reduced cardiovascular, cancer andrespiratory mortality

Advanced Primary Care Whole person, patient centered Easy access; bring care to where people areExpanded prevention and treatment: Sexual health and wellbeing, screening, PrEP and PEPVaccine counselingHIV, viral hepatitis, STI treatmentIntegration of services with primary care Multidisciplinary TeamBehavioral healthOral healthSocial servicesPublic healthCare management and navigation across the health care and social support systemsAttention to social determinants of health and the health of communities

Advanced Primary Care Models Health Center ProgramPatient Centered Medical HomeState Advanced Primary Care InitiativesCenter for Medicare and Medicaid Innovation (CMMI) Comprehensive Primary Care Plus Primary Care First

Health Center Program: Borne Of The War On Poverty Authorized in 1965 in Section 330 ofthe Public Health Service Act Consolidated in 1996 to combine theseparate authorities Community Health Center Program Migrant Health Center Program Health Care for the HomelessProgram Public Housing Primary CareProgram

Health Center Program: FundamentalsServe High Need AreasPatient Directed Must serve a high need community orpopulation (e.g., HPSA, MUA/P) Private non-profit or public agency thatis governed by a patient-majoritycommunity boardComprehensiveNo One is Turned Away Provide comprehensive primary careand enabling services (e.g., education,outreach, and transportation services) Services are available to all, with feesadjusted based upon ability to payCollaborativeAccountable Collaborate with other communityproviders to maximize resources andefficiencies in service delivery Meet performance and accountabilityrequirements regarding administrative,clinical, and financial operations

Health Center Program Nearly 1,400 health centers operate over 13,000 service delivery sites that servenearly 30 million patients. Health centers provide patient-centered, comprehensive, integrated care byoffering a range of services: Primary medical, oral, and mental health services Substance use disorder and medication-assistedtreatment (MAT) services Enabling services: case management,health education, and transportationSource: Uniform Data System, 2019; HRSA’s Electronic Handbooks (EHBs), November 2020

Health Center Program: National ImpactBureau of Primary Health Care

Clinical QualityHealth Centers Compared to National AveragesClinical Quality MeasureHealth Centers (2019)National AverageControlling Diabetes (HbA1c 9)68%59%Controlling High Blood Pressure ( 140/90)65%59%Prenatal Care in First Trimester74%74%Health Centers Compared to Healthy People 2020 GoalsClinical Quality MeasureHealth Centers (2019) Healthy People 2020Ischemic Vascular Disease – Use of Aspirin81%52%Dental Sealants for Children Between 6-9 Years57%28%Uniform Data System, 2019HEDIS measures, Medicaid-HMO, 2018, NCQAChild Health USA 2014, HRSA Maternal and Child Health BureauHealthy People 202015

Medication Assisted Treatment (MAT) At Health CentersPatients Receiving MATProviders Eligible to Prescribe MAT160,0008,000142,9197,000 121%803800120,0006,00094,52880,00064,59760,000 138%7004,0003,0002,973 0Health Centers140,000Health Centers Providing MAT 0201720182019002017Uniform Data System 2017-201920182019201720182019

5/4/2021American Rescue Plan Act: 7,600,000,000 To Health Center Program

Cherokee Health System: Behaviorally Enhanced HealthcareHome Behaviorist, Psychiatrist, CHC on PC teamShared patient panel and care planIntegrated health recordShared support staff, physical space, andclinical flow Access and collaboration at point of care Team based co-management and carecoordination Continuum of specialty mental rated Primary Behavioral HealthCarePrimary CareBehavioralHealthOB and PediatricsSpecialty OBAddiction CareSpecialty PedsBehavioral tClinical Pharmacy

Collecting Data On Social Determinants Of HealthA national standardized patient risk assessment protocol designed toengage patients in assessing and addressing social determinants of healthNACHC PRAPARE

Patient Centered Medical Home (PCMH): Pro-ActiveMultidisciplinary Team-based CareGraphic: UMass Medical School

Payment ModelsEarly models: Care management fees plusfee for service (FFS)Importance of Risk AdjustmentPerformance based incentive payment Quality and utilizationProspective payments Per member/per month (PMPM)payment for comprehensiveprimary care services based onpatient panelShort term Care Transformation FeeAsh et al. JAMA Int Med 2017

State Advanced Primary Care Initiatives:Care Transformation Collaborative- Rhode IslandUniversal Behavioral Health Screening Multi-payer, public-private partnership, Expanding PCMH: 128 primary carepractices, serving 700,000 RI residents Supplemental PMPM and performancebased payments Community Health Teams Integrated Behavioral Health Project – 41primary care practices Association between reduced total cost ofcare and PCMH, even larger with integratedbehavioral healthCTC-RI100%90%80%70%60%Cohort 1 Depression Screening50%Cohort 1 Anxiety Screening40%Cohort 1 Substance Abuse Screening30%Cohort 2 Depression Screening20%Cohort 2 Anxiety Screening10%Cohort 2 Substance Abuse Screening0%Q4 '15Q1 '16Q2 '16Q3 '16Q4 '16Q1 '17Q2 '17Q3 '17Q4 '17Q1 '18Q2 '18

Advancing Primary Care Innovation in Medicaid Managed Care Center for Health Care Strategies initiative, supported by the CommonwealthFund Using state’s Medicaid Managed care levers to advance primary care: Addressing social determinants of healthIntegrating behavioral health and primary careUsing technology to improve access to careEnhancing team-based primary care 10 states: DE, HI, NV, TN, TX, VA, WA, PA, LA, RI, Technical assistance, shared learning, peer to peer learningAdvancing Primary Care Innovation in Medicaid Managed Care

Center for Medicare & Medicaid InnovationComprehensive Primary Care Plus 5 year demonstration – year 43,070 primary care practicesMulti-payerPayment model: Track 1 FFS, Care management fee,performance based payment Track 2 – Comprehensive Primary CarePayment, reduced FFS, performancebased payment Care delivery requirements andmilestonesCPC Primary Care First Primary Care First5 year demonstrationAdvanced primary care practicesMulti-payerPayment model: PMPMFFSPerformance based paymentHigher payments for complex patientpopulation Model for practices with highcomplexity patient Includes linkage to behavioralhealth and social determinants ofhealth supports

PCMH and Advanced Model Impact: The DataQuality, cost, utilization 2017 Primary Care Collaborative Review: Improved quality, cost and utilization outcomes, but not uniformly Year 3 Comprehensive Primary Care Plus: A few small favorable impacts on some measures of service use, quality of care,and patient experience Increased Medicare expenditures2017 Primary Care Collaborative Impact reportCPC Third Annual Report

PCMH and Advanced Model Impact: The DataHealth Disparities 2017 Systematic Review: PCMH interventions showed smallimprovements in health disparities1 Stakeholders views on PCMH and health disparities: Minimal or indirectinfluence on health care disparities2This is an important moment to more directly position the PCMH modelto address health care disparities. Although the philosophy behind thePCMH model lends itself to addressing health care disparities, thispotential has not yet been fully realized by the accreditation process.21. Olayiwola et al J Health Dispar Res Pract 20172. De Marchis et al Pop Health Man 2019

Advancing Primary Care: Barriers and FacilitatorsBarriersFacilitators Lack of access: insurance, distance,workforce, hours of service CMS, State Medicaid programs andexpansion Medical mistrust, stigma, confidentialityconcerns Bureau of Primary Health Care Bias, lack of cultural and linguisticcompetency/humility Risk adjusted value-based payment models Multi-payer: public & private Leadership and accountability Partnerships and collaborations Case management, peernavigators/community health workers Technology, data, data sharing Community and patient engagement Advocacy Lack of workforce diversity, capacity,knowledge, skills Primary care provider ”burnout” Payment model, rates, incentives and gaps Policies and larger structural factors

Primary Care SpendPrimary Care Spend Percentage 2019Concern: Primary Care spending decreased 2017-2019* Primary Care utilization is flat or declining** Patients with usual source of care rose slightly 20132016 and leveled off after ACAPromise: 10 states measuring primary care spend with aim toincrease PCC Primary Care Spending Dec 2020Primary Care Collaborative Briefing Paper Dec 2020Multi-stakeholder advisory groupsState Innovation model (SIM) grants from CMMI andMedicaid waivers provide supportSpending targets setRI, CT, DE, OR – 10-12%* Commercial and Medicare Advantage** Commercially insured population

What’s Needed: Enhancing Primary Care for Health Equity Expand the definition of Advanced Primary CareIncentivize and monitor for Health EquityEnhance data collection and reporting by subpopulationSynergize with other Healthcare Transformation: Accountable Care Organizations, Accountable Entities,Coordinated Care Organizations . Community Based Care teams Accountable Communities for Health Increase investment in Primary Care Align policies and practices across agencies, sectors Involve patients, families, communitiesPhoto: Business & Finance CEM Toolbox courtesy of richepstein