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4 Policy and Funding Levers F ederal policy and funding are the greatest levers available to the Health Resources and Services Administration (HRSA) and the Cen- ters for Disease Control and Prevention (CDC) to encourage the integration of primary care and public health on the ground. While the passage of the Patient Protection and Affordable Care Act (ACA) is argu- ably the most significant health policy event since the creation of Medicare and Medicaid in 1965, other advocacy and legislative efforts have recently been undertaken that create opportunities for primary care and public health to work together. These efforts attest to the momentum that exists for improving the health system, as well as the commitment to incorporat- ing population health goals into health policy. One of the policy efforts endorsed by the Obama administration is “place-based initiatives.” As explained in a memorandum: Place-based policies leverage investments by focusing resources in targeted places and drawing on the compounding effect of well-coordinated action. Effective place-based policies can influence how rural and metropolitan areas develop, how well they function as places to live, work, operate a business, preserve heritage, and more. Such policies can also stream- line otherwise redundant and disconnected programs. (The White House, 2009, p. 1) The place-based initiatives policy is based on findings from social epidemiology that place-based factors act as determinants of health, inde- pendently of other factors (Poundstone et al., 2004). This policy recognizes that different approaches are needed for different geographic areas and that 105

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106 PRIMARY CARE AND PUBLIC HEALTH leveraging multiple actions with a shared goal has a cumulative effect. It also encourages agencies to cooperate in the development of initiatives and to coordinate funding streams. For example, the Sustainable Communities Regional Planning Grant Program is a collaborative effort of the Depart- ment of Housing and Urban Development, the Department of Transporta- tion, and the Environmental Protection Agency to support planning for community improvement and address, among other issues, public and environmental health concerns. Another effort under way is the Health in All Policies movement. Health in All Policies refers to the consideration of “health, well-being and equity during the development, implementation and evaluation of policies and services” (WHO, 2010, p. 2). It recognizes that policies that affect health often are not “health policies” per se; rather, policies in all sectors of society can affect the health of the population. For example, a study undertaken by the University of North Carolina (Bell and Standish, 2005) showed the positive impact on the dietary habits of surrounding African American communities when political and business decisions were made to relocate and facilitate access to supermarkets. The recent Institute of Medi- cine (IOM) report For the Public’s Health: Revitalizing Law and Policy to Meet New Challenges (IOM, 2011b, p. 9) recommends that “states and the federal government develop and employ a Health In All Policies (HIAP) approach to consider the health effects—both positive and negative—of major legislation, regulations, and other policies that could potentially have a meaningful impact on the public’s health.” Linked to the Health in All Policies concept is the health impact assess- ment, defined by the World Health Organization (WHO) as “a combination of procedures, methods, and tools by which a policy, program, or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population” (European Centre for Health Policy, 1999, p. 4). Health impact assessments provide an assessment of the health effects of a policy prior to its implementation. Dannenberg and colleagues (2008) surveyed the use of health impact as- sessments in the United States and cited 27 examples, including one that examined the socioeconomic effects of an after-school program in Los An- geles; another that examined how a rental voucher program for low-income families in Massachusetts impacted housing affordability, housing stability, and the neighborhood environment; and another that looked at the effects of a community redevelopment project on physical activity. A recent report of the National Research Council (2011) describes the growing popularity of health impact assessments in the United States and proposes a framework for organizing and explaining their necessary elements. An example of a legislative effort focused on health system improve- ment is the American Recovery and Reinvestment Act (ARRA) of 2009.

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107 POLICY AND FUNDING LEVERS Designed as an economic stimulus bill, ARRA included approximately $150 billion directed at health and health care (Steinbrook, 2009). In addition to $87 billion for Medicaid and $1.1 billion for comparative effectiveness research, a few other programs are worth mentioning. For example, $2 bil- lion was allocated to HRSA for health centers, specifically for construction, equipment, health information technology, and the provision of services; $1 billion was allocated for prevention and wellness, including clinical and community-based prevention activities designed to address chronic diseases; and the National Health Service Corps and other HRSA-supported work- force programs received $500 million. Also included in ARRA was the Health Information Technology for Economic and Clinical Health (HITECH) Act, designed to improve the way the health care system operates (Blumenthal, 2010) by encouraging the collection and use of patient-level data through electronic health records. Using these data to inform population-level policies is one way in which primary care practices and public health departments can work together around a shared goal. Although many of ARRA’s provisions ended after 2 years, it is important to recognize that even before the ACA became law, there was a movement to invest in and improve the nation’s health system. The remainder of this chapter examines provisions of the ACA, key policy components that should be incorporated into future legislation to facilitate the integration of primary care and public health, and funding streams that provide levers for achieving integration. THE PATIENT PROTECTION AND AFFORDABLE CARE ACT That the ACA touches on virtually every aspect of health policy that has been debated over the last 25 years belies its expeditious and oppor- tunistic origin. As a legislative feat, the ACA stands on its own merit. As an all-encompassing piece of health policy that addresses the potential to institutionalize population health, it is an incomplete blueprint. In all fairness, the very title of the law speaks to its main aim—to safe- guard health insurance coverage “for those that have it” and to make health insurance more affordable and accessible to the 51.5 million nonelderly Americans who are medically uninsured (Carrier et al., 2011). The majority of the act’s provisions deal with health insurance reform and regulations and the structural basis for enabling those who have been crowded out of affordable health insurance to obtain coverage. Within the building blocks of this reconstruction of Americans’ health care coverage are policy elements covering the health care workforce and its training; innovation in care delivery; health disparities; data mining; and renewed investments in primary care, public health, and prevention. While these provisions were well promulgated, the ACA neither set out to nor

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108 PRIMARY CARE AND PUBLIC HEALTH provides a strategy to achieve population health improvement. Similarly, it does not explicitly address the integration of primary care and public health. Instead, it provides a menu of initiatives on which agencies and communities might converge to make gains in improving population health. The ACA, by being about health insurance reform at its core, suggests that the long-term success of expanded insurance coverage must be ac- companied by a set of activities that reset the basis on which health care is considered and rendered. In other words, health insurance deals only with payment of medical costs, whereas population health investments provide an opportunity for containing and maintaining health care costs within an affordable trajectory. The committee believes that within the numerous pro- visions of the ACA lie the seeds of opportunity to catalyze the integration of primary care and public health and embed population health improvement as an objective in achieving wellness and health for Americans. Of particular note, the ACA authorizes both HRSA and CDC to launch a number of new programs that on their own merit promise to be notewor- thy, but if coordinated and managed collaboratively from their inception could generate significant momentum toward population health improve- ment at the national, state, and local levels. In its review of HRSA and CDC activities in the ACA, the committee sought to identify provisions with the potential to yield long-lasting change in the integration of primary care and public health. Although other Department of Health and Human Services (HHS) agencies, notably the Centers for Medicare & Medicaid Services (CMS), and other federal departments and agencies have significant roles to play in promulgating a population health perspective, HRSA and CDC have unique roles under health care reform. Ultimately, the extent to which HRSA and CDC are able to build upon this movement toward population health improvement is as much depen- dent on how these agencies, and more generally HHS, operate as on how they implement new programs. Leadership in the two agencies will need to reinvent the process and culture for implementing categorical grant pro- grams, meeting congressional mandates, and complying with regulations while spurring the collaboration and cross-cutting accountability that are critical to establishing population health improvement as an operational imperative. The following subsections highlight what the committee believes are particularly promising opportunities within the ACA. They fall into four categories: community investments and benefits, coverage reforms, health care transformation, and reshaping of the workforce.

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109 POLICY AND FUNDING LEVERS Community Investments and Benefits The ACA makes direct investments in community health transforma- tion and brings new focus to community benefit activities. Community Transformation Grants The Community Transformation Grants program,1 established through allocations from the Prevention and Public Health Fund, is a particularly compelling example of a public health-led initiative that could be used to integrate primary care and public health. The program consists of two parts: Community Transformation Grants and a National Network. Community Transformation Grants have been awarded to 61 state and local government agencies, tribes and territories, and national and community-based organizations (CDC, 2011). The goal of the program is to reduce chronic disease rates, prevent secondary conditions, reduce health disparities, and assist in developing a stronger evidence base for effective prevention programs. These goals are to be met by supporting the imple- mentation, evaluation, and dissemination of community preventive health activities that are grounded in evidence. Implemented by CDC, the program will support up to 75 communities across the country over a 5-year period, with projects increasingly expanding their scope and reach if federal re- sources allow. Funding is available for capacity building or implementation, and activities must grow out of an area health assessment (HHS, 2011). Under CDC guidelines, the Community Transformation Grants pro- gram gives priority to the prevention and reduction of type 2 diabetes and the control of high blood pressure and cholesterol. Clinical preventive services are embedded in the basic structure of the Community Transfor- mation Grants program, making health care providers a core partner in the types of broad-based coalitions whose involvement is essential to the program. All applicants are expected to focus on tobacco-free living; active living and healthy eating; and increased use of high-impact, quality clinical preventive services. Applicants also may choose to address social and emo- tional wellness and a healthy and safe physical environment (HHS, 2011). The National Network is aimed at community-based organizations that are positioned to accelerate the speed with which communities adopt promising approaches to health transformation. Under the award program, network members can carry out this dissemination activity in two ways: first, by disseminating Community Transformation Grants strategies to their partners and affiliates, and second, by supporting and funding sub- 1 Patient Protection and Affordable Care Act of 2010 (ACA), Public Law 148, 111th Cong., 2d sess. § 4201 (March 23, 2010).

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110 PRIMARY CARE AND PUBLIC HEALTH recipients in the use of Community Transformation Grants strategies to initiate change locally. Support for subrecipients can include helping them create leadership teams and providing technical assistance and guidance. The Community Transformation Grants program and the National Network share a set of important purposes: to launch multiple interventions whose goal is making fundamental improvements in population health; to lessen the burden on the health care system while achieving its central in- volvement in the effort; to develop a new approach to the collection and use of public health information in order to bring an immediacy and action orientation to long-standing surveillance practices; and to accelerate the rate at which public health innovations are replicated nationally, regardless of whether the replication sites receive support from the Community Trans- formation Grants program. In this sense, the Community Transformation Grants program can be viewed as the public health counterpart to the CMS Innovation Center (CMMI) discussed later in this chapter, whose mission is to test and speed the acceleration of health care system transformation. Nowhere in the ACA is this potential parallelism developed more deeply, and it would be advantageous for both HRSA and CDC to be aware of the communities in which the Community Transformation Grants program and CMMI are involved. As community resources for wellness improve through the Community Transformation Grants program, it may be possible to begin to link those resources to CMMI pilots, which must be able to link their patients and physician practices to community resources. Similarly, the Community Transformation Grants sites will be important to HRSA in guiding health centers engaged in efforts to strengthen their clinical preven- tive service activities, including the development of affiliations with other community resources in such areas as nutrition, exercise, mental health and wellness, and cessation of tobacco use. Community Health Needs Assessments One of the most important potential sources of community support created by the ACA may be the community benefit obligations of nonprofit hospitals that seek federal tax exempt status. A critical step HRSA and CDC might take jointly is a national collaboration with hospitals in ensur- ing that primary care and community health are given priority as hospitals move forward with their mandatory community health needs assessments and development of implementation strategies. Internal Revenue Service (IRS) guidelines in advance of formal regulations were issued in July 2011,2 and the first mandatory reporting period for hospitals will be in 2012. 2 IRS Notice 2011-52 (July 7, 2011).

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111 POLICY AND FUNDING LEVERS In brief, section 501(c)(3) of the Internal Revenue Code3 establishes the legal standard for determining whether nonprofit hospitals will be treated as tax exempt for federal income tax purposes. In 1969 the IRS issued Rev- enue Ruling 69-545,4 which significantly rolled back previous reduced-cost care obligations in favor of a broader community benefit standard. This standard effectively went unenforced for years. In recent years, congres- sional scrutiny increased, culminating in amendments to the ACA5 spelling out new obligations of all hospitals seeking federal tax exempt status (it is important to know that most state tax codes parallel the federal code). A 2006 Congressional Budget Office (CBO) report valued the total tax exemption at $12.6 billion in 2002 (CBO, 2006). The ACA amends the Internal Revenue Code by adding new section 501(r), “additional requirements for certain hospitals.”6 The new require- ments apply to all facilities licensed as hospitals, as well as organizations recognized by the Treasury Secretary as hospitals.7 In the case of multihos- pital chains, each separate facility is held independently to the new require- ments.8 Hospitals failing to meet their obligations are subject to an excise tax of $50,000 for any taxable year in which they are not in compliance;9 in addition, they will experience the adverse publicity of being found out of compliance. The amendments impose new standards designed to ensure financial assistance to indigent persons, curb excessive charges for medically indigent patients, bar aggressive collection tactics, and ensure compliance with fed- eral emergency care requirements. Of greatest interest to the committee is the obligation to undertake a community health needs assessment. The community health needs assessment is a triennial process10 that must commence no later than the taxable year 2 years after the ACA’s enactment. The assessment must be accompanied by an implementation strategy that grows out of the needs assessment and, as discussed below, ongoing reporting on implementation efforts. The process is dynamic, evolving, and action oriented. The ACA also establishes minimum requirements for the assessment itself. Under the law, an assessment must “take into account input from 3 26 USC 501(c)(3). 4 Rev. Rul. 69-545, 1969-2 C.B. 117. In the IRS’s words, Revenue Ruling 69-545 “remove[d] the requirements relating to caring for patients without charge or at rates below cost” (Rev. Rul. 69-5454, 1969-2 C.B. 117). 5 ACA § 9007 adding IRC § 501(r). 6 ACA § 9007 adding IRC § 501(r), 26 U.S.C. § 501(r). 7 Internal Revenue Code (IRC) § 501(r)(2). 8 IRC § 501(r)(2)(C). 9 IRC § 4959, added by ACA § 9007. 10 IRC § 501(r)(3).

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112 PRIMARY CARE AND PUBLIC HEALTH persons who represent the broad interests of the community served by the hospital facility” (IRS, 2011, p. 7). It is important to stress that the term used is “community,” not the specific patients served by the hospitals. That is, the statute appears to require that hospitals assess the needs of the entire community covered by their service area, including members of the com- munity who may, for a variety of reasons, receive care elsewhere, or receive no care at all. Furthermore, for a specialty hospital with a large geographic reach (e.g., a children’s hospital or a hospital with a regional shock trauma unit), the needs assessment presumably will need to cover a community that is coextensive with this larger service area. The development of the community health needs assessment must include individuals with public health expertise, thereby underscoring the obligation of facilities to involve knowledgeable individuals, not merely use public health data. In other words, the law emphasizes an assessment process that, with respect to both content and process, is inclusive of pub- lic health practice and expertise. Even the term “community health needs assessment” is drawn from the public health literature (see, e.g., Jordan et al., 1998; Robinson and Elkan, 1996), furthering the connection between hospital obligations and public health practice. While the legislative history refers to hospitals’ ability to use public health information (Rosenbaum and Margulies, 2010), the text itself underscores the inclusive nature of the obligations. The IRS’s July 2011 notice reinforces these obligations, defining ambig- uous terms and calling for an active and inclusive needs assessment process and, more important, an implementation strategy that is responsive to the needs assessment. The results of a needs assessment certainly could be rein- vestment of hospital resources in uncompensated inpatient care discounts. But this would be the case only if the needs assessment were not carried out with heightened attention to primary care and community prevention needs. Hospitals now have a reason to focus on these investments as well, given the emergence of a Medicare payment policy that penalizes exces- sive readmissions and that serves as a model for state Medicaid programs and private payers. Accordingly, it may be possible for HRSA and CDC to engage with community hospitals and national hospital associations in developing approaches to hospital community benefit planning and imple- mentation strategies that can support the types of activities touched on in this report for which sufficient investment funding is lacking. Examples of these activities include the extension of primary care services into nontradi- tional settings; the formation of collaboratives among community primary care providers and local health departments, with the aim of strengthening primary care; community health promotion activities involving diet, exer- cise, and injury risk reduction; and other population-level interventions.

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113 POLICY AND FUNDING LEVERS Coverage Reforms When the ACA is fully implemented, it will expand coverage under Medicaid and the Children’s Health Insurance Program (CHIP) to 17 mil- lion Americans and reduce the number of uninsured to 23 million (CBO, 2011). Americans with incomes below 133 percent of the poverty level will be eligible for Medicaid coverage (CBO, 2011; The Henry J. Kaiser Family Foundation, 2011). Medicaid Preventive Services One of the ACA’s provisions concerns preventive services for Medicaid populations. The ACA effectively creates two groups of eligible beneficia- ries: individuals entitled to coverage under pre-ACA state plan standards and those entitled to coverage under the Medicaid eligibility expansion. In the case of traditional beneficiaries, the act clarifies that full coverage of all preventive services specified for privately insured persons is a state option and further incentivizes coverage through an increase in the federal medical assistance rate.11 In the case of newly eligible adults, preventive services, as defined under the law, are a required element of Medicaid “benchmark” coverage, a somewhat different coverage standard from that used for the traditional population.12 In meeting this provision, primary care providers and public health departments can become participating Medicaid providers and furnish preventive services to adult and child populations. In addition, HRSA and CDC might consider collaborating with CMS on the development of joint guidance regarding coverage of preventive services. Such guidance might explain both the required and optional preventive service provisions of the law, as well as federal financing incentives for coverage of such services. The guidance also might describe best practices in making preventive services more accessible to Medicaid beneficiaries through the use of expanded man- aged care provider networks; out-of-network coverage13 in nontraditional locations such as schools, public housing, workplace sites, and other places; qualification criteria for participating providers; recruitment of providers; measurement of quality performance; and assessment of impact on popula- tion health. The ACA establishes a grant program under which the secretary of HHS will award grants to states that seek to incentivize the use of preven- 11 42 U.S.C. § 1396d(a)(13) and 1396d(b) as amended by ACA § 4106. 12 42 U.S.C. § 1396u-7(b), as amended by ACA § 2001. 13 Medicaid agencies are free under federal law to add out-of-network coverage for services also covered on an in-network basis. Many agencies take such an approach for certain types of services, such as school health services.

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114 PRIMARY CARE AND PUBLIC HEALTH tive services by Medicaid beneficiaries.14 The aim of the program is not simply increased participation in prevention programs but actual outcomes showing reduced health risks; thus, its purpose is to achieve behavioral change and scalability in other states. Program priorities include smoking cessation, weight loss, lower cholesterol and blood pressure, and avoidance of the onset of diabetes. Because of the serious shortage of Medicaid pro- viders in many communities, HRSA and CDC have a crucial role to play in the implementation of state demonstrations, particularly in outreach to community providers, training and technical support to state Medicaid agencies, active outreach to public health departments and health centers in demonstration states, and collaboration with CMS in the development of outcome standards and scalability criteria. Community Health Centers One major challenge to the rapid expansion of health insurance cover- age is the need for expanded capacity for primary care delivery (Adashi et al., 2010). In Massachusetts between 2005 and 2009, the number of un- insured individuals dropped from 657,000 to 295,000, and health centers and other safety net providers proved to be valuable assets in meeting the increased demand. Health centers’ service volume increased by 31 percent. The uninsured in these practices fell from 35 percent to 19 percent, but by 2009, health centers were seeing 38 percent of all the uninsured in the state—up from 22 percent in 2005 (Ku et al., 2011). The ACA and its companion Health Care and Education Reconcilia- tion Act allocate a major infusion of funding to the expansion of health centers.15 This is unquestionably one of the most important opportunities in the ACA to better integrate primary care and public health because of the unique practice characteristics of health centers. The original vision of health centers reflected what later came to be known as community- oriented primary care, that is, an approach to primary care practice that embeds public health principles into daily practice. These principles include needs assessments, prioritization of services based on population health characteristics, comprehensiveness, financial and cultural accessibility, evidence-based practice using tools such as modern health risk assessment approaches, continuous interaction with the community, and measurement of performance against community health goals, in addition to measures of individual patient-oriented clinical quality indicators. These aspirations still can be seen in the overall direction and management of health centers, but 14 ACA § 4108. 15 ACA § 5601.

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115 POLICY AND FUNDING LEVERS health centers also have been under increasing pressure to improve clinical productivity, particularly in an era of limited resources. An imperative for HRSA and CDC is to preserve the hybrid qualities of health centers and promote activities and linkages that maintain the health centers’ primary role in clinical preventive services and community engage- ment. When possible, for example, health centers should be partners in Community Transformation Grants. Similarly, research on the experiences of health centers in the delivery of clinical preventive services is essential to understanding how the delivery of clinical preventive services might be improved for at-risk populations. Of necessity, outreach campaigns to promote clinical preventive services in underserved communities, as well as initiatives aimed at improving the quality of primary care for populations with serious and chronic health conditions, must focus on how to improve the performance of health centers. Most important perhaps, every effort should be made to forge what often has been an uneasy relationship between health centers and public health departments. Many factors feed into this unease, including the his- torical roots of health centers as a counter to the segregation in health care that once pervaded a large region of the United States (Geiger, 2002, 2005), the fact that health centers have no direct legal financial accountability to health departments, and the different cultures found in health centers and public health departments. That said, there are instances in which partner- ships between health centers and public health departments line up well. Typically, these are situations in which health departments have a declared interest in monitoring and intervening in the clinical care of patients who represent a perceived public health risk. For example, patients who are in- fected with tuberculosis (TB) can be managed by a primary care physician, but often public health departments are responsible for following up with patient contacts to establish the risk of spread in a given community. The level of public health intervention is likely to be even more pronounced if the patient is immunocompromised, as in the case of HIV-infected individu- als, or if the patient has a case of active TB, with a high risk of infecting members of a community. In communities where TB is a significant public health concern, there can be explicit agreements between health centers and health departments regarding mutual notification of TB cases, care coordination, and follow-up. Similar arrangements may be in place for communities with high rates of sexually transmitted diseases. In addition to areas that have traditionally provided opportunities for working together, such as infectious diseases and emergency preparedness, there are many anecdotal examples of collaboration between health cen- ters and public health departments addressing the broader determinants of health. In California, for example, through the Black Infant Health Program, many health centers and public health departments worked to

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132 PRIMARY CARE AND PUBLIC HEALTH health has been significantly less than the investment for primary care) (Steinbrook, 2009). In For the Public’s Health: The Role of Measurement in Action and Accountability (IOM, 2011a, p. 2), the IOM states “that the United States lacks a coherent template for population health information that could be used to understand the health status of Americans and to assess how well the nation’s efforts and investments result in improved population health.” To gauge performance in addressing health disparities and improving popu- lation health, well-developed measures are needed at all levels—local, state, and national. Efforts to develop measures, coordinate data collection, ana- lyze outcomes, and translate this information for decision makers are being undertaken in some locations. In the Geisinger system, optimal outcomes were identified and used as the basis for developing short- and long-term metrics. This approach, along with the use of real-time data from electronic health records and insurance claims, has contributed to improved outcomes and cost reductions (Steele et al., 2010). Another example is WellMed, a primary care-based ACO in Texas. The measurement and accountability systems WellMed has implemented have contributed to lowered mortality rates and better outcomes compared with state outcomes for the over-65 population (Phillips et al., 2011). In contrast to these examples, in which coordination was crucial to success, efforts currently under way by CMS, the National Committee for Quality Assurance, certifying boards, and payers are disjointed. The efforts undertaken by the various stakeholders could be coordinated and structured to become a routine part of patient care. In addition to coordination, an important element related to metrics is how the collected data are used. Ideally, measures should be used as a feedback loop in the provision of care, giving providers quality measures for their patient panel, and perhaps even as decision support at the point of care. Collected data also can be used to identify groups or communities with poor outcomes that may be small in number or distributed across mul- tiple practices, and therefore not easily recognized by individual practices. Aggregated data can be used to identify these groups so they can be targeted by collaborative outreach, engagement, and improved services. Shared Community Resources for Primary Care and Public Health Integration The most important way to encourage the integration of primary care and public health is to prevent further erosion of either sector. As states seek to reduce health care spending, public health funding is an easy target for program cuts. One way to combat these cuts is to physically unite or col- locate public health departments with local health centers. Doing so would

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133 POLICY AND FUNDING LEVERS reduce the infrastructure costs of maintaining separate operating resources. Also, communities could find ways to join public health initiatives with primary care practices. For instance, HRSA could recommend the use of public health workers in health centers as community agents responsible for patient education, behavioral and lifestyle modification, and assistance to patient communities in overcoming social determinants that adversely affect community health. These workers could utilize training and tools developed by CDC to achieve these goals, and would be responsible for relaying com- munity health metrics to CDC and state and local health departments for inclusion in local, state, and national data reports. These shared resources, embedded in the community and community relationships, would help pro- vide complex care management; assist with practice transformation, health information technology connectivity, care, and coordination of community services; and assist in monitoring the health of the public. This consolida- tion also could provide an opportunity for patients to receive all of their personal care and public health services in one stop and lead to improved economies of scale due to shared space, shared resources, and shared staff. Another opportunity for sharing community resources is around work- force. For example, the Vermont Blueprint for Health employs community care teams as a link between primary care practices and public health services, including community-based chronic disease prevention programs, as well as social and economic support programs. While team composition is determined locally, all teams are led by a nurse, and most consist of be- havioral health counselors and social workers (Bielaszka-DuVernay, 2011). Community care teams can be based in primary care practices and assist patients with such tasks as making appointments, completing insurance paperwork, or arranging child care. Thus, these teams ensure that people have comprehensive services to support their health and well-being by con- necting the work of primary care practices to community-based preventive and other social services. Box 4-2 presents some examples in which sharing of community re- sources to support the integration of primary care and public health is working well. The shared capacity to use patient and population data is another example of a resource available to promote the integration of primary care and public health. Important efforts are under way at HRSA to share patient data in a safe way (compliant with the Health Insurance Portabil- ity and Accountability Act [HIPAA]) and combine them with population data to produce information of value to practices and communities. While HRSA is making these efforts, CDC could work to ensure that its data analyses are not so far removed from the community level as to be of little use to providers at the local level. To this end, it may be necessary to de- velop programs that not only aggregate data to the state and national levels

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134 PRIMARY CARE AND PUBLIC HEALTH BOX 4-2 Examples of Shared Community Resources In Yavapai County, Arizona, Community Health Services oversees both the community health center and the public health department. Community Health Services promotes the integration of the two by collocating services in the same buildings and using their separate boards as a vehicle for bridging their activities. The County Board of Supervisors, the community health center board, and the board of health have overlapping representation, including the same physician, nurse, and county representative (Personal communication, Robert Resendes, Director of Yavapai County Community Health Services, March 28, 2011). Hudson River HealthCare, a primary care network in upstate New York, uses an innovative workforce to link with public health. Patient care partners assist patients with prescription assistance programs, referrals to outside agencies, and food and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) assistance, as well as patient education and self-management support. Community care partners provide similar services but are physically located in the community. They work in homeless shelters, after-school programs, community centers, and hospital emergency rooms. Hudson River HealthCare considers staff working in both of these positions to be integral to its work (Per- sonal communication, Kathy Brieger, CEO, Hudson River HealthCare, May 2, 2011). but also are capable of disaggregating the data based on geographic loca- tion and patient composition, as well as a nationally accessible platform for storing and disseminating these data. This disaggregation, which could be done at the state and local levels, would allow primary care providers not only to view their geographic population, but also to compare their popula- tion with similar populations across the state and nation. Currently, most practices lack the fundamental capability to turn their patient data into information that allows them to compare their practice with the practices of peers, to identify learning opportunities and areas of shared concern, and to look at their data in the context of community. Shared data resources, particularly with an analytic component to keep the data sharing safe and useful, would be important for primary care and public health integration. FUNDING STREAMS In addition to legislation, funding streams can be used as a lever to encourage integration. To better understand this lever, it is helpful to un- derstand the role of HRSA and CDC (as well as CMS) in funding health centers and health departments.

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135 POLICY AND FUNDING LEVERS Funding for Health Centers and Health Departments Health centers, state health departments, and local health departments receive revenue from a variety of sources. Figures 4-1, 4-2, and 4-3 show the average sources of revenue for health centers, state health departments, and local health departments, respectively. While the data do not reveal whether federal funding was primarily from HRSA or CDC, the nature of the two agencies’ activities suggests the likely source: federal direct and pass-through funding for health centers would be supplied primarily by HRSA, while federal funding received by state and local health departments could be assumed to be received primarily from CDC. Figure 4-1 shows that federal direct and pass-through funding ac- counted for only 23.2 percent of health center revenues in 201025 (Kaiser Family Foundation, 2010). The other 78 percent comprises Medicare and Medicaid funding (5.8 and 37.7 percent, respectively), other public and private insurance (9.5 percent), direct payment by users (5.9 percent), and other funds provided through state and local grants and contracts and other sources (Kaiser Family Foundation, 2010). Figure 4-2 shows that in 2009, 45 percent of state health departments’ budgets were derived from federal funding, with an additional 4 percent provided directly by Medicare and Medicaid. This funding comprised a number of federal resources, including CDC funding and other federal grants, contracts, and cooperative agreements, such as WIC vouchers and Environmental Protection Agency funding. The remainder of funds con- sisted of state general funds (23 percent), other state or territorial funds (16 percent), other sources of revenue (5 percent), and fees and fines (7 percent) (ASTHO, 2011). Figure 4-3 shows that on average in 2010, only 23 percent of local health department revenue was derived from federal funding outside of Medicare and Medicaid funding. This 23 percent includes federal funds granted directly to local health departments (6 percent); federal pass- through funds, which are granted to states for dispersal throughout vari- ous state programs (14 percent); and ARRA and Public Health Emergency Preparedness (PHEP) grant funding (1 and 2 percent, respectively). The largest single source of local health department revenues was local funding (26 percent) (NACCHO, 2011). 25 Thisfigure varies widely across the states, from 11.2 percent in Wisconsin to 43.8 percent in Arkansas. Fifteen states and the District of Columbia rely on federal grants for less than 20 percent of their annual budgets, while 13 states and Puerto Rico receive more than a third of their income from federal grants (Kaiser Family Foundation, 2010).

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136 PRIMARY CARE AND PUBLIC HEALTH 6% 8% State and Local 3% 7% Grants/Contracts Federal Grants 6% 23% Medicare Other Public Insurance Medicaid 6% Patient Self-Pay 38% Foundations/Private 3% Grants/Contracts Private Insurance Other FIGURE 4-1 Figure 4-1.eps annual funding for health centers by revenue Percentage of total source, 2010. SOURCE: Kaiser Family Foundation, 2010. 16% 23% State General Funds 5% Federal Funds 7% Medicare and Medicaid 4% Fees and Fines Other Sources 45% Other State/Territorial Funds FIGURE 4-2 Percentage of total annual funding for state health departments by revenue source. Figure 4-2.eps SOURCE: ASTHO, 2011.

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137 POLICY AND FUNDING LEVERS 1% 3% 2% Local State Direct 6% Federal Pass-Through 27% Fees 13% Other Medicaid 6% Federal Direct 7% Medicare 21% PHER Grants 14% ARRA Grants FIGURE 4-3 Percentage of total annual local health department revenues by revenue source. NOTE: ARRA = American Recovery and Reinvestment Act; PHER = Public Health and Emergency Response. SOURCE: NACCHO, 2011. Figure 4-3.eps Federal Funding Opportunities Given that HRSA and CDC jointly represent only 1.8 percent of the HHS budget (see Appendix A), it is prudent to look beyond them to other agencies that can assist in funding the integration of primary care and public health. Numerous offices and agencies within HHS have programs designed to promote the health and well-being of individuals, children, families, and communities. Partnering with them could assist HRSA and CDC in fostering integration. For example, the National Institutes of Health (NIH) provides funding for 229 research/disease areas, including cardiovascular disease, colon cancer, stroke, tobacco use, nutrition, and obesity (NIH, 2011). In addition, NIH oversees the Clinical and Translational Science Awards. These awards promote collaboration among diverse sets of stake- holders to identify local health challenges and design practical solutions, and could serve as a mechanism for encouraging integration. The Social Services Block Grant (SSBG) is one of the most flexible funding sources, providing states with funds for a wide variety of social service and health-related programs. Moreover, up to 10 percent of a state’s annual SSBG allotment can be transferred to three health care block grants (the Preventive Health and Health Services Block Grant, the Maternal and

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138 PRIMARY CARE AND PUBLIC HEALTH Child Health Services Block Grant, and the Substance Abuse Prevention and Treatment Block Grant) and the Low-Income Home Energy Assistance Program (U.S. House of Representatives Committee on Ways and Means, 2000). Within the Administration for Children and Families is the Commu- nity Services Block Grant, which provides services and activities addressing employment, education, housing, nutrition, emergency services, and health (HHS Administration for Children and Families, 2011). Similarly, CMS oversees programs such as the Children’s Health In- surance Program (CHIP), which funds primary care services for children, and the Medicaid program. The Medicaid program pays for health and long-term care services for certain low-income individuals, including chil- dren, the elderly, and people with disabilities. States have broad authority to define eligibility, benefits, provider payments, and delivery systems. As a result, Medicaid programs vary widely by state. As mentioned above, CMS also administers the Medicaid Incentives for Prevention of Chronic Disease Program, which provides incentives to Medicaid beneficiaries who participate in prevention programs and demonstrate changes in health risks and outcomes, and the newly created CMMI, which is working on primary care and public health issues. Finally, the Substance Abuse and Mental Health Services Administra- tion promotes public health for mothers and children through a variety of programs, such as the Substance Abuse Prevention and Treatment Block Grant, the Mental Health Services Block Grant, and the Children’s Mental Health Services Program. It also focuses on integrating behavioral health and primary care, as well as reducing the use of tobacco and promoting health and wellness workplace programs. Implications of the Current System In examining the current funding system for primary care and public health, it becomes clear that the system is not well positioned to promote integration. For example, a number of grants from HRSA, CDC, and other agencies are aimed at addressing the same issues, and as a result create overlap on the ground. These competing funding streams have the effect of creating silos at the local level rather than encouraging cooperation across entities. Similarly, as discussed in more detail in Appendix A, fund- ing streams from HRSA and CDC (with the exception of the Preventive Health and Health Services Block Grant) are inflexible. This inflexibility limits what local entities can do with the funds and how they could be used for integration. Finally, it should be noted that the funds available to HRSA and CDC for supporting and integrating primary care and public health are small

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