Important Points Made by the Speakers
- Federally qualified health centers (FQHCs) are well positioned to serve as efficient and high-quality patient-centered medical homes if given the proper resources. (Fiscella)
- Better care for the 2.2 million people who are in prison or jail will be essential to reduce health disparities. (Fiscella)
- Health information technology could enable planning, needs assessment, accountability, efficiency, and care processes that promote equity. (Fiscella)
- The community health needs assessments required of tax-exempt hospitals can be an important lever for health equity. (Somerville)
Safety net institutions such as FQHCs, free clinics, and local hospitals will continue to play a pivotal role in reducing health disparities under the ACA. These institutions are embedded within their communities and understand the challenges faced by the people they serve. However, there are some key issues that these facilities must address under health care reform, such as financing, workforce issues, and moving toward integrated systems. Two speakers discussed ways in which policy actions could foster more effective and efficient operations of these vital organizations.
Ten years ago the state of Delaware decided to make disparities in outcomes from colorectal cancer1 a statewide priority, said Kevin Fiscella, professor of family medicine and public health sciences and associate director of the Center for Communication and Disparities Research at the University of Rochester Medical Center. The state made colonoscopies affordable for the uninsured, paid for treatment for those with cancer, and partnered with community-based organizations at a grassroots level using navigators.2 Over the course of the decade, Delaware increased rates of colorectal cancer screening among African Americans by 50 percent, which completely closed the gap in colorectal cancer screening between whites and African Americans; eliminated the disparity in colorectal cancer incidence according to the stage of diagnosis; and virtually closed the gap in colorectal cancer mortality according to race or ethnicity. “It is possible when there is commitment and one truly turns that commitment into action,” he stated.
Fiscella built his presentation around 11 recommendations that he labeled “provocative.”
Fiscella’s Recommendation 1: Adopt the National Quality Forum’s definition for health care disparities.
The National Quality Forum has defined health care disparities as “differences in health care quality, access, and outcomes adversely affecting members of racial and ethnic minority groups and other socially disadvantaged populations” (NQF, 2012). Other definitions have become outmoded, Fiscella said, and a common definition is needed to establish a common base of reference.
Fiscella’s Recommendation 2: Adopt blended payments for FQHCs, such as prospective payment systems, in addition to global payments, through affiliations with accountable care organizations (ACOs).
FQHCs and correctional facilities (jails, prisons, and detention facilities) are the providers of primary care to a large group of socially disadvantaged patients, and both are under-resourced relative to patient needs. FQHCs serve more than 22 million patients across the country, are patient operated,3 culturally diverse, and mission driven, with services being based on documented community needs assessments. They provide comprehensive services
1 Although colorectal cancer rates have declined among whites, rates have increased for African Americans.
2 For reports on the project, see http://www.dhss.delaware.gov/dhss/dph/dpc/consortium.html (accessed July 26, 2013).
3 This means that at least 50 percent of the board of directors for an FQHC must be actual patients of that FQHC.
that research has shown to be of high quality and efficiency. They are well positioned to implement the patient-centered medical home concept if they are given the proper resources.
Payment to FQHCs through the prospective payment system, which provides an enhanced Medicaid rate for each visit but not for other aspects of care, has kept these centers afloat over time but the prospective payment system has not given most FQHCs sufficient capital to implement changes or to move ahead. Fiscella advocated a global payment system that would provide FQHCs with the resources to support essential features for patient-centered medical homes while enhancing access to specialty care through ACOs. Such a system could also help preserve community governance and autonomy for FQHCs. In addition, health information technology could enable the planning, needs assessment, accountability, efficiency, and care processes that promote equity. Once data on race, ethnicity, language, and health indicators are collected in structured fields, these data can be transmitted and manipulated, making it possible to monitor equity.
Fiscella’s Recommendation 3: Expand the structured data elements required for meaningful use to include key measures relevant to safety net patients, for example, cancer screening and other evidence-based procedures, along with hospitalizations and emergency department use.
This step would enable the creation of dynamic report cards on equity at various levels of aggregation for use in planning and accountability. It could also reduce the costs and errors associated with manual data entry and foster effective population management and clinical decision support for FQHCs. Today, information from a colonoscopy report, for example, still arrives as a scanned report, which required that someone doing a report on colorectal cancer screening examine the actual patient record rather than run a report from a cancer registry. In addition, such data could facilitate clinical decision support for population management.
The meaningful use standards defined by Centers for Medicare & Medicaid Services (CMS) provide payments to physicians and hospitals based on patients’ use of online personal health records. The downside of this initiative, said Fiscella, is that it is worsening health care disparities because of inequities in Web access and health literacy.
Fiscella’s Recommendation 4: Offer larger payments to providers for online use of personal health records by patients who need more assistance, including patients with Medicaid.
Payments that depend on a graduated percentage of Medicaid patients being served (i.e., bonus payments increase with a greater proportion of Medicaid patients) would better align resources with needs and encourage safety net providers, including some hospitals, to support poorer minority
patients in accessing their online personal health records. This could be done through personal assistance, instruction, and partnerships with libraries and other community-based organizations, though it will inevitably require effort and resources.
Fiscella’s Recommendation 5: Implement team training through the use of principles from team science with adaptation to the primary care safety net. This will require support for a training infrastructure.
Creation of patient-centered medical homes requires a fundamental transformation of practice design and work flow, said Fiscella. Providers need to change their routines, stop believing that they have to do it all, and share the duties associated with the delivery of care. This requires a fundamental shift from clinician-centered to team-based, patient-centered care. The science of teams has been applied to aviation, the military, and some fields of medicine, but it has not yet been effectively applied to primary care, much less to safety net providers. Achieving equity and value requires sharing and delegation of tasks.
Fiscella’s Recommendation 6: Require accreditation of all health care providers who provide care in correctional facilities.
At any given time, about 2.2 million people, most of whom are poor and members of minority groups, are in prison or jail. Members of these populations have high rates of mental health morbidity, substance use disorders, and other health problems. Most inmates lack any health insurance, and most health care providers in these institutions lack electronic health records (EHRs) and to date have not been eligible for meaningful use incentives. The coordination of care on entry, for the exchange of information, and on release is poor. The greatest risk of death for inmates is during the two weeks following their release, said Fiscella.
There is no systematic system for accountability of health care quality in correctional facilities. Therefore, a requirement for accreditation would represent an important step toward ensuring appropriate health care in correctional facilities.
Fiscella’s Recommendation 7: Promote insurance enrollment and continuity of insurance coverage in jails and prisons.
Inmates need to have insurance and be enrolled in health exchanges before they are released so their care can continue without interruption. Insurance navigators could interact with inmates to make sure that they get insured and are connected with care when they leave jail or prison. This will help reduce rates of recidivism and save money in the long run because of the great expense of keeping people in correctional systems.
Fiscella’s Recommendation 8: States and localities should actively promote eligibility of physicians who work in correctional facilities in federal meaningful use programs by suspending rather than terminating an inmate’s Medicaid eligibility.
Although physician eligibility for participation in meaningful use programs may seem like a technical issue, it is important, said Fiscella. In many correctional facilities, when inmates go into jail or prison, their Medicaid coverage is terminated, which means that inmates cannot be counted toward meaningful use criteria for physicians. Suspending rather than terminating their eligibility would help correctional institutions qualify for meaningful use payments. Persons with suspended but not terminated Medicaid count toward the minimal percentage of individuals in the population with Medicaid coverage needed to qualify for CMS meaningful use payments. This additional revenue could fuel the adoption of EHRs and foster participation in health information exchanges in correctional institutions.
Fiscella’s Recommendation 9: Create dedicated program announcements among existing federal funding agencies to establish and maintain the research infrastructure necessary to inform best practices for care within the safety net.
Successful health care systems, such as the U.S. Department of Veterans Affairs, Kaiser Permanente, and Group Health, have the infrastructure needed for applied research and development. On the other hand, safety net practices have few opportunities to build such infrastructure. The Community Health Applied Research Network, supported by the Health Resources and Services Administration, and the partnership between Connecticut’s Department of Corrections and the University of Connecticut represent notable, worthy exceptions. Dedicated funding is needed from both federal and non-federal funders to establish and maintain the research infrastructure necessary to inform best practices within the safety net, Fiscella said.
Fiscella’s Recommendation 10: States and the federal government should prohibit the segregation of health care by payer. This proscription could be linked to the receipt of federal (Medicare or Medicaid) or state (Medicaid) payments.
Social psychology has demonstrated that perpetuation of two-tiered systems of care, such as practices composed of clinic patients (often poor, minority, Medicaid, or uninsured patients) and private patients creates a culture among health care trainees, clinicians, and staff that perpetuates unconscious bias. Dual systems of care also undermine the continuity of care for socially disadvantaged patients, who are disproportionately cared for by trainees who come and go.
“Separate but equal failed in education and has failed in health care,” said Fiscella. “The creation of integrated systems of care offers potential for reducing bias and promoting equity in care continuity and improved access.”
Fiscella’s Recommendation 11: Foster natural health care career ladders for low-income and minority health care workers as a means of promoting workforce diversity and team-based cultural competency.
Both the ACA and the HHS Action Plan to Reduce Racial and Ethnic Health Disparities (HHS, 2011) promote workforce diversity but successful strategies are in short supply. Today, the health care workforce in FQHCs, correctional institutions, and hospitals is quite diverse; however, it is typically a pyramid that gets less diverse as pay grades rise toward the top of the pyramid. Minority and low-income workers need a natural career progression with support from community and institutional partnerships, tuition assistance, flexible working hours, and mentoring, with high-need areas given priority. Many people who work as personal care aids in uncertified fields want to become certified technicians and then move up to nursing positions. Fiscella indicated that most of the people with whom he works already have full-time jobs and are going to school. By “shortening the distance between the rungs on the career ladder,” low-income and minority health workers could move up the pyramid and bring greater diversity to the health care workforce at higher pay grades.
The HHS Action Plan is unprecedented and represents “a critical step toward improving equity,” Fiscella said. However, it would be improved by aligning resources with need, especially for safety net providers. It could also have articulated more clearly specific benchmarks for each federal agency. Each federal agency should establish specific and actionable metrics and then publicly report on the progress that it has made to meet those metrics and on the steps that it will take to improve in areas where no progress has occurred. Such efforts will have the additional benefit of setting expectations for states to take the same actions.
“Separate but equal failed in education and has failed in health care.”
The definition of health equity that Martha Somerville, director of the Hilltop Institute’s Hospital Community Benefit Program in Baltimore, Maryland, prefers is “attainment of the highest level of health for all people.” She believes that “achieving health equity requires . . . focused and ongoing societal efforts to address avoidable inequalities, . . . injustices, and the elimination of health and health care disparities” (National Partnership for Action to End Health Disparities, 2011, p. 9). This distinction between health and health care disparities, Somerville noted, is one of the guiding principles behind the Hospital Community Benefit Program.
Hospital community benefits are initiatives, activities, and investments by tax-exempt hospitals to improve health in the communities they serve. These benefits are an expression of the charitable missions of these hospitals and are also a condition for their tax-exempt status.
The ACA reinforces and clarifies the expectation that tax-exempt hospitals provide benefits, in addition to fully reimbursed health care services, to their communities.
It also establishes new sanctions for failure to meet federal community benefit requirements. For example, it provides for the imposition of a $50,000 excise tax for non-compliance as an intermediate sanction, short of taking away a hospital’s tax-exempt status.
The ACA also establishes processes to ensure that hospitals’ community benefits are responsive to the needs of the community. The ACA requires that hospitals conduct a community health needs assessment at least every 3 years to identify needs and priorities and develop a strategic plan to address those needs. It also requires that hospitals adopt written financial assistance policies that clearly state the hospital’s eligibility criteria for financial assistance and requires that these policies be clearly communicated to patients and the community. In addition, it establishes financial protections for individuals who qualify or may qualify for financial assistance. For example, it limits hospital charges and prohibits extraordinary collections until a patient is determined to be ineligible for financial assistance.
The community health needs assessment is an important lever for health equity, Somerville said. First, a hospital must define its community. Although a hospital may use a geographic definition for its community, it is also permissible to target specific populations. For example, a pediatric hospital might want to define its community as the children within a certain geographic area, or several hospitals in a rural area might jointly conduct a community needs assessment for their aggregated service areas. Proposed Internal Revenue Service (IRS) regulations state, however, that a hospital “may not define the community to exclude medically underserved, low-income, or minority populations who are part of its patient populations,
live in geographic areas in which its patient populations reside, . . . or otherwise should be included based on the method the hospital facility uses to define its community.”
Second, a hospital must assess the health needs of its community, identify and prioritize significant needs, and identify potential measures and resources to address those needs. Every hospital must develop its own needs assessment report and make it widely available to the public, and members of the public can go to their neighborhood hospitals and ask for the schedules that hospitals file with the IRS.
The community health needs assessment needs to reflect input from persons who represent the broad interests of the community, and this must include input from “members of medically underserved, low-income, and minority populations in the community served by the hospital facility, or individuals or organizations serving or representing the interests of such populations,” noted Somerville. For each significant health need identified by the assessment, a hospital must either describe how it will address the need or explain why it will not address the need. For example, a hospital might indicate that its resources are inadequate to meet a particular identified need or that the need is being or will be addressed by a collaborating hospital, said Somerville.
For community needs assessments, community benefit planning, and the implementation of health improvement initiatives, hospitals may engage in multisector collaborations with community health centers, public health agencies, businesses and employers, community-based organizations, schools, and public safety organizations. Such a collaborative approach captures diverse perspectives and expertise and facilitates leveraging of the community’s public and private resources for the common purpose of community health improvement.
Somerville listed activities that the IRS recognizes as community benefits:
- Free and discounted care,
- Under-reimbursed care (under Medicaid and other means-tested government programs),
- Community health improvement services and community benefit operations,
- Health professions education,
- Subsidized health services,
- Research, and
- Cash and in-kind contributions to community groups.
A recent analysis looked at hospital community benefit spending in 2009, which was the first year that hospitals were required to report their
community benefit expenditures or costs at the federal level, and found that community health improvement services represent only about 8 percent of total community benefits reported (see Figure 5-1). The IRS defines these services as “activities or programs carried out or supported by the health care organization for the express purpose of improving community health.” To report an activity or program as a community health improvement service, a hospital must establish that the activity or program responds to a community need. It must also be seeking to achieve a community benefit objective, such as eliminating disparities in access to health services or disparities in health status among different populations. Community need may be demonstrated through:
- A community health needs assessment, or
- Documentation that the activity or program was initiated or continued on the basis of a request from a public health agency or community group, or
- Performance of the activity or program with unrelated tax-exempt or government organizations for the express purpose of improving community health.
In addition, the activity or program must seek to achieve a community benefit objective, such as eliminating disparities in access to health care services or improving disparities in health status among different populations.
FIGURE 5-1 Community health improvement and contributions to community groups.
SOURCE: Young et al., 2013.
Somerville concluded by urging hospitals to consider refocusing their community benefit resources on the broader determinants of health status, including unhealthy behaviors such as smoking and unhealthy eating. In addition, hospitals can support community-building initiatives that focus on upstream factors (social determinants of health) that negatively affect population health. Examples of negative determinants include economic decay and unemployment, low educational attainment, substandard housing, food insecurity, and unwalkable neighborhoods, all of which disproportionately affect poor and minority populations. “To the extent that we’re talking about bending the cost curve of health care and reducing health care costs, we have to look beyond the walls of the hospital,” she said.
Although the IRS has not recognized all community-building initiatives to be reportable as community benefits, if an initiative is undertaken for the express purpose of improving community health, responds to an identified need, and is based on evidence, said Somerville, it may be reported as community health improvement services, that is, as a community benefit. As examples, she cited a hospital in Ohio that trained and assisted local vendors subcontracting with its suppliers to develop the skills and infrastructure needed to become contractors themselves. By restructuring the supply chain to directly contract with local suppliers, the hospital created jobs and improved economic opportunities in its community. Another hospital supported paid internships for local high school students to help them complete their degrees and enter medical paraprofessional vocations. These are the kinds of creative interventions that hospitals can undertake to address the social determinants of health, said Somerville.
When communities mount initiatives to improve health, they can bring in hospitals as partners to combine community and hospital community benefits to address the communities’ needs and improve population health.
Roundtable member Francisco Garcia commented that very few correctional facilities use EHRs in Tucson, Arizona, where he works. He noted that a major challenge is to explain why this should be built into the contracting for the provision of health care services. Fiscella responded that correctional facilities likely do not use EHRs more often due to the costs; correctional facilities have highly constrained budgets.
“To the extent that we’re talking about bending the cost curve of health care and reducing health care costs, we have to look beyond the walls of the hospital.”
A participant from the Partnership for Strong Communities, a statewide housing policy and advocacy organization, asked if there are examples of communities that have used community benefit funds for targeted initiatives around factors such as food insecurity and housing instability. Somerville responded that there are examples of this occurring.
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