NATIONAL ASSOCIATION OF HEALTH SERVICES

EXECUTIVES

28TH ANNUAL EDUCATION CONFERENCE

Affordable Care Act: Delivering Culturally and Linguistically Equitable and Quality

Care

Public Policy and Advocacy Forum

Friday, October 18, 2013

Miami, FL

9:45am – 11:00am

INTRODUCTION OF PANELISTSModerator

Andrew M. Wiesenthal, MD, SM Director, Deloitte Consulting, LLP

Panelist 1

Joseph R. Betancourt, MD, MPH Director, The Disparities Solutions Center Senior Scientist, The Mongan Institute

for Health Policy Director of Multicultural Education, Multicultural Affairs Office, Massachusetts General Hospital

Associate Professor of Medicine, Harvard Medical School

Panelist 2

Maria R. Cooper, MA Health Policy Analyst, Texas Health Institute

Panelist 3

Louis R. Preston, JR., M.Div, CDM Diversity Officer, Florida Hospital Director, Interpreter Services, Florida Hospital

AFFORDABLE CARE ACT (ACA) : CULTURALLY AND

LINGUISTICALLY, EQUITABLE & QUALITY CARE

Moderator

Andrew M. Wiesenthal, MD, SM Director, Deloitte Consulting, LLP

BACKGROUND ON HEALTH DISPARITIES IN THE U.S.

“At the most basic level, health is freedom. It’s the freedom to go about our daily lives without experiencing pain. It’s the freedom to live long enough to achieve our goals and get to know our grand-children. It’s the freedom from constant worries about a chronic condition or accumulating health care bills.”

Secretary Kathleen Sebelius, Department of Health and Human Services

"Of all the forms of inequality, injustice in health care is the most shocking and inhumane."

Dr. Martin Luther King, Jr.

A NATIONAL HEALTH CONCERN

By 2050, racial and ethnic minorities are estimated to comprise 54% of the population¹

Nearly 9 out of 10 adults have difficulty using the everyday health information²

Rapid growth in the racial, ethnic, and linguistic composition leads to:³

Miscommunication of critical health care information

Lack of compliance with prescribed treatment and medication1 US Census Bureau

2U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National Action Plan to Improve Health Literacy. Washington, DC: Author.3 CMS MLN Matters dated October 1, 20124 JAMA (July 2013), American Cancer Society, CDC

Cancer (5-year survival rates)

Breast Cancer‒Black women: 55.9%‒White women: 68.8%

Colon Cancer‒Black men and women: 55%‒White men and women: 66%

Hypertension Rates

2005-2008‒ Black adults: 42%‒ Mexican-American adults:

25.5%‒ White adults: 28.8%Obesity Rates

Prevalence amongst women (older than 20) in 2008

‒ Black women: 51%‒ Mexican-American women:

43%‒ White women: 33%

ACA BACKGROUND

In March 2010, President Obama signed comprehensive health reform, the Patient Protection and Affordable Care Act (ACA), into law. ACA Section 2719(a)(1)(B) states that group health plan and

health insurance issuer shall provide notices to enrollees, in a culturally and linguistically appropriate manner

How the Health Care Law Benefits You Because of the Affordable Care Act, the 85 percent of

Americans who have insurance have more choices and stronger coverage than ever before.

Includes provisions to standardize the collection of data on health care quality Efforts to reduce disparities

Federal surveys and programs collect and report data on race, ethnicity, sex, primary language, and disability status Aim to understand disparities

CULTURALLY & LINGUISTICALLY APPROPRIATE CARE

Health care delivery by interacting with patients/consumers from many different cultural and linguistic backgrounds

Cultural competence as an "ongoing commitment or institutionalization of appropriate practice and policies for diverse populations”.¹

Cultural competence is a reflection of the health system's ability to deliver care that meets patients' cultural, social, and communication needs according to Dr. Bentacourt.¹¹Dreachslin, J., & Myers, V. (2007). A systems approach to culturally and linguistically competent care. Journal

Of Healthcare Management, 52(4), 220-226.

A TIME OF HEALTHCARE TRANSFORMATION AND

VALUE

Panelist 1

Joseph R. Betancourt, MD, MPH Director, The Disparities Solutions Center Senior Scientist, The

Mongan Institute for Health Policy Director of Multicultural Education, Multicultural Affairs Office, Massachusetts General Hospital

Associate Professor of Medicine, Harvard Medical School

A TIME OF HEALTHCARE TRANSFORMATION AND VALUEValue-based purchasing and health care reform will alter the

way health care is delivered and financed

Increasing access and assuring appropriate utilization

Decreasing ED use, linkage to primary care

Emergence of ACO’s and Patient Centered Medical Homes

Importance of Wellness, Population Management, Preventing ACS

Focus on transitions of care, safety and patient experience

Importance of preventing readmissions, avoiding medical errors, and

improving patient satisfaction

THE ROLE OF COMMUNICATION

Communication

Patient Satisfaction

Adherence

Health Outcomes

COMMUNICATION AND HEALTHCARE TRANSFORMATION

ACO’s, Population Health and the Patient

Centered Medical Home

Communication is key to adherence, chronic disease

management and preventing avoidable hospitalizations

Transitions of Care and Readmissions

Communication is key to discharge planning and

preventing readmissions

Patient Experience

Communication is key to satisfaction and experience

THE NEWLY INSURED POPULATION APPROXIMATELY 50% MINORITY

12

WHY CULTURAL COMPETENCE?

Disparities in Health Care 2002

Racial/Ethnic disparities found across a wide range of health care settings, disease areas, and clinical services, even when various confounders (SES, insurance) controlled for

Findings: Many sources contribute to disparities—no one suspect, no one solution

Rec: Cultural Competence training for all health care professionals

HOW ABOUT THE IMPACT ON QUALITY? THE ROLE OF COMMUNICATION, CULTURAL COMPETENCE, AND CARE

Safety Minorities have more medical

errors with greater clinical consequences

Effective Minorities received less

evidence-based care (asthma) Patient-centeredness

Minorities less likely to provide truly informed consent

Timeliness Minorities more likely to wait

for same procedure (transplant) Efficiency

More test ordering in ED for minorities due to poor communication

Equity

…AND PAYMENT REFORM AND HEALTH CARE REFORM?

ACO’s, PCMH’s and Population Health

Minorities more likely to have ACS admissions;

communication about use of services key

Transitions of Care and Readmissions

Minorities more likely to be readmitted with CHF in

30d; communication about what to do, where to

go key

Patient Experience

We see variations in HCAHPS by race and

ethnicity; communication and service is key

ACCREDITATION, QUALITY MEASURES, AND HC REFORM

Joint Commission: Disparities/Cultural competence Standards

National Quality Forum: Disparities and Cultural Competence Quality Measures, developing disparities measures, incorporating into MAP

AHA Call to Action: REaL Data, Governance, Cultural Competency Training

Health Care Reform has multiple provisions addressing disparities

IOM’S UNEQUAL TREATMENTWWW.NAP.EDU

Recommendations

Increase awareness of existence of disparities

Address systems of care Support race/ethnicity data collection, quality improvement,

evidence-based guidelines, multidisciplinary teams, community

outreach

Improve workforce diversity

Facilitate interpretation services

Provider education Health Disparities, Cultural Competence, Clinical Decision making

Patient education (navigation, activation)

Research Promising strategies, Barriers to eliminating disparities

DISPARITIES LEADERSHIP PROGRAM

OUR EXPERIENCE With the 2013-14 class, the Disparities Leadership

Program will have trained: 211 participants 98 organizations

47 hospitals 21 health plans 20 community health centers 1 hospital trade organization 1 federal government agency 1 city government agency 7 professional organizations

1. GATHER THE DATA REAL DATA COLLECTION

Collect REaL and Education data of all patientsPiloted different versions

Gets key info Doesn’t confuse patients Can be done in a timely fashion

Registrar Training Preamble FAQ’s

PR Poster CampaignQA and Registrar Feedback

“Secret Santa” Presentation on impact

Net-Net: It can be done, is being done, no need to reinvent the wheel

2. MAKE THE DATA USEFULMGH DISPARITIES DASHBOARD EXECUTIVE SUMMARYGreen Light: Areas where care is equitable

National Hospital Quality Measures HEDIS Outpatient Measures (Main Campus) Pain Mgmt in the ED

Yellow Light: National disparities, areas to be explored Mental Health, Renal Transplantation All cause and ACS Admissions (so far no disparities) CHF Readmissions (so far no disparities) Patient Experience (H-CAHPS shows subgroup variation)

Red Light: Disparities found, action being taken Diabetes at community health centers

Chelsea (Latino), Revere (Cambodian) Diabetes Project Colonoscopy screening rates

Chelsea CRC Navigator Program (Latinos)

3. EDUCATE PROVIDERS AND STAFFLINK TO TRANSITIONS, SAFETY, PATIENT EXPERIENCE

Quality Interactions Cross-Cultural Training offered as option as part of MGPO QI Incentive; case-based, evidence-based, interactive e-learning program which allows learners to develop a skill set to provide quality to patients of diverse cultural backgrounds; has been used to train 125,000 health care professionals nationwide

987 doctors completed at MGH; more than 88% said program increased awareness of issues, would improve care they provide to patients, and would recommend to colleagues; average pretest score 51%, posttest score 83%

Trained 1500 frontline staff with Healthcare Professional Version

1. Available at: http://www.qualityinteractions.org/prod_overview/clinical_program_features.html.

4. ENGAGE, EMPOWER AND ACTIVATE PATIENTSPatient Activation Poster Campaign

In 2011, MGH launched a poster campaign modeled after the national Speak Up campaign developed by the Joint Commission and Centers for Medicare and Medicaid Services in 2002.

The Speak Up campaign urges patients to take a role in improving quality and preventing medical errors by becoming active, involved, and informed participants of the health care team.

5. DEVELOP CULTURALLY COMPETENT INTERVENTIONS DIABETES DISEASE MANAGEMENT PROGRAM

A quality improvement / disparities reduction program with 3 primary components:

Telephone outreach to increase rate of HbA1c testing

Individual coaching to address patients’ needs and concerns regarding diabetes self-management to improve HbA1c

Group education meeting ADA requirements

*Also focus on link between mental health, chronic disease management, and prevention

Diabetes Control Improving for All: Gap between Whites and Latinos Closing

24% 24%

20%

37%

34%

29%

0%

10%

20%

30%

40%

50%

2007 2008 2009

Year

% o

f P

ati

en

ts w

ith

Po

orl

y C

on

tro

lle

d D

iab

ete

s (

Hb

A1c

>

8)

Whites

Latinos

* Chelsea Diabetes Management Program began in first quarter of 2007; in 2008 received Diabetes Coalition of MA Programs of Excellence Award

*

PREPARING FOR THE FUTURE Addressing variations in quality—such as racial/ethnic

disparities in health care—will be essential going forward if

we are to achieve equity and high-value

This is not just about equity for equity’s sake—ethics and

cost are key—as equity connects to all areas of quality:

Population Management

Transitions of Care and Readmissions

Appropriate Utilization and Avoidable Hospitalizations

Patient Safety

Patient Experience

Hospitals ignore this at their own peril…action will separate

winners from losers…

HEALTH INSURANCE EXCHANGES

Panelist 2

Maria R. Cooper, MA Health Policy Analyst, Texas Health Institute

The ACA has potential to enfranchise as many as 19 million racially & ethnically diverse individuals starting in 2014

Insurance Provisions: State Exchanges

Navigator Program & C/L Information C/L Summary of Benefits C/L Claims Appeals Process

Use of Plain Language in Health Plans Non-discrimination in Federal Programs Remove cost-sharing for AI/AN Market incentives for Reducing Disparities

HEALTH INSURANCE EXCHANGES

STATE EXCHANGE DECISIONS

Source: Kaiser Family Foundation, State Health Facts, June 20, 2013

HEALTH INSURANCE MARKETPLACESPROJECTED ENROLLEES BY RACE & ETHNICITY

58%11%

25%

6%White

Black or African American

Hispanic or Latino

Other

42% or over 12 million Non-Whites25% will speak a language other than English at home

HOW DO THE MARKETPLACES PLAN TO ADDRESS DISPARITIES?

Source: Andrulis DP, Jahnke LR, Siddiqui NJ, and Cooper MR. Implementing Cultural and Linguistic Requirements in Health Insurance Exchanges, 2013. Texas Health Institute: Austin, TX. Available at: http://www.texashealthinstitute.org/health-care-reform.html

What challenges do marketplaces face in addressing disparities?

How to elevate disparities to a priority level when focus is on exchange startup, IT, benefit design, etc.

How to effectively reach a range of diverse individuals: Culturally or linguistically isolated Not familiar with concept of insurance Low literacy and low health literacy Mixed-citizenship Distrust of government, federal programs, new law

Training navigators & outreach workers

Measurable outcomes for evaluation: Are equity objectives present in mission and planning? Do health plans use active purchasing? Partnerships with trusted advocates and representatives? Language access services and C/L appropriate communication?

ACTIONABLE ITEMS AND NEXT STEPS

July 2013

ACA: A HOSPITAL’S PERSPECTIVE

ACA : Triple Aim Triple Aim

Quality Cost Population health

$155 B in hospital Medicare cuts

Expanded coverage, but there will be uninsured Individual penalty is

$95 in 2014 Hardship

exemptions No Medicaid

expansion in Florida Panelist 3 Louis R. Preston, JR., M.Div, CDM

LANGUAGE ACCESS AT FLORIDA HOSPITAL• In-person

• FH Staff for Spanish interpretations• Agency interpreters in ASL and Other Languages

• Over-the-phone• Video Remote Interpretation (VRI)• Translation of Documents

• Vital documents, Patient medical records, other documents relaying medically relevant information

POTENTIAL BENEFITS FOR UTILIZING QUALIFIED MEDICAL INTERPRETERS(QMI) Cost Reductions under the Affordable Care

Act

Increased patient satisfaction with care provider communication and overall patient experience – evident in increase in HCAHPS scores

Enhanced provider/hospital Federal compliance – by increasing compliance with Federal Laws

CREATION HEALTHWhereas: the ACA promotes access to health care services and preventive care, and

Whereas: the Seventh-day Adventist (SDA) church has espoused whole-person preventive healthcare from its inception,

Therefore: Adventist Health System and others will benefit from ACA incentives for health promotion – not merely the treatment of disease.

God’s Guide to Health and Harmony

“Are we ever going to produce a diverse workforce and leadership that look different than what we are now, or do we study ourselves to death and look the same way we’ve always looked?”

Don Jernigan, Leu Gardens, August 6, 2004.

Executive Accountability

Over the five year period commencing in 2008 and ending in 2013 it is the goal of each AHS facility to have its employee workforce, beginning with administration, reflect it’s own community’s diversity…

DIVERSITY IN LEADERSHIP

Don Jernigan, PhDAdventist Health System

President and CEO

OPEN DISCUSSIONAndrew M. Wiesenthal, MD, SM

awiesenthal@deloitte.com

Joseph R. Betancourt, MD, MPH

jbetancourt@partners.org

www.mghdisparitiessolutions.o

rg

www.qualityinteractions.org

Maria R. Cooper, MA

mcooper@texashealthinstitut

e.org

Louis R. Preston, JR., M.Div, CDM

louis.preston@flhosp.org