Addressing Provider Access Barriers in Communities of Color Opportunities and Challenges in the Affordable Care Act Nadia J. Siddiqui, MPH Senior Health Policy Analyst Texas Health Institute January 23, 2015 | Washington, D.C. | Families USA Health Action Conference
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Addressing Provider Access Barriers in Communities of Color Opportunities and Challenges in the Affordable Care Act Nadia J. Siddiqui, MPH Senior Health.
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Addressing Provider Access Barriers in Communities of Color
Opportunities and Challenges in the Affordable Care Act
Nadia J. Siddiqui, MPHSenior Health Policy AnalystTexas Health Institute
January 23, 2015 | Washington, D.C. | Families USA Health Action Conference
Setting the Context
Working to advance health equity is central to the ACA.
Over 3 dozen provisions directly address health disparities, diversity, cultural/linguistic competence.
Dozens of other general provisions that work to advance racial/ethnic health equity.
60+ Provisions on Advancing Health Equity
Health Equity Provisions Cut Across 5 Primary Priorities:
Health Insurance Marketpla
ce
- Culturally & linguistically appropriate marketing, outreach, and education- Non-discrimination- Special provisions for American Indians
Health Care
Safety Net
- Medicaid/CHIP- Community Health Centers- Nurse-Managed Clinics- School Based Health Clinics- Community Health Needs Assessment- DSH Payment Cuts
Health Care
Workforce
- Primary Care Provider Supply- Loan & Scholarships for Underserved- Pipeline Programs- Minority-Serving Institutions- Cultural Competency
Public Health & Preventio
n
- Prevention & Public Health Fund - CTGs- Obesity- Cancer- Diabetes- Oral Health- American Indian Health
Research,
Quality & Innovatio
n
- National Quality Strategy- PCORI- NIH/NIMHD- CMS Innovation- ACOs- Medical Homes- Agency OMHs- Race/Ethnicity Data Standards
Overall Realization of ACA's Health Equity Provisions (56 Provisions)
Last Updated: December 2013
More Fully Real-
ized48%
Partially Realized
29%
Not Real-ized23%
“Realization” measured in terms of the extent to which a provision received funding or was implemented through regulations, taskforces, or other activity. Source: Texas Health Institute, Research Last Updated December 2013. Funded by W.K. Kellogg Foundation
Implementation Progress of ACA’s Health Equity Advancing Provisions by Topic (56
Provisions) Lasted Updated: December 2013
9
1
74
6
1
1
6
41
3
6
3
4
More Fully Realized Partially Realized Not Realized
N = 10
N = 5
N = 19
N = 11
N = 11
Source: Texas Health Institute, Research Last Updated December 2013. Funded by W.K. Kellogg Foundation
Multi-Pronged Approach to Addressing Provider Shortages
• Financial support (e.g., loan repayment, scholarships)
Provider Incentives
• Advance practice professionals (e.g., NPs, PAs)• Interdisciplinary, team-based care models • Other: telemedicine, HIT, extended hours,
o Reauthorized by ACA through FY 2015, $1.5 Billion; FY 2015 budget invested an additional $3.9 Billion through FY 2020
Up to $50,000 in loan repayment and scholarships for health professionals who work 2 years in HPSA
Students to Serve (S2S) Loan Repayment Program: $120,000 over 4 years to medical students in exchange for 3 years in underserved area
Matching funds to states for loan repayment programs
o Grown 3 times: 9,200 NHSC providers, serving 9.7 mil patients; One-third non-white providers
Provider IncentivesOther Incentivizing Strategies
o Visa Waivers for Foreign Medical Graduates to serve in underserved communities
o Partnering with community settings—e.g., health centers, clinics, and hospitals in rural or underserved areas—to serve as “rotation sites” for medical residents & providing stipendso e.g., Rural Physician Associate Program
o Recruitment financial incentives – e.g., signing bonuses
o Career development support and opportunities
Systems SupportAdvanced Practice Professionals
Systems SupportAdvanced Practice Professionals
o ACA Support: PAs: $30 million for 700 new PAs by 2015
NPs: $31 million for 600 new NPs by 2015; $15 million for 10 nurse-managed health clinics to support training of 900 NPs and serve 94,000 patients
State workforce development: $5.6 million to help states increase primary care workforce by 10-25%
o HRSA estimates that projected increases in NPs and PAs between 2010-2020 could potentially reduce the expected shortage of primary care providers in 2020 by about two-thirds
Primary care provided by NPs is “as safe and effective as care provided by doctors”1
NPs can provide up to 80% of care that primary care physicians currently provide 2
NPs/PAs are often more reflective of communities
NCQA medical home recognition standards permit NPs and PAs to lead medical homes where allowed by state law
NPs/PAs associated with smaller or rural community health centers as well as those with highest uninsured rate 3
NPs/PAs more involved with preventive patient education vs physicians who are more involved with complex care 3
1. IOM, The Future of Nursing: Leading Change, Advancing Health, 20102. Santoro & Speedling. Investing in the Future of Health Care Workforce. 20123. Leighton Ku et al, Community Health Centers Employ Diverse Staffing Patterns,
Health Affairs, January 2015
Systems SupportAdvanced Practice Professionals
Systems SupportEmbracing Interdisciplinary, Team-Based Care
Physician led teams, supported by NPs/PAs, nurses, medical assistants, clerical staff, case managers, social and community health workers
Team members performing “top of their license”
Physician focus on complex cases; NPs/PAs providing majority of routine, primary, and preventive care
Critical role of culturally competent health coaches or community health workers Health literacy
Health insurance and systems navigation
Addressing social, behavioral, and economic barriers
Systems SupportOther Systems-Level Facilitators
Community-Wide InitiativesBuilding a Diverse, Health Professions Pipeline
o Investment in “pipeline” from K-12 to post-graduate
o Targeting traditionally underrepresented minority and economically disadvantaged students
o Programs provide: Health career awareness
Mentorship
Scholarships
Shadowing or training in community settings
Community-Wide Initiatives Title VII Programs Reauthorized by the ACA
o Physicians who graduate from a Title VII Program are 2-4 times more likely than other graduates to serve in an underserved area. o Scholarships for Disadvantaged Students
Supports a large number of nurse practitioners
60% underrepresented minorities
o Health Careers Opportunity Program Dramatic funding cuts, phased out in FY 2015
o Partnerships between academic institutions and community-based clinics in urban, suburban, and rural settings to build the “pipeline”
o Accountable Care Communitieso e.g., UW Accountable Care Network - spans 46
cities and neighborhoods with 700+ primary care providers, 4,000 specialists, 573 clinics, 20 hospitals
o e.g., Hennepin Health Social ACO - hospitals, clinics partnering with social service organizations to address broader social determinants that influence health care access and outcomes
In Closing…
o ACA creates a unique “Window of Opportunity” for expanding and building a diverse, culturally competent health professions workforce to address provider shortages.
o BUT Authorized ≠ Appropriated!
o Limited funding for many programs, along with active and passive resistance to the law threaten to deflect resources and delay or diminish the law’s vision and potential.
Points to Consider Moving Forward
Reassessing “Scope of Practice” laws for advanced practice professionals and identify room for flexibility & innovation
Advocating for and assuring support for the health professions pipeline, especially targeting students from diverse racial, ethnic, and socioeconomic backgrounds
Looking to collaborative solutions that encourage clinical-academic-community partnerships across urban, suburban, and rural settings
Building on the ACA’s support to address provider shortages through team-based, medical home, telemedicine, accountable care, and other systems innovations
Thank You!
Nadia J. Siddiqui, MPHSenior Health Policy Analyst