Redesigning Preconception Health Service Delivery to Achieve Health Equity Michael C. Lu, MD, MPH Department of Obstetrics & Gynecology David Geffen School of Medicine at UCLA Department of Community Health Sciences Center for Healthier Children, Families and Communities UCLA School of Public Health Third National Summit on Preconception Health & Healthcare Tampa FL June 14, 2011

Redesigning Preconception Health Service Delivery to Achieve Health Equity Medical home for women’s health Women and children’s accountable care organization (ACO) Best Babies Zone

The definition of insanity is doing the same thing over and over and expecting different results Benjamin Franklin

Prenatal Care 1.0 Receptionist & Clerks Medical Assistant Ultrasound Tech Nurse Manager Lu MC. Healthcare reform and women’s health: A life-course perspective. Curr Opin Obstet Gynecol 2010;22:487-91

Prenatal Care 2.0 Oral Health Teratogen Information Services Primary & Specialty Care Family Support Social Services WIC Receptionist Medical Assistant Ultrasound Tech Nurse Manager High Risk OB Mental Health Lu MC. 2010;22:487-91

Redesigning Preconception Health Service Delivery to Achieve Health Equity Medical Home for Women’s Health

Prenatal Care 3.0 Genetic Counseling & Prenatal Diagnosis Ultrasound Center OB Hospitalist Oral Health Mental Health Dietitian & WIC Primary & Preventive Services Health Education Family Planning Family Support & Social Services High Risk OB Specialty Clinics Preconception & Interconception Care Prenatal Care Lu MC. 2010;22:487-91

Women & Children’s Accountable Care Organization Redesigning Preconception Health Service Delivery to Achieve Health Equity

Women and Children’s ACO Reduce costs Averted NICU admissions Averted maternal morbidities Averted disease & disability in children Averted heart disease, diabetes, and cancer in adults? Improved care Solo or small group practices to share resources & savings with the medical home Promote population health Not only from care coordination, but from optimization of fetal (and preconceptional) origins of health & disease

Women & Children’s ACO Genetic Counseling & Prenatal Diagnosis Ultrasound Center OB Hospitalist Oral Health Mental Health Dietitian & WIC Primary & Preventive Care Health Education Family Planning Family Support & Social Services High Risk OB Specialty Clinics Preconception & Interconception Care Prenatal Care OB

What Can Medicaid Do to Improve Perinatal Outcomes? Single largest payer of perinatal healthcare in U.S. Pays for > 40% of all births Spends $39 billion a year on perinatal healthcare $21 billion for pregnancy and delivery $18 billion for newborn care Andrews RM. The national hospital bill: The most expensive conditions by payer, Healthcare Cost and Utilization Project. Statistical brief #59. September 2008

Women and Children’s ACO Demonstration Coverage for pre- and inter-conception care States with family planning demonstration or state option Start-up costs CMMI or HRSA should provide start-up costs in under-resourced communities Risk-sharing Minimize risk-sharing Assignment rule Assignment should not exclude FQHC’s that provide care through team approach rather than direct physician care Performance measurement Develop perinatal quality measures incl service coordination in ambulatory settings Collaborative learning Support center to facilitate collaborative learning, improvement & innovation Integration with Kids ACO Design in collaboration with Kids ACO demonstration

Best Babies Zone Redesigning Preconception Health Service Delivery to Achieve Health Equity

Health Development Educational Development Community Development Economic Development Best Babies Zone

Best Healthcare “Accountable care neighborhood” for women’s health Preconception and interconception care Quality improvement in prenatal & intrapartum care Comprehensive women’s health services across life course continuum Integrated with public health & social services programs in the community (e.g. Nurse Family Partnership, Healthy Start) Cost savings are reinvested in the community

Best Education

Too Much, Too Late?

Public Expenditures Children 0-17, Sweden, 1995

Best Opportunities Opportunity Incubator Macroeconomic policies Microfinance Business incubator & job training Financial literacy & asset development for families High-function safety net programs

Best Community Healthy Community Clean air and water (environmental justice) Healthy foods & physical activities Fatherhood & Family Social capital Racial equity

BBZ Incubator Assessment Blueprint Capacity-Building Community engagement Transformative leadership Improvement & innovation Measurement, mapping & evaluation Policy & advocacy Design thinking Development Evaluation

Accountable Care Neighborhood Promise Neighborhood Choice Neighborhood Byrne Criminal Justice Innovation Best Babies Zone

“If you want 1 year of prosperity, grow grain. If you want 10 years of prosperity, grow trees. If you want 100 years of prosperity, grow people.” Chinese Proverb

"We must become the change we want to see.” - MOHANDAS GANDHI