Peter Damiano Director, Public Policy Center University of Iowa State Advisory Group Meeting Via Webinar June 19, 2013 Iowa Safety Net, the ACA and Related Primary Care Delivery System Changes: An Update

1. Completed Inventory reports 2. Subcommittee activities 3. Policy briefs underway 4. Related projects Health Benefits Exchange survey Update: The Iowa Safety Net and ACA project

1. Steering Committee (10 members) 2. Leadership Group (20 members) 3. State Advisory Group (65 members) 4. National Advisory Committee (8 members plus CMWF staff) 5. Subcommittees for: Safety net provider (FQHCs/Rural Health Clinics) Safety net payer (Medicaid) Safety net primary care service area (Oral Health) Committee structures

Steering Committee: Meets Weekly Pete Damiano-PI Chris Atchison Chair, Safety Net Adv Council. Ted Boesen IAPCA Exec Dir. Keith Mueller UI CPH Professor Sarah Dixon Gale, IAPCA Suzanne Bentler PPC Res. Spec. Michelle Holst IDPH Jennifer Steenblock IDHS Elizabeth Momany PPC, Assoc. Res. Sci. Marni Bussell IDHS State Advisory Group and Leadership groups meet quarterly Virginia Tonelli, IAPCA Deb Kazmerzak, IAPCA

National Advisory Committee Catherine Hess Barbara Wynn Deborah Scott Andrew Hyman Daniel Hawkins William Finerfrock Edward Schor Leighton Ku

Completed Inventory Reports

1. Federally Qualified Health Centers (FQHCs) 2. Rural Health Clinics (RHCs) 3. Free Clinics 4. Family Planning Clinics 5. Community-based Adult Mental Health Centers Includes legal analysis of the ACA as it relates to each provider type Completed Safety Net Provider Inventory Reports (financing, delivery system, clients)

1. Medicare 2. Medicaid 3. Children’s Health Insurance Program (CHIP) 4. IowaCare 5. Ryan White Other Reports 1. Public Health Block Grant and related services 2. Uninsured in Iowa Available at: search: safety net study Safety Net Payer Inventory Reports (financing, clients)

Subcommittee Activities

1. FQHC/RHC subcommittee – Safety net provider 2. Oral health subcommittee – SN primary care service 3. Medicaid subcommittee – SN payer Subcommittee activities

Primary goal: evaluate the capacity of the FQHCs and RHCs in Iowa and the barriers to expansion (facilities and workforce) Secondary goal: evaluate the current and future care coordination activities and whether they can function as part of a community utility model FQHC/RHC Subcommittee

1. Established an FQHC/RHC subcommittee o 2 meetings conducted 2. Developed capacity survey instrument to FQHCs/RHCs concerning: o Capacity for providing care currently, o Barriers to growth, o Interest in community utility-type functions (More detail to follow) FQHC/RHC Subcommittee

Primary goal: evaluate the current access to and utilization of dental services and state of oral safety net (FQHCs and private practitioners) Secondary goal: Better understand the factors affecting dentists’ participation in Medicaid Additional support from the Dentaquest Foundation Oral Health Subcommittee

1. Established a National Oral Health Advisory Committee o 3 meetings conducted 2. Inventory report on oral health in Iowa (access, utilization health status) o First draft complete and reviewed by NAC 3. Survey Iowa private dentists about Medicaid participation and attitudes (1400 private practice, all specialties) o Data collected, being analyzed o Draft Report July 2 4. Conjoint analysis survey (scenarios)-300 dentists agreed to participate o ed to dentists: August 1 Oral Health Subcommittee

Topics: 1. Oral health delivery system 2. Financing of oral health care 3. Access and utilization of oral health services 4. Oral health status of Iowans 5. State oral health promotion/disease prevention programs Data Sources: 1. State and national health departments and agencies 2. Non-profit think tanks (e.g., KFF, CDHP, Pew) 3. Peer-reviewed journal articles 4. Professional organizations (e.g., ADA, ADHA, ASTDD, NACCHO) Oral Health Inventory Report

1. Current Medicaid participation 2. Attitudes towards Medicaid 3. Attitudes towards underserved populations 4. Attitudes towards CHCs 5. Attitudes towards corporate dental practices 6. Current practice patterns 7. Current and future use of Expanded Function Dental Auxiliaries (EFDAs) 8. Use of health IT Dentist Survey Domains

Originally evaluating ability for Medicaid to absorb expansion o Partially captured in the capacity survey with FQHCs/RHCs Now focusing on ACO, Community Care Team and health home development o Participating in NASHP Medicaid TA project o Community care team policy brief o Participation of safety net providers in ACOs for policy brief Medicaid subcommittee

Policy Briefs

1. Safety net provider revenue and potential impacts of ACA expansion on FQHCs 2. Capacity of FQHCs and RHCs to deal with new patients post ACA insurance expansion 3. Incorporating safety net providers into ACOs 4. Care coordination/care management and the role for the safety net 4 Policy Briefs In Progress

1. Financing of care for FQHCs, RHCs, Title X family planning clinics, free clinics and Community- based MH Centers in Iowa o Including revenue sources, demographic characteristics of populations 2. Modeling of revenue for FQHCs based on experience in Massachusetts o Chose FQHCs because most data were available and most experience known Draft report to CMWF: July 5 Policy Brief 1: Safety Net Funding sources

Online survey with all FQHCs and RHCs in Iowa – 14 FQHCs – 138 RHCs Questions by domain Current Demand Increase in Demand Current Capacity Increase in Capacity PCMH Org. Readiness for Change Policy Brief 2: Capacity of FQHCs/RHCS

Survey currently in the field o survey ed with hyperlink to 14 FQHCs, 138 RHCs in Iowa: June 10 o Data collection complete: July 5 o Draft brief to CMWF: August 30 Site visits to be conducted in August 2013 with 3 FQHCs and 3 RHCs Will lead to policy briefs on ability of FQHCs and RHCs to accept new patients from ACA Policy Brief 2: Capacity of FQHCs/RHCS

Primary Research Question: – What are the opportunities and barriers for the inclusion of safety net providers in ACOs that are developing in the state? Based on structured interviews with: – Health system leaders and providers – Public and and private payers/insurers Interviews began April 29 Policy Brief 3: Safety Net and ACOs

Have interviewed: – Mercy Des Moines – Wellmark – COOP – IME To be interviewed: – Fort Dodge Pioneer ACO – UIHC/Mercy CR – Genesis – Mercy Mason City Policy Brief 3: Safety Net and ACOs

1. Current care coordination activities being provided by FQHCs and RHCs 2. Interest in providing these in the future 3. How to define these activities 4. How they could integrate with ACOs to provide more efficient care Policy Brief 4: Care Coordination and the Safety Net

Primary care providers Long-term care Public health departments Maternal/child health providers Area Agencies on Aging Family planning agencies Community action organizations Patient/family advocates Specialists/hospitals Legal aid services Organ associations Behavioral health providers Oral health providers Partners in Community Utility

High-Level Primary Care Medical Home Functions Primary Care Medical Home Access & Continuity, Multi-Modal Identify & Manage Patient Populations Plan & Manage Care Provide Self- Care & Community Support Track & Coordinate Care Measure & Improve Performance

High-Level Regional Functions Regional Entity Accountability and Reporting Medical Management and Care Coordination Primary Care Provider Support Patient Engagement & Education Outreach & Enrollment Transportation Logistics

High-Level State Functions State Level Entity Data, Reporting, Analytics, and Risk Stratification Evaluation of Regional Entities and PCMHs Social Determinants of Health Technical Assistance, Best Practices, Network Development Pharmacy, Pain Management, and Behavioral Health Resources Telehealth Infrastructure

Related project

Consumer and business attitudes – Convenience sample with association members – Online and paper version Topics include: – Current coverage and importance of having/providing it – Knowledge and attitudes towards aspects of ACA – Where they get information about ACA and coverage – Importance of plans’ design such as provider panel – Need for help with online plan selection – How they get information about ACA and plans and what sources do they trust the most Survey available at: Health Benefits Exchange Survey

Participating organizations – Iowa Caregivers Assoc – IA Public Health Association – Chamber Alliance – Iowa Association of Business and Industry (ABI) – Professional Developers of Iowa (PDI) – AARP – FQHCs-select Respondents: – Over 500 completed so far – Most are consumers with employer-based insurance Health Benefits Exchange Survey

Discussion Vinny