1. Advancing the Science of Transformation in Integrated Primary Care: Informing Options for Scaling-up Innovation  
Session 3: Addressing health equity and disparities across diverse communities: Policy implications & Discussion
Jonathan Foley, Westcott Partners LLC

2. Purpose
Describe the use of certain indicators of need in a primary health care funding formula in the context of a comprehensive reform of New Zealand’s primary health care system; and,
Assess the impact of this funding approach on primary health care delivery systems and populations served by those systems
Comment on the implications of New Zealand’s experience to efforts to address social determinants in the United States

3. Context
Primary Health Care Strategy – comprehensive reform of the way primary health care was delivered, financed, and governed.
Specific objectives included:
Making primary health care affordable with co-pays reduced or, in some cases, eliminated
Increasing utilization of needed services, especially preventive services and health screenings
Promoting better coordination of care
Reducing health inequalities through new models of care
Primary Health Organizations (PHOs) – GP practices and clinics aggregated in local areas to be focal point. Non-profit with community representation.
Needs-based population funding formulae – means for allocating government subsidy; incorporates ethnicity and area deprivation index

4. Health disparities
New Zealand Ministry of Health, “Decades of Disparity: Ethnic Mortality Trends in New Zealand 1980–1999,” 2003
New Zealand Ministry of Health, “Decades of Disparity II: Socioeconomic mortality trends in New Zealand, ,” 2005.
income is weighted by ethnicity.

5. Health Disparities (cont.)
Percent of NZ Health Survey (2002/2003) respondents answering positively to selected questions (age standardized)
Disease/ condition
Gender
Maori
Pacific
European/
other
Asian
Heart disease
Male
13.6
5.9
9.4
8.1
Female
10.6
7.9
8.5
4.6
Stroke
2.5
n/a
2.0
2.8
1.4
Diabetes
9.5
3.4
6.7
11.9
2.4
8.7
Asthma
21.6
20.8
6.3
27.2
10.8
25.9
COPD
6.0
High blood pressure
23.7
16.2
17.6
14.4
23.9
18.2
19.2
13.1
High cholesterol
15.9
14.6
13.4
12.0
11.1
13.2
12.3
Obesity
29.0
38.0
18.0
4.3
27.5
47.8
19.8
6.9
Current Smoker
42.9
34.8
21.3
18.9
51.1
31.6
19.9
3.6
Seen GP in last year
67.8
75.1
77.7
63.8
82.5
83.7
87.0
73.8
Mammogram
69.0
57.1
76.9
55.6
Cervical screen
72.8
54.4
77.5
43.1
New Zealand Ministry of Health, “A Portrait of Health: Key results of the 2002/03 New Zealand Health Survey,”

6. For the most recent version, see “NZDep2013 Index of Deprivation,” June Atkinson, Clare Salmond, and Peter Crampton, published by the Department of Public Health, University of Otago, Wellington, May,

7. Health equity innovation
Funding formulae allocate more money to PHOs with greater concentrations of Maori, Pacific Islanders, and most deprived enrollees
PHOs use funding to:
Lower fees for enrollees
Develop outreach programs that improve access – e.g., transportation services, nurse clinics on marae or remote locations, community health workers
Run health promotion services and campaigns that influence health behaviors – e.g., smoking cessation, safe driving, healthy eating
Connected to mainstream medical care through PHO

8. Pacific women as keys to family health
Culturally appropriate services
Community based health promotion

9. Evaluation of impact
Lower fees, especially for children, elderly and Access practices
Increased utilization of primary and preventive services
PHOs an established part of the delivery system
Some reduction in health inequalities
Evidence of innovations in service delivery

10. Lessons Learned
Rapid implementation driven by political momentum enabled broad- based reform across the country;
DHBs and general practitioners do not have as much ownership of strategy because of rapid implementation;
Fee reductions limited by soft regulatory approach and GP resistance;
Tensions between universal and targeted approaches;
Not enough attention to planning and evaluating service delivery innovations aimed at reducing inequalities;
Impact of service delivery innovations dependent on capacity and expertise of local practitioners.

11. Rapid Implementation
Primary Health Care Funding Path

12. Implications for the United States
Several versions of area deprivation indeces available – strong correlation with health outcomes; use readily available Census data
Existing and promising programs to address health inequalities through focus on social risk factors:
Community health centers – 1200 centers, 25 million served
Patient Centered Medical Home – comprehensive, coordinated, team approach
Accountable Health Communities – 44 communities
IMPACT Act – possible adjustments to Medicare payments based on social risk factors
Scaling up depends on:
Clearer understanding of what works
Local capacity and expertise to undertake new models of care
Appropriate funding
Ongoing accountability mechanisms, evaluation and feedback
Political will