Health Policy$ense

The Affordable Care Act and Minority Health: Part III (New Models of Delivering Care)

ACA Drives Interest in ACOs, Shared Savings Programs, Bundled Payments and Community Health Workers

As the Affordable Care Act’s health insurance marketplaces begin their second year of open enrollment, LDI examines the current and potential impact of the ACA on the health of minority populations. This third post of a five-part series examines how new models of care delivery encouraged by reform will affect minority populations.

Although most of the public attention on the ACA focuses on covering the uninsured, the law also funds a variety of initiatives to improve the way care is delivered. The Centers for Medicare and Medicaid Services (CMS), along with a growing contingent of private payors and providers, are testing new payment and delivery models. These arrangements transfer more performance risk to providers, create incentives for care coordination of high-risk populations, and expand the role of primary care. The implication for providers, who are becoming more at-risk for patient outcomes, is that they must take a more active role in managing their sickest patients – often, these patients are racial and ethnic minorities.

Among familiar programs such as Medicare ACOs and Shared Savings Programs, value-based purchasing and bundled payments, there are several programs focusing on Medicaid and CHIP populations. Since 60% of Medicaid beneficiaries are racial and ethnic minorities (and half are Black or Hispanic), these programs have potential to address longstanding health disparities. Here we highlight just a few examples of the initiatives that have direct implications for minority health.

Less likely to have access
Minority groups, Blacks and Hispanics in particular, are less likely to have access to adequate emergency mental health treatment. The Medicaid Emergency Psychiatric Demonstration, authorized under the ACA, provides $75 million to reimburse private psychiatric hospitals for treating Medicaid patients who experience a mental health emergency. In the past, Medicaid has not paid for these services in “institutions for mental disease” (IMDs) unless the patient was previously admitted to a general hospital for the same condition. Under the three-year program, 11 states and DC are testing whether Medicaid coverage will reduce emergency department utilization, improve discharge planning, and improve transitions of care that will decrease readmissions. An initial report to Congress found that the vast majority of beneficiaries were determined eligible to participate in the demonstration as a result of suicidal thoughts or gestures. The demonstration runs through December 31, 2015.

Chronic disease burden
Minorities bear a disproportionate burden of chronic diseases such as diabetes and hypertension. The Medicaid Incentives for the Prevention of Chronic Diseases Model, also authorized under the ACA, funds 10 states to implement prevention programs around smoking cessation, weight loss and control, lowering cholesterol and blood pressure, and avoiding or managing diabetes. An initial report to Congress found that states had run into implementation and coordination challenges around how to enroll patients and deliver economic incentives. All states are giving participants monetary incentives in the form of cash, gift card or other money-value item, or flexible spending account funds. Incentives range from $20 to $1,150 annually to reward participants for program participation and for achieving specified health outcomes. States are also incentivizing participating providers. Most states are conducting the program as a randomized controlled trial with incentivized and non-incentivized patients. The program runs through the end of this year.

Disparities in prenatal care
Racial and ethnic minority women face significant disparities in prenatal and maternal care. The Enhanced Prenatal Care Models program, also authorized under the ACA, tests four models of prenatal care interventions: group visits to encourage peer-to-peer learning and support, visits to birth centers that provide team-based care and counseling, and visits to maternity care homes – which appear to be patient-centered medical homes adapted for maternal needs. Across 20 states and four years, $41.4 million will fund 182 providers, state agencies, and managed care organizations to implement the program in Medicaid and CHIP populations. CMS expects that this amount will fund the cost of enhanced care for 90,000 women.

All of these programs are ongoing, so their impact on minority health is still speculative. We will keep an eye out for final evaluations in the coming years. That some of these programs are focused on Medicaid beneficiaries and other low-resource groups underscores their potential to improve population health for minorities and economically disadvantaged groups. The latest progress report on CMS’ Innovation Center can be found here.

Community health workers
The ACA also encourages delivery system innovation through its workforce provisions, which we will review in more detail tomorrow. One section encourages the use of community health workers (CHWs) in underserved communities through grants from the Centers for Disease Control and Prevention (although no funds have been appropriated as yet.) CHWs share an ethnic, linguistic, cultural or experiential connection with the population served, and may improve outcomes for chronically ill, poor, and primarily minority patients. The Patient-Centered Outcomes Research Institute (PCORI), established by the ACA, recently awarded $1.9 million to Penn’s Center for Community Health Workers to use CHWs to improve outcomes among low-income chronically ill patients. If successful, this new model of care may be able to address longstanding disparities in outcomes that cannot be ameliorated by improved insurance coverage alone.