“We have to understand that by not addressing these socioeconomic issues, we’re going to spend more money on our health and suffer worse morbidity and mortality. By not paying for it now, we’re paying for it later in terms of lost health and lives.” Tracey Cohen, MD, Neighborhood Health Plan of RI

Research shows that the social circumstances in which we are born, live and work – our jobs, schools, built space, transportation, even the quality of civic life – get under the skin, influencing our behaviors, access to resources, chronic stress levels and ultimately increasing or decreasing our chances for health.

Racial and ethnic health inequities don’t just reflect income. More African American, Native American, Latino and Pacific Islanders are in poor or fair health than whites at practically every income level.

“Recognizing this, RI payors are driving delivery system change by creating, providing, or paying for services which are designed to bridge socioeconomic barriers.” Renee Rulin, MD, MPH, RI, Medical Director, Medicaid/United Health Care

“Right now we’re in a period of total disruption of the healthcare system. The Affordable Care Act will be disruptive, but the biggest disruption will come from the shift to electronic medical records, which will completely flip how healthcare is delivered, and how our socioeconomic stressors are resolved.

“Primary care provider systems and practices will be increasingly encouraged by payors to offer a more holistic range of services, so private practices look more like community health centers and a fuller range of socioeconomic stressors can be managed from one place.

“We will see health insurance carriers responding to what health consumers want as opposed to what employers want and as opposed to what providers offer. As a new consumer based healthcare system evolves, there is an immediate opportunity to be part of the conversation about what plans and payment models consumers want to have and what provider services are most effective.” Christine Fergueson, Director, RI Health Insurance Exchange

“Now is the time to engage (in developing criteria for these new models of payment),” as Christy Ferguson said, “I want you to come to me and say ‘this is what I want.’ ”

Good to Know

“Many people in RI are underserved because of RI’s role as a safe haven for immigrants and undocumented folks. We need more data in order to formulate new policies to better serve this population.” Mary Reich Cooper, MD, JD Co Chair, Women’s Health Council

Defining Measures

Starting in 1990, keynote speaker Michelle Berlin, MD, MPH, began to partner with the National Women’s Law Center (NWLC) and NIH to look at creating data collection on women’s health disparities and inequities, so that better policies could be promoted. She helped to define 26 health status indicators that are now used nationally and state-by-state to evaluate the status of women’s healthcare delivery. Divided into four categories, the units of measure are collected in every state across a consistent continuum of socioeconomic indicators that assess:

1. Women’s access to health care services

2. Addressing both wellness and prevention

3. Key health conditions, diseases and causes of death

4. Living in a healthy community

The results show that, as a country, our national grade has been unsatisfactory.

Click here for slides showing where RI meets the grade and where we need to improve. Michelle Berlin, MD, MPH, Oregon Health & Science University

Why Women Are More at Risk in RI

Rhode Island’s cost of living is 2.5 times above the poverty level. Assistance from RI Works is 65% below the federal poverty level, and 44,000 women are without health coverage.

Poor RI women are no longer on the policy agenda to increase their benefits because there is such a lack of respect among legislators for the single mother population. The ACA will provide more insurance to all Rhode Islanders including women through the new Health Benefits Exchange. We must make sure it is affordable. Linda Katz, JD, Executive Director, Economic Progress Institute

A high percentage of new mothers, especially with premature babies, have significant social and environmental stressors. They suffer from a combination of depression, domestic violence and substance abuse. Rates of mental health issues in mothers have gone up 64% as home situations continue to worsen.Betty Vohr, MD, Women And Infants Hospital

Health Payment Reform’s Triple Aim

1. Improve the patient experience
2. Improve health of the population
3. Reduce per capita cost of health

RI Medicaid is evolving from fee for service payment to value-purchasing with managed care organizations. The new goal is to pay for what is important to the patient, and to wrap a better delivery system around member practices. Renee Rulin, MD, MPH

Blue Cross Blue Shield of RI is supporting the Patient Centered Medical Home model, encouraging the development of a care team within practices and having staff work to the top of their licensure. Andrea Galgay, MBA

Neighborhood Health Plan of RI focuses on care across the socioeconomic spectrum because “the ROI is better when the whole person is considered.”Tracey Cohen, MD

Roadmaps to Innovative Care

Providence Community Health Centers We “crosswalk them.” Working with underserved populations, the Health Center decreases the barriers to care and helps patients understand their own disease process combined with their mental health issues. Patients develop their own multi-part plan and then are helped to get to the right resource when they need it.  Angela Reda, RN, Providence Community Health Centers

Health Leads goal is a healthcare system that addresses all of the patient’s basic resource needs as a standard part of quality care. Health Leads physicians, currently at Hasbro, write prescriptions for food, childcare, employment, job training, housing, and then walk patients over to the volunteer teams who follow the patient until their needs are met. Health Leads offers systemic deep integration of a practical solution for resolving socioeconomic determinants to health. Sonia Sarkar, MPH, Health Leads

Patient Centered Medical Home programs develop a patient care team within medical practices where all staff work to the top of their licensure and the whole patient is treated. The focus is on proactive care, like planning to complete tests and labs prior to patient visit with PCP. Patient engagement is the key. Andrea Galgay, MBA, Blue Cross & Blue Shield Of RI

Partnering with Parents Complex social environments contribute to the greatest risk of infant rehospitalizations. We’ve shown that increased parental support and education reduces infant rehospitalizations by 60% and since the average cost of rehospitalization is $22,000, this kind of intervention can have a significant impact on health care costs. Betty Vohr, MD, Women & Infants Hospital

In Your Practice

Many private practices don’t have the facilities to partner with Medical Home models or access to all the stakeholders needed to care for vulnerable families.

Right now, payors like Blue Cross Blue Shield, United Health Care, RI Neighborhood Health and developers of the new Health Insurance Exchange are actively seeking ways to wrap a better health care package around your practice. Let them know what you and your patients want.

Suggestions for improving access to care and a more holistic approach can include:

• Opening morning and evening after hours and on weekends to improve access for working parents and single mothers.
• More proactive service, like arranging to have lab tests completed prior to the PCP visit.
• Empowering a care team to offer more comprehensive care, because the results are significantly better when the whole person is considered.
• Most local insurers will now pay for adding Nurse Case Managers and Peer Navigators who connect all the dots for patients and pay attention to how they are living.
• Provide home visits
• Provide a training curriculum before taking child home; manage infant’s early care; give a new mother lots of assurance.
• Connect families with resources in the community, include housing and other environmental issues; add a Family/Parent Resource Counselor.
• Treat the whole family. Take a whole team approach.
• Provide contraceptive counseling to help women make better choices; one key question to ask at every patient encounter: “Do you want to become pregnant in the next year?”

Conference Survey Summary shows what percentage of conference attendees belong to each healthcare provider category.

The Affordable Care Act: A Quick Guide for Physicians  explains ACA’s key provisions that impact physicians and patients.