Peter Damiano Director, Public Policy Center University of Iowa State Advisory Group Meeting

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

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

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

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

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

6. Completed Inventory Reports

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

8. Safety Net Payer Inventory Reports(financing, clients) • Medicare • Medicaid • Children’s Health Insurance Program (CHIP) • IowaCare • Ryan White Other Reports • Public Health Block Grant and related services • Uninsured in Iowa Available at: http:ppc.uiowa.edu search: safety net study

9. Subcommittee Activities

10. Subcommittee activities • FQHC/RHC subcommittee • Safety net provider • Oral health subcommittee • SN primary care service • Medicaid subcommittee • SN payer

11. FQHC/RHC Subcommittee • 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

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

13. Oral Health 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

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

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

16. Dentist Survey Domains • Current Medicaid participation • Attitudes towards Medicaid • Attitudes towards underserved populations • Attitudes towards CHCs • Attitudes towards corporate dental practices • Current practice patterns • Current and future use of Expanded Function Dental Auxiliaries (EFDAs) • Use of health IT

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

18. Policy Briefs

19. 4 Policy Briefs In Progress • Safety net provider revenue and potential impacts of ACA expansion on FQHCs • Capacity of FQHCs and RHCs to deal with new patients post ACA insurance expansion • Incorporating safety net providers into ACOs • Care coordination/care management and the role for the safety net

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

21. Policy Brief 2: Capacity of FQHCs/RHCS 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

22. Policy Brief 2: Capacity of FQHCs/RHCS Survey currently in the field • survey e-mailed with hyperlink to 14 FQHCs, 138 RHCs in Iowa: June 10 • Data collection complete: July 5 • 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

23. Policy Brief 3: Safety Net and ACOs • 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

24. 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

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

26. Partners in Community Utility • 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

27. High-Level Primary Care Medical Home Functions

28. High-Level Regional Functions

29. High-Level State Functions

30. Related project

31. Health Benefits Exchange Survey • 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: http://iowahealthinsurancesurvey.com

32. 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

33. Discussion Vinny