Linking Community Development & Health

1. Linking Community Development & Health Susan Dentzer Editor-in-Chief

2. Health Affairs thanks For its generous support of the November 2011 issue and briefing

3. Opening Remarks Elaine Bratic Arkin Robert Wood Johnson Foundation

4. Forging New Connections Between Community Development and Health How the Health and Community Development Sectors are Combining to Improve Health and Well-Being Sandy BraunsteinFederal Reserve Board of Governors

5. We Are Working Side By Side Source: Los Angeles County Department of Public Health

6. Overlapping Geographies And Overlapping Goals • Leading cause of premature death is not access to health care, it is rooted in social, environmental and behavior risks, which are often influenced by the community in which you live. • Community developers focused on improving neighborhoods that struggle with poverty, overcrowded housing, and high unemployment. • Public health focused on combating poor health outcomes, including high rates of obesity, asthma, and chronic disease • Both sectors are focused on the same communities, often the same people, and the problems they both address are interrelated.

7. How To Collaborate? • Started a series of conferences at Federal Reserve Banks across the country – DC, LA, Boston, New York, Houston – on how community development can work with the health sector to attack negative social determinants of health. • Highlight good local examples of collaborations like in Seattle, where public health and housing leaders reduce exposure to allergens in low-income homes that can cause asthma in children. • Promote new national initiatives that combine both sectors: Healthy Food Financing Initiative, HHS and HUD’s Choice Neighborhoods program, new Federally Qualified Health Clinics as community anchors not just medical exam rooms.

8. What’s Next? • Build the infrastructure to help foster collaboration • Data and measurement, capital, policy • Build the “business case” for collaboration: bend the cost curve. • Research and share the lessons learned from collaboration underway.

9. Conclusion • If leaders in the community development and public health sectors can grasp this moment in time to capture the imagination of visionaries, and bring   expertise and considerable resources to bear in order to align their efforts, both can be rewarded by moving closer to our common goal of an America where every individual has the opportunity to live a long and fulfilling life. 

10. Partnerships Among Community Development, Public Health, And Health Care Could Improve The Well-Being Of Low-Income People David J. Erickson Center for Community Development Investments, Federal Reserve Bank of San Francisco

11. Despite Obstacles, Considerable Potential Exists For More Robust Federal Policy On Community Development And Health Mariana Arcaya, Harvard School of Public Health/Federal Reserve Bank of Boston Xavier de Souza Briggs, Massachusetts Institute of Technology

12. Paper Aims • Where is community development best positioned to shape health outcomes? • A window of opportunity at the federal level • Challenges to reform • Strategies and tools for progress

13. Improving Living Conditions • Structural determinants of health • Exposure to health risk factors • Vulnerability to health risk factors • Mitigation or exacerbation of health consequences • Policy • Targeted funding • Knowledge generation and assessment

14. A Window Of Opportunity • New federal “place-based” policy • First ever White House Office of Urban Affairs and Office of Rural Affairs • Developing effective place-based policy: community health and access to opportunity • Beyond need indicators: regionalism and coordinated federal spending • Implementation of the Affordable Care Act

15. Challenges To Reform • Fragmented jurisdictions of the congressional committee system • Budget scoring rules • Deficit-oriented oversight • “Wrong pocket problem” Limited incentives for progress unless : • Spending and savings accrue to a single agency • Initiative under the jurisdiction of a single committee • Evidence of probable impact is very strong.

16. Tools And Strategies • Policy advocacy coalitions • Robert Wood Johnson Foundation and the Federal Reserve System • Systems of innovation • Test new models, refine approaches, scale what works, terminate what does not • Health impact assessment methodology

17. Thank you. Mariana Arcaya Harvard School of Public Health Federal Reserve Bank of Boston Metropolitan Area Planning Council marcaya@hsph.harvard.edu Xavier de Souza Briggs Massachusetts Institute of Technology Xbriggs@mit.edu

18. Bringing Researchers And Community Developers Together To Revitalize A Public Housing Project And Improve Health Douglas Jutte University of California, Berkeley, School of Public Health

19. Community Health Centers And Community Development Finance Institutions: Joining Forces For Healthy Communities Ronda Kotelchuck, CEO Primary Care Development Corporation (PCDC)

20. CHCs, CDFIs Share Similar Origins, Missions And Evolution Community Health Centers • Origins in War on Poverty/OEO • Provide affordable, comprehensive primary and preventive care to low income communities • $11B industry: 1,200 CHCs operating 8,000 sites, employing 200,000 people, serving 23M low income Americans • Governed by consumer-dominated boards • Overseen by HRSA/US Dept. of Health and Human Services Community Development Financial Institutions • Origins in War on Poverty/OEO • Provide affordable financing and TA to sustainable projects in low-income communities • Over $23 billion in assets: 1,000 CDFIs spread across all states and territories. • Typically invest in housing, community facilities, day care, charter schools, small businesses • Accountable to target markets • Overseen by CDFI Fund/ US Treasury

21. CHCs Play Three Important Roles In Community Development • Primary care is a crucial support for community revitalization • CHCs are businesses generating community jobs and secondary spending • CHCs are agents in addressing the social determinants of health

22. The Health Care Paradigm Is Changing

23. Interest In CHCs Is Growing Among CDFIs • Two CDFIs historically involved: NCB Capital Impact, Primary Care Development Corporation (PCDC) with partners including JPMorgan Chase, Citibank, Bank of America and HSBC. • New CDFI interest: • CDFIs see a new market emerging: CHCs are sustainable businesses and healthcare models. • CHCs need affordable capital, especially to take advantage of federal CHC expansion initiatives ($1.5B of capital appropriated to double CHC capacity; $60B of capital need estimated) • New CDFI initiatives

24. What Needs To Happen? • Awareness and collaboration at all levels: • Community: Individual CHCs, CDFIs • Region: Primary Care Associations, CDFI Coalitions • National: National Association of CHCs, Opportunity Finance Network • Governmental: DHHS and Treasury • Cross exposure and training: • CHCs – In the use of credit • CDFIs – In the CHC business model, operations • Joint policy interests: • CHC and CDFI program funding, expansion • Health care payment reform • Research for policy, strategy, action: What are the… • Most important factors in CHC and CDFI growth, effectiveness, sustainability? • Most powerful social determinants? • Most effective interventions?

25. New Community Health, Food Service And Environmental Protection Workers Could Boost Health, Jobs and Economic Growth Nicholas Freudenberg, DrPH; Emma Tsui, PhD City University of New York School of Public Health For more: nfreuden@hunter.cuny.edu

26. Proposal: Creating Entry-level Jobs That Promote Health • Community health workers • Environmental remediation and protection workers • Food service workers

27. Jobs That Promote Health And Development • Exist in sectors expected to grow in next decade • Offer long term potential to save public money • Help to reorient health care system towards prevention and the control of chronic diseases • Should offer living wages, benefits and career ladders

28. Barriers • Limited evaluation and cost-benefit studies • Private sector opposition • Austerity mentality • Need for upgraded jobs with adequate wages Windows Of Opportunity • Dire jobs crisis • Existing funding streams • Need to reduce cost of health care • Need to align food and health policies

29. Neighborhood Characteristics And Access To Patient-centered Medical Homes For Children Jaya Aysola, MD, MPH E. John Orav, PhD John Z. Ayanian, MD, MPP Harvard Medical School Brigham and Women’s Hospital

30. Why Do We Care? • Policy efforts to expand Patient-Centered Medical Homes • High quality primary care model • Significant disparities in access to medical homes exist • Factors contributing to these disparities are not well established • Social determinants may play a role

31. Study Aim • Examine the relationship between: • Neighborhood characteristics: cohesion, safety, physical environment AND • Whether children receive care from a patient-centered medical home • Nationally representative survey of parents/guardians of children (n=91,642)

32. What We Found • 93% had access to both a personal provider and usual source of care • Only 58% had access to a medical home • Children more likely to have access: • Non-Hispanic whites • Higher income households • Privately Insured

33. Place Matters For Medical Home Access Medical Home Access* (%) Medical Home Access* (%) *Rates shown are after adjustment for several socioeconomic and demographic variables. P<0.001

34. Neighborhood Characteristics • Stronger predictors for medical home access than income or race • Reduced income disparity by half • Not associated with access to a primary care provider • Associated with patient or family centered care

35. If You Build It, Will They Come? • Community engagement key for expansion of medical homes • Practice models should: • Expand care teams to include community health workers • Form community partnerships with trusted community entities • Identify ways to build collaborative relationships between providers and patients/families

36. Acknowledgements • Shimon Shaykevich, MS • Ichiro Kawachi, MD, PhD

37. An All-Payer System: Solution For The Alleged Cost-Shift Uwe Reinhardt Princeton University

38. Variations In Medicare Payments For Surgery Highlight Opportunities And Challenges For Bundled Payment Programs David C. Miller, MD, MPH Assistant Professor Department of Urology Center for Healthcare Outcomes & Policy University of Michigan

39. Bundled Payments For Inpatient Surgery • Surgery represents a large component of national health care spending • CMS and other payers are considering bundled payments for inpatient surgery • Lump sum payment to hospitals, physicians, and other providers • Aimed at improving care coordination and reducing duplicative or unnecessary services • Implications of bundled payments depend on extent of true variation in current payments (payers) and patterns of variation across procedures and specialties (hospitals)

40. Effects Of Price- And Case Mix Adjustment On Variations In Medicare Payments For Surgery Miller et al, Health Affairs, Nov 2011

41. Source Of Payment Variation Depends On The Procedure % Variation in total Medicare episode payments Miller et al, Health Affairs, Nov 2011

42. Correlations In Medicare Payments For Surgery Vary Across Procedures And Specialties Miller et al, Health Affairs, Nov 2011

43. Implications For Bundled Payments • Wide variation in payments imply opportunities for substantial savings for CMS and other payers • Depends on where payers set the payment rate and on the procedures and services included in the “bundle” • Probably important to include post-discharge care in the lump sum payment • Bundled payments could prove to be a financial “wash” for many hospitals • Hospitals expensive for multiple procedures (up to 30% in our analyses) will have strong incentives to reduce costs

44. Kicking The Tires: Evaluating The Road Test Of PROMETHEUS Payment Peter Hussey RAND Corporation

45. Is The Mandate Really The “Linch Pin” To The ACA? John Sheils The Lewin Group

46. Without The Individual Mandate, The Affordable Care Act Would Still Cover 23 Million; Premiums Would Rise Less Than Predicted John Sheils Randall Haught

47. Exhibit 1: Individual Coverage Under The Affordable Care Act With And Without The Individual Mandate SOURCE Lewin Group estimates. NOTE Numbers may not sum to totals because of rounding. a The percentages are equal to average costs for covered people under the Affordable Care Act (ACA) without the mandate over average costs under the Affordable Care Act as with the mandate.

48. Exhibit 2: Coverage Under The Affordable Care Act, With And Without The Individual Mandate And Penalty SOURCE Lewin Group estimates. NOTES These estimates assume the act is fully implemented in 2011. CHIP is the Children’s Health Insurance Plan. TRICARE is the health care program serving Uniformed Service members, retirees and their families. a Does not include those eligible for both Medicaid and Medicare. b Other includes the Indian Health Service or any other state or local sources of coverage.

49. Exhibit 3: Coverage Loss And Premium Increases Under The Affordable Care Act Without The Individual Mandate And Penalty SOURCES: Congressional Budget Office, Note 4 in text; Gruber, Note 5 in text; The Lewin Group, The Lewin Group estimates. NOTE These estimates are compared to the Affordable Care Act as written.

50. Projecting Medicaid Enrollment, Costs, And Workforce Needs Under Health Reform: Uncertainty Behind The Numbers Katherine SwartzHarvard University School of Public Health