Damiano 1 Iowa Safety Net, the ACA and Related Primary Care Delivery System Changes National Academy for State Health Policy Annual Meeting Kansas City, MO October 4, 2011

Damiano 2 Assist policymakers and safety net providers to plan for change-financial and organizational Conduct large scale strategic planning effort not otherwise possible Using national and state-level experts with academic assistance to evaluate the potential impacts of ACA on states Identify opportunities for integration and coordination in the health care delivery system. Major Goals

Damiano 3 1. Medical 2. Preventive 3. Dental 4. Mental health 5. Pharmacy Emphasis on primary care

Damiano 4 ACA creates changes and opportunities for safety net providers-currently uncertain environment Increasing public and private coverage Funds for FQHCs Establishment of ACOs Funds for HIT, HIE, EHRs and meaningful use Funds for prevention Medical home development Background

Damiano 5 Why Iowa: 1. Iowa Safety Net Network was established – Legislatively mandated organization that already brought all safety net providers together into a loose confederation – Made communication and collaboration much easier 2. IowaCare program for low income, uninsured adults – Adults up to 200% FPL – Provides experience with population that will be Medicaid eligible in 2014 Background

Damiano 6 Determine the current funding, expenditures, and infrastructure of the health care safety net at the state level, using Iowa as an example. Evaluate the potential implications of PPACA on funding, expenditures and infrastructure of safety net- related activities at the state level. Develop strategies for improving integration and coordination of safety net providers and organizations within the health care delivery system using Iowa as a model for change. Objectives

Damiano 7 Provides a state-level demonstration, informed by experts on a key delivery system question Identifies implications of ACA on financing and operations of safety net providers Focuses attention on an issue often overlooked Develop recommendations for improving coordination and integration. Contributes to the knowledge of policymakers, providers and the public Contributions

Damiano 8 1. Holding weekly steering committee meetings 2. Identifying background information: funding levels, funding sources, characteristics and locations of safety net providers in Iowa. 3. Updated organizational structure at state level to reflect the Safety Net Network’s State Leadership group and State Advisory Group. 4. Added representatives from Wellmark BC/BS (Tom Newton), Iowa Health Systems (Sabra Rosener), and Iowa State Board of Health to state advisory group. 5. Identified the National Advisory Committee members. Progress to date

Damiano 9 6. Added Legislators to Advisory Group (Sen. Jack Hatch (D) and Rep. Linda Miller (R)), and four consumer members 7. Held our first two State Leadership Group meetings 8. Collecting comments from all parties regarding the positive and negative impacts of the ACA for their groups and opportunities for coordination with the private sector 9. Held first State Advisory Group meeting 10. Created a Basecamp, project management site where all participants will be able to obtain all background reports, project timelines etc. 11. Holding first National Advisory Committee meeting Progress to date

Damiano 10 Primary Care Safety Net Providers in Iowa 1. Federally Qualified Health Centers (FQHCs) 2. Rural Health Clinics (RHCs) 3. Free Clinics 4. Family Planning Clinics 5. Mental Health/Substance Abuse Treatment Centers Background being collected-Providers

Damiano 11 Payers of Primary Care Safety Net Services in Iowa 1. Medicare 2. Medicaid 3. Children’s Health Insurance Program (CHIP) 4. Title V 5. Ryan White Background being collected-Payers

Damiano 12 Basecamp

Damiano 13 ProviderConcernsBenefitsOpportunities RHCManpower shortage Changes necessary to take advantage Smaller clinics not prepared to take advantage Reimbursed for services Access to specialty care Depends on RHC inclusion Work with local boards RHC affiliate with private providers HHDisincentive created – “cherry-picking” Cost to upgrade to e-charting Undocumented individuals Concern about staff shortages Transformation grant Streamlined access Access to affordable insurance easier – reducing safety net need Patient information e- exchange Partnerships Public Health Certain groups and industries attempting to carve out their piece to remain viable as ACA develops Remove fragmentation and streamlining will help make better use of public $$ Benefits of partnerships between private providers and state/federal public health programs FQHCsCongress won’t support ACAFewer uninsured More resources Integration and coordination with private providers Community Health Unfamiliarity in navigating system (patients) Worker shortage (provider) Funding stream uncertainty (primary care) Disjointed funding stream (Care system) Iowa as a leader Health improvements with basic primary care Reimbursement for group previously uncovered Developing capacity Managing chronic illness improvements Greater patient empowerment Provider Concerns, Benefits and Opportunities regarding ACA in Iowa

Damiano Ability to integrate with ACOs 2. Ability to be part of products offered by health benefits exchanges 3. Impact on workforce shortages in primary care, behavioral health, etc. --more challenging for safety net providers to address 4. Patient-centered medical homes/community utilities/enabling services needed to help patients be successful. 5. Impact on social determinants of health for patients 6. Implications of barriers such a stigmas with government-funded program expansion Additional Safety Net Questions

Damiano 15 Questions?