1. Providing Access to Healthy Solutions (PATHS): Reforming Law & Policy to Foster Equitable Responses to Diabetes Maggie Morgan Center for Health Law and Policy Innovation of Harvard Law School October 2013

2. Center for Health Law and Policy Innovation, Harvard Law School 1.Health Law and Policy Clinic Projects to reform federal and state policies to improve access to care for people living with chronic diseases 2. Food Law and Policy Clinic Projects to reform food and environmental policies at both the state and federal level

3. Providing Access to Healthy Solutions (PATHS) 1.Identify State-Specific Diabetes Law & Policy Successes and Challenges 2. Engage Diverse Stakeholders in PATHS Process & Support Coalition Development and Advocacy 3.Develop Set of Recommendations & Implementation Strategy 4. Engage Partners in Implementing Reforms and Best Practices 4-Year Project to Improve Type 2 Diabetes Care & Prevention Two Main Areas of Work 1.Health care access and delivery of care 2. Food, physical activity, and prevention

4. Ensuring all patients in all communities have access to comprehensive services, including: 1. All necessary clinical services, incl. behavioral health – Effective use of diverse types of providers – Solving provider shortages 2. Lifestyle management assistance – Ensuring proper diabetes self-management – Integrating food/physical activity programs into the healthcare system PATHS Goal 1: Reforming the Healthcare Access and Delivery System

5. 1.Lack of coordination among providers: Healthcare “silos” 2.Lack of integrated behavioral health services 3.Absence of quality and payment incentives: Rewarding “Quantity over Quality” 4.Inefficient use of different types of providers 5.Provider shortages (esp. in high-need areas) 6.Food delivery and other vital community services not reimbursed A Broken System: Current Healthcare Delivery

6. Whittier Street Health Center Comprehensive diabetes clinical care and self- management education Community outreach and engagement, including community health worker mobilization Duke University Use of technology to identify and intervene in high- risk communities and patients Community-based and patient-centered interventions to reduce health disparities Whittier St. and Duke: Models for Coordinated Care to Reduce Disparities

7. Duke trains a variety of health workers, including new types of workers such as CHWs and health information officers, to use innovative technology to coordinate care and improve education and outreach in high-need areas In addition to providing traditional clinical care, Whittier Street uses dieticians, social service workers, and community health workers/peer supporters to conduct patient outreach and education Care teams with a variety of health workers can address a wide spectrum of health, nutrition, and non-medical needs in innovative, community-specific ways Diverse Health and Community Providers

8. Whittier Street provides Diabetes Self- Management Training (DSMT) and physical activity programs to target high-risk communities in Boston Duke’s clinical teams make home visits to patients in need of high-intensity interventions Both focus heavily on combining clinical care with needed social and community supports and mobilization Expanding Access to Key Services

9. 1.High rates of uninsured hinder outreach to underserved and high-risk populations. 2.Proper integration of clinical and behavioral health is a persistent difficulty. 3.Lifestyle management services such as Diabetes Self Management Training (DSMT) and food delivery remain under-reimbursed (or not reimbursed at all). 4.Essential providers in coordinated care teams (such as CHWs, pharmacists, and social workers) lack sustainable sources of reimbursement. Need to reduce the uninsured population and find sustainable sources of financing beyond grants!!! However…Important Policy Gaps Remain

10. 1.Reduces the Number of Uninsured 2.Reforms Payment and Care Delivery Models 3. Emphasizes Diverse Care Teams 4.Addresses Provider Shortages How Can the ACA Help?

11. Improves Medicaid: Expands eligibility Provides essential health benefits (EHB) Improves reimbursement for primary care providers (from 2013- 14 only) Allows for free preventive services Expands Access to Private Insurance: Provides subsidies/tax credits up to 400% to purchase insurance Supports outreach, patient navigation and enrollment Mandates inclusion of community providers in new health networks 1.Reduces the Number of Uninsured

12. Medicaid Health Homes – A promising way to ensure whole person care while promoting cost savings for the most vulnerable population: the chronically ill Accountable Care Organizations – Could promote integration of care and increased preventive care through efforts to contain costs Integrating behavioral health and diabetes care – Many diabetes patients have comorbid behavioral health conditions that make it difficult to manage their disease 2. Reforms Payment and Care Delivery Models

13. A variety of ACA provisions focus on expanding care teams to include different types of health professionals. A few examples: 1.Coordinated care models such as health homes provide new reimbursement opportunities for providers who are not traditionally recognized as reimbursable providers. 2.New provider networks (e.g. ACOs) are increasingly being held to certain quality measures while attempting to reduce health care costs—can be an opportunity to integrate new providers (e.g. food as medicine providers). 3.The 2013-2014 increase in Medicaid primary care reimbursement rates includes NPs and PAs. 3. Emphasizes Diverse Care Teams

14. 1.Increases the primary care workforce by training more doctors, nurses, NPs and PAs. 2. Includes more graduate medical education training positions, particularly primary care and general surgery and increases funding for health scholarships and loans. 3.Expands funding for community health centers. However, provider shortages will still remain a problem, particularly in rural areas. Our PATHS research has identified several needed reforms, such as relaxing scope of practice laws and expanded use of telemedicine. 4. Addresses Provider Shortages

15. Food and Nutrition Economic Ability to Purchase Healthy Food Geographic Access to Healthy Food Nutrition Education Physical Activity Role of the Built Environment Promoting an Active Lifestyle PATHS Goal 2: Improving the Food and Physical Activity Landscape Improving the School Environment Comprehensive (Food & Physical Activity)

16. Food and Physical Activity Policy Recommendations Food Maximize program participation: – Example: School food, SNAP, WIC Raise standards – Example: Competitive foods Link food and healthcare – Example: Food as medicine Physical Activity Maximize use of current resources – Example: Joint use initiatives Zone for health – Example: Sidewalk requirement Raise physical activity requirements – Example: Recess and physical education

17. 1.We need to find ways to make the successes of Duke and Whittier Street scalable and sustainable. 2.These programs help to reduce inequality in diabetes outcomes by: – Targeting coordinated care efforts at populations with the highest need – Collecting data which can be used to develop diabetes quality measures to reduce disparities – Exploring and measuring how technology may be used to in high-risk areas to reduce disparities – Expanding care teams to address community-specific needs, including a move beyond traditional clinical care to focus on broader environmental and lifestyle challenges Summing Up….

18. For an electronic copy of this presentation and other information about PATHS, contact: mmorgan@law.harvard.edu mmorgan@law.harvard.edu This presentation was funded through a grant from the Bristol-Myers Squibb Foundation, with no editorial review or discretion