Medicaid Advisory Committee September 27, 2017 9:00-12:00 Oregon - - PowerPoint PPT Presentation

Medicaid Advisory Committee

September 27, 2017 9:00-12:00 Oregon State Library Salem, Oregon

Welcome & Introductions

Meeting objectives

• Regular business (e.g. approve minutes)
• Approve committee work plan for social determinants of health in

Oregon’s CCOs

• Receive agency Medicaid update
• Understand State Plan Amendments (SPA) and receive update on

upcoming/in progress SPAs

• Understand the role of OHA’s Office of Equity & Inclusion (OEI) and OEI’s

perspective on social determinants of health

• Agree on a shared definition of social determinants of health for Oregon

CCOs

• Receive update on the Oregon Health Policy Board’s Action Plan for

Health

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Webinar Housekeeping

• Join audio using

computer mic/speakers

• r telephone
• Public line is muted
• Send questions using

the “Questions” box in the control pane

• Q&A and public

comment near the end

• Meeting/webinar is

being recorded and will be posted online

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9:00

Welcome and Introductions Adopt minutes

Co Chairs 9:15

Social Determinants of Health (SDoH) in Oregon’s CCOs

• OHA SDoH initiatives
• Review and approve committee work plan

Amanda Peden, MAC staff

9:30

Agency Medicaid update David Simnitt/ Jeremy Vandehey/Anna Lansky

9:45

State Plan Amendments

• Background and Q&A
• SPA Dashboard

Jesse Anderson

10:00

Office of Equity & Inclusion (OEI) overview and social determinants of health Leann Johnson

10:30

Break

10:40

Defining social determinants of health of Oregon CCOs Committee

11:25

Public Comment All

11:10

Oregon Health Policy Board update – Action Plan for Health Steph Jarem

11:55

Closing Co-Chairs Agenda

Social Determinants of Health Work Plan

MAC SDoH Work Plan: Needed action steps

• Approve SDoH work plan
• Approve extended November meeting for additional

SDoH presentations

• Designate SDoH workgroup members (MAC member

subcommittee)—sign up during break

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• OPIP/Pediatric Health Complexity –

integrate social complexity score for SDOH

• Health Information Exchange SDOH

integration (future efforts)

• Environmental public health tracking
• Health Impact Modeling (e.g. reduction
• f greenhouse gas emissions based on

transportation plan scenarios)

• Statewide Supportive Housing

Strategy Workgroup

• Opioid STR Grant – housing services
• Health in All Policies
• Health Impact Assessments
• Healthy Redevelopment Initiative/

Brownfield Initiative

• Climate and Health Resilience State

Plan

• Public Health Division, Maternal &

Child Health - various SDOH efforts

• Health Equity Subcommittee of

Oregon Health Policy Board

• Regional Health Equity Coalitions

(RHECs) support & Technical Assistance

• Traditional Health Worker (THW)

Commission

• HIV Care & Treatment Program

(services related to SDOH)

• DHS Long Term Services & Supports K

Plan (Home & Community Based Services

Population Health Health System Transformation Equity

• Health-related services rules

and guidance

• OHPB CCO 2.0

recommendations & implementation

• Transformation Center TA
• Learning collaboratives, equity

consultations, early learning

• FQHC Alternative Payment &

Care Model (APCM)

• MAC Framework

OHA’s Social Determinants of Health Initiatives

Data and technology

OHA staff workgroups on SDOH, equity, and trauma-informed care

Black – general/all SDOH Purple – Housing Green – Built environment/ environmental Orange – Child health/early learning

Social Determinants of Health – MAC committee role

• MAC is the main state advisory body for the Medicaid

program

• Recommend framework and guidance for leveraging aspects
• f Medicaid to address SDoH through CCOs
• Support CCO efforts to continue and expand social

determinants of health work and establish coordinated and strategic initiatives 9

Framework for addressing Social Determinants of Health in Oregon CCOs

 Shared definition of social determinants of health  Role of CCOs in addressing SDoH: recommend the role and key strategies CCOs should continue to use or should adopt to address SDoH in their communities

Recommendations for using Health-related Services to address SDoH

 Create guide(s) for CCOs to address social determinants of health using health-related services. Phase 1 June – Dec 2017 Phase 2 Jan – Apr 2018

Products

Health-related services and social determinants of health guide(s) Framework for social determinants of Health in Oregon (committee memo)

MAC SDoH Scope of Work

Proposed committee work plan

Date (2017/2018 Task Description Deliverable

May – July 2017 (Staff) Develop work plan, introductory presentations on SDoH (OPCA) and Health-related services (HRS) Draft work plan Sept 27 In-person Approve work plan; designate MAC SDoH workgroup agree on definition of SDoH for CCOs Final work plan, definition, WG Oct/Nov (Staff & WG) Develop & field stakeholder survey Stakeholder survey Nov 3 In-person – 3.5 hours (extended) Presentations & discussion – role of CCOs in addressing SDOH Dec 6 In Person Review survey results & select priority areas for health- related services guide(s); Review & discuss draft framework for SDoH in CCOs 1-2 priority areas for HRS guide(s) Jan 24 Webinar Presentations on measuring impact of SDoH on health in priority areas Feb-April (Staff & WG) Develop HRS guides (compile evidence on and key strategies to address priority areas); consult CCOs on MAC draft framework Framework on SDoH for CCOs (memo) March 28 In-person Identify example interventions for HRS guide(s) in priority area(s) April 25 In-person Approve final SDoH framework and HRS guides Final framework, guides and memo

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Agency Medicaid Update

Jeremy Vandehey, Interim Director of Health Policy & Analytics, OHA David Simnitt, OHA Medicaid Director Anna Lansky, Deputy Director of ODDS, DHS

Agency Medicaid Update: OHA

• Welcome to Jeremy Vandehey and update on OHA leadership
• Eligibility update: OHA has completed Medicaid eligibility

renewals for all members whose renewals were put on hold following the Cover Oregon failure

• Federal policy update:

– Congress has until Sept 30 to reauthorize funding for CHIP before it expires; use current budget reconciliation resolution for ACA – CHIP Reauthorization – Sens. Wyden & Hatch reached agreement for 5-year reauthorization, no further action in senate or house is scheduled – ACA-related reforms – Graham-Cassidy bill vote pulled, but could resurface after other priorities (i.e. tax reform)

• MAC Guiding Principles for Oregon Medicaid shared with OHPB &

Oregon legislature by OHPB board chair

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Agency Medicaid Update: DHS

Oregon’s State Plan

Jesse Anderson, State Plan Manager, OHA

Medicaid State Plan

• Every state that participates in a Medicaid or a CHIP program

must file a document called the State Plan.

– It is essentially our contract with the Centers for Medicare and Medicaid Services (CMS) that allows us to draw down federal match for the programs.

• All State Medicaid agency’s must comply with some basic

requirements:

– Serve certain mandatory populations. – Provide certain mandatory services. – Provide services that are “sufficient in amount, duration, and scope and provided statewide.

What initiates a State Plan Amendment (SPA)

• There are various reasons an amendment would be filed. These

include:

– A change in federal law – Change in state law – Legislative discussions, budget notes, budget reductions – Reimbursement changes

SPA timelines

• Once a state plan amendment is submitted, CMS has 90 days to

review and approve or deny the SPA.

• If during the initial 90 day period, CMS needs more time to

review, they will issue a Request for Additional Information (RAI).

– This will start a new 90 day period in which the state can respond to the questions. – Once the state has responded, CMS begins a new 90 days in which to review and approve or deny the SPA.

SPA notice requirements

• Tribal consultation- 30 days prior to submission of a state plan.

– CMS allows an expedited review when necessary.

• Public notice- required if changes to reimbursement or

reimbursement methodologies, a public notice is required prior to the SPA’s effective date.

– Public notice must describe the proposed change; estimate the increase or decrease in expenditures; give contact person, address for written comments to be received. – Comments received during the comment period are reviewed and acted upon if warranted.

Difference between Waiver and State Plan

• The State Plan adheres strictly to the federal Medicaid requirements as
• utlined in the Code of Federal Regulations (CFR).
• Waivers are time limited, the state plan is not.
• Waivers specify ways that the state Medicaid program will operate

differently from what is outlined in the CFR. – OHP operates under the 1115 Demonstration Waiver, however there are several other types of waivers (1915(b)(4), 1915(c),(i),(j)).

Reasons for waivers

• States typically seek waivers to:

– Provide different kinds of services – Provide Medicaid services to new groups – Target certain services to certain groups – Test new service delivery and management models

• Demonstrations are not unlimited in their latitude. Not all

provisions of federal statute and regulation can be waived by CMS, and by definition, a waiver cannot last forever.

• Demonstrations must also meet budget neutrality standards and

they must meet a purpose consistent with Medicaid goals.

OHP demonstration waiver

• Since 1994, the Oregon Health Plan (OHP) has operated under

the 1115 Demonstration waiver.

• Examples of how the waiver operates differently from CFR

include:

– Prior to the ACA expansion Oregon expanded Medicaid coverage to populations that would not otherwise be eligible for Medicaid (e.g., OHP Standard); – Prioritized List of Services:

• CFR does not allow states to deny services based upon diagnosis;
• Federally mandated EPSDT services that are “below the line” on the Prioritized

List are not covered by OHP.

– Ability to restrict populations to mandatory enrollment in managed care; – Differences in how Oregon processes eligibility (e.g., Fast Track).

State Plan Status Report

Advancing Equity & Inclusion at the State Level

The Social Determinants of Health (SDoH)

Leann Johnson, MS, Director of OHA Equity & Inclusion

• Vision: All people, communities

and cultures co-creating and enjoying a healthy Oregon.

• Mission: To engage and align

diverse community voices and the Oregon Health Authority to ensure the elimination of avoidable health gaps and promote optimal health in Oregon.

• “Research over the last several decades has

shown that race- and ethnicity-based health disparities are a result of persistent social and economic inequities, which have a greater influence on health outcomes than either individual choices or health care system interventions.”

(Bliss et al, Public Health Management and Practice, 2016)

Health Inequities

Percent of Population Change: 2000 – 2010 White alone 83.6% (n=3,899,353) 8.2% increase Black or African American alone 1.8% (n=70,188) 24.3% American Indian and Alaska Native alone 1.4% (n=54,591) 17.7% Asian alone 3.7% (n=144,276) 39.4% Native Hawaiian or other Pacific Islander alone 0.3% (n=11,698) 68.1% Some other race alone 5.3% (n=206,666) 41.3% Two or more races 3.8% (n=148,175) 38.2% Hispanic or Latino ethnicity 11.7% (n=456,224) 63.5%

Oregon’s Population Change 2000 - 2010

Oregon Language Data

Hispanic

• r

Latino (of any race) Black/AA alone, not Hispanic

• r Latino

AIAN alone, not Hispanic

• r Latino

Asian alone, not Hispanic

• r Latino

Two or more races, not Hispanic

• r Latino

White alone, not Hispanic

• r Latino

Total Population 437,802 64,116 38,714 136,424 110,607 2,999,166 Population 5 years and

• lder

383,111 59,574 36,357 128,561 96,134 2,848,792 English Only 29.3% 88.4% 92.4% 26.5% 91.5% 95.5% Language Other than English 70.7% 11.6% 7.6% 73.5% 8.5% 4.5% Speak English “less than very well” 36.6% 3.7% 0.4% 35.2% 1.2% 1.1%

Source: U.S. Census Bureau, 2008-2010 American Community Survey 3-Year Summary File: Selected Populations.

• Significant and persistent disparities in health
• utcomes are caused by structural inequities in:

– Employment opportunities – Law and justice systems – Education – Housing – Neighborhood environment – Transportation, etc.

(Bliss et al, Public Health Management and Practice, 2016)

Social Determinants of Health (SDoH)

• It is imperative to engage the populations of

people and members of the community who are most impacted by health inequities and sidelined by health disparities

• OEI works to create a forum where

community input and community voices intersect with program and policy

Community Engagement

• Process: community driven/population based
• Outcome

– Affordable and safe housing and neighborhoods – Employment opportunities – Education opportunities – Access to healthy food – Engagement with government and health entities – Transportation

SDoH Priorities in Oregon Modified Policy Delphi (2014)

Wealth Inequity

White American Indian/ Alaskan Native African American Hispanic Poverty Rate 15.7% 33.6% 40.7% 30.1% Per Capita Income Last 12 Months $27,428 $16,549 $16,361 $13,609

Income Inequities in Oregon

Source: 2012 American Community Survey (1-Yr. Estimates)

Educational Attainment Inequities

Oregon NCES Statewide High School Graduation Rates & Dropout Rates

Demographic Characteristic Graduation Rate Difference Dropout Rate Difference All students 73.18% 3.98% White 75.21% +2.03% 3.54%

• 0.44%

Native American/Alaskan Native 55.73%

• 17.45%

7.97% +3.99% African American/Black 59.37%

• 13.81%

6.23% +2.25% Hispanic 67.00%

• 6.18%

5.18% +1.2% Limited English Proficient 58.93%

• 14.25%

6.70% 2.72%

• People of color suffer worse health outcomes than

white people (Boston Public Health Commission, 2015)

• People with Limited English Proficiency (LEP) do not

have full language access as it relates to their health and services

• People with disabilities are the most

underrepresented group, along with people from the Latino populations, in Oregon Health Authority employment (ACS data, OHA parity report 2016/Q4)

Disparities: Who is left behind

• Between 2013 and 2014 the only race and

ethnicity reporting feeling healthier (children and adults) were white OHP members

• Between 2013 and 2014 Latino OHP members

were the only group reporting feeling less healthy (children and adults)

(OHA Health Status CAHPS Report, 2014)

Disparities: Who is left behind

• Oregon’s uninsured are disproportionately people of

color, LGBT and low wage workers

• Undocumented children have difficulty getting the

care they need

• People who identify as transgender are less likely to

have health coverage than the general population

(Mend the Gap, Oregon Health Equity Alliance 2015)

Disparities: Who is left behind

• Black/African American 97.8%
• White only 95.9%
• Asian/Pacific Islander 95.3%
• Statewide 94.7%
• Two or more races 94.6%
• Other race only 91.1%
• American Indian/Alaska Native 90.9%
• Hispanic/Latino (any race) 88.9%

(Oregon Health Insurance Survey, OHA, 2015)

Disparities: Health Insurance Coverage

• Social Inclusion/Social Exclusion
• Structural Determinants of Health?
• Social Determinants of Health Equity?

Additional Context

• The state of Oregon “has made strides in

closing the gap in access and quality care adopting nationally recognized standards for data collection, cultural competency, and advancing innovative community based health worker models. Oregon must see through the long-term implementation of these measures…” (Facing Race: The 2015 Oregon Racial Equity

Legislative Report, community-based assessment)

Health Equity

• Develop and Implement Policy

– ADA, EEO/AA, Title VI, Non-Discrimination for OHA and the Public – Race, Ethnicity, Language and Disability Data Collection Policy (REALD) – Language Access – Recruitment and Retention of a diverse workforce – Cultural Competence Continuing Education – Culturally and Linguistically Appropriate Services (CLAS) standards

• Support and Develop Diverse and Culturally Competent Staff

– Developing Equity Leadership Through Training and Action (DELTA) – Implementation of Workforce and Contractor Diversity policies – Developed and manage Health Equity Workforce (i.e. Traditional Health Workers, Health Care Interpreters) – Training and Consultation in OHA and throughout the state

• Engage the Community/Reduce Health Disparities Through Funding

and Capacity-Building

– Regional Health Equity Coalitions (Six throughout the state) – Health Equity Policy Committee, etc. – Effective clinical models

How OEI helps advance health equity

• Traditional Health Worker Commission
• Health Care Interpreter Council
• DELTA Advisory Committee
• Regional Health Equity Coalitions
• Cultural Competence Continuing Education
• Community Advisory Council
• Health Equity Committee (Oregon Health

Policy Board)

Community Engagement

Office of Equity and Inclusion, A Division of the Oregon Health Authority Leann Johnson, 971-673-1285 Leann.r.Johnson@state.or.us Thank you!

Discussion

Defining Social Determinants of Health for Oregon’s CCOs

Social Determinants of Health – Definition Activity

Step 1: Adopt basic definition of social determinants of health drawing from existing definitions Step 2: Consider definition of social determinants of equity and application to committee definition Step 3: Develop list of social determinants of health factors 46

Step 1: Basic definition

• 1. Select definition of social determinants of health from

existing definitions.

• 2. Recommend any tweaks to apply definition to a CCO context.

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Option A: World Health Organization The social determinants of health are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping conditions of daily life. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries. Option B: Healthy People 2020 Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Conditions (e.g., social, economic, and physical) in these various environments and settings (e.g., school, church, workplace, and neighborhood) have been referred to as “place.” In addition to the more material attributes of “place,” the patterns of social engagement and sense of security and well-being are also affected by where people live. Option C: CDC, Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health Social determinants of health are life-enhancing resources, such as food supply, housing, economic and social relationships, transportation, education, and health care, whose distribution across populations effectively determines length and quality

• f life.

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A B C

Step 2: Social Determinants of Equity

Social determinants of equity are the structures, policies, practices, norms, and values that create societal structures and systems of power that fairly distribute life-enhancing resources. The social determinants of equity include racial and social justice and shared power. – Dr. Camara Jones, former President of the American Public Health Association Play video, starting 12min 45 sec – 19 min 25 sec (7 minutes) 49

Step 2: Question

Should the concepts of “social determinants of health disparities” and “social determinants of equity” be incorporated into the MAC’s definition? If so, how?

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Neighborhood and Build Environment Health and Health Care Social and Community Context Education Economic Stability

• Access to Foods that

support healthy eating patterns

• Quality of Housing
• Crime and Violence
• Environmental

Conditions

SOCIAL DETERMINANTS OF HEALTH (SDOH)

• Access to Health Care
• Access to Primary

Care

• Health Literacy
• Social Cohesion
• Civic Participation
• Discrimination
• Incarceration
• High School Graduation
• Enrollment in Higher

Education

• Language and Literacy
• Early childhood education

and development

• Poverty
• Employment
• Food Insecurity
• Housing Instability

Step 3: Social Determinants of Health Factors

Adapted from Healthy People 2020: https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

Step 3: Instructions

• On your own, brainstorm as many social determinants of

health as you can think of

• Consider social determinants of health factors on flip chart

pages

• Discuss and add social determinants that are not captured on

the pages 52

Public Comment

OHPB Action Plan for Health 2017-2019 “Refresh”

Steph Jarem, Policy Analyst, OHA

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History of the Action Plan for Health

• Created in 2009-2010, with input from hundreds of

stakeholders

• Served as the comprehensive health reform plan for Oregon
• Guided by Oregon’s Triple Aim:

– Better health – Better care – Lower costs

• Established a strong vision

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High-level Plan for Refresh

• After 5 years of health system transformation, Oregon is

moving beyond initial implementation phase

• Need to establish a roadmap for continued innovation,

building upon best practices, evidence, data, and stakeholders’ experience

• Build upon and update original Action Plan for Health

framework

Framework of Action Plan

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Key Actions

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• The true “work” of the Action Plan
• Work has been prioritized at OHA
• List is dynamic and still in draft form

Focus Area 2.4 - Social determinants of health (SDOH) 2.4a Statewide supportive/supported housing strategy 2.4b Health-related Services (HRS) guidance and TA 2.4c OPIP/Pediatric Health Complexity 2.4d Provide sustainable and long-term financial resources to RHECs to address social determinants of health in their region 2.4e Identify a set of services/criteria for activities and services that may be funded through HRS

MAC

2.4f Transformation Quality Strategy - SDOH Transformation area (under consideration) 2.4g Develop framework for addressing the SDOH in the CCO Model

MAC

Next steps

• Development of a dashboard/report that includes:

– Action – Status of action: – Selected:

• Highlighted achievements
• Areas of concern
• Policy opportunities

In development Action Launched In progress Action halted Target Met X X X X

Questions?

Steph Jarem Stephanie.jarem@state.or.us

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