Policy and Advocacy - Testimony

           To:          The Honorable Vincent Gray, Chair, DC Council Committee on Health

                Members of the Committee on Health

From:    Patricia Quinn, Director of Policy and External Affairs, DC Primary Care Association

Re:         Budget Oversight for the DC Department of Health (DC Health)

Date:     April 9, 2018

 

The DC Primary Care Association (DCPCA) works to build a healthier DC by strengthening safety net primary care, improving care coordination across sites of care, and improving access to health information for better health outcomes. Our partners in this work include community health centers serving 1 in 4 District residents in every ward of the city, District government agencies including DC Health, and other providers in the DC health ecosystem. What follows are DCPCA’s recommendations regarding the fiscal year 2019 budget for DC Health.

 

Recommendation: Support funding that promotes patient navigation, cross-sector partnership, and prevention in the Cancer and Chronic Disease Bureau.

DCPCA currently partners with DC Health on a promising cancer screening navigation pilot. Direct funding for health system and social supports navigation and care coordination, paired with investments in timely, actionable health information exchange are the District’s best option for impacting persistent inequity in health outcomes for those already fighting cancer and chronic disease. DCPCA provides staffing support and data management to an unprecedented collaboration of seven District Federally Qualified Health Centers (FQHCs) in a clinically integrated network (CIN). The CIN is combining standardized, evidence-based high quality care management at the center level with centralized transitions of care, triage, and data analysis to improve care and reduce utilization of high-cost hospital services. We look forward to reporting on its progress and innovation in the months ahead.

 

In addition, DCPCA supports investment in efforts such as DC PACT, a coalition of clinical, community support, and government partners focused on reframing the culture of health care delivery to address social needs. Our near-term strategic goals include standardizing social needs screening citywide and leveraging the development of the District’s health information exchange capacity to include bi-directional communication between community supports and clinical care. In conjunction with DC Health’s Office of Health Equity, increased investment in addressing social drivers of health and support for cross-sector partnerships will impact both the prevention and the effective treatment of chronic disease.

 

Recommendation: Support increased funding for School Health, including resources for school nursing and implementation of a navigation component to better link school and community health.

 

The Mayor’s proposed budget funds the requirement for full-time nursing at all DC public and public charter schools. DCPCA also recommends a pilot family navigation module focused on leveraging resources within and without the schools to support better health and educational outcomes. Additionally, DCPCA recommends exploring opportunities to integrate school health data into the District’s growing health information exchange.

 

Recommendation: Support new funding to improve birth outcomes/decrease preterm birth, and continue investment in evidence-based home visiting.

 

DC Health just released The Perinatal Health and Infant Mortality Report, and the data point to persistent preterm birth challenges and significant disparities in initiation of prenatal care. Our preliminary review of the Perinatal report and of data included in the Medicaid Core Set data notes the following:

 

  • Close to HALF (49%) of black women and more than 1 in 3 (35%) Hispanic women are not getting into prenatal care until their 2nd or 3rd trimester or not receiving any care at all. (Perinatal report)[i]
  • Fewer than half of women in D.C. on Medicaid are receiving the recommended number of prenatal visits: According to Medicaid data from the Child Core Set, only 36% of women in D.C. on Medicaid and CHIP received at least 81 percent of the expected number of prenatal visits. (Medicaid Child Core set)[ii]
  • Fewer than half of women on Medicaid or CHIP had a postpartum visit in the recommended window after giving birth: According to Medicaid data from the Adult Core set, only 49% of women in D.C. on Medicaid, CHIP, or dual eligible had a postpartum care visit between 21 and 56 days after birth. (Medicaid Adult Core set)[iii]
  • The percentage of preterm births has not changed in the past ten years—clearly, new strategies are in order (Perinatal report.)[iv]

The closures of the obstetrics units at United Medical Center and Providence Hospital prompted DCPCA to initiate a “human-centered design” project to understand and address the reproductive health needs of women in the District, particularly low income women in Ward 7 and 8. Human-centered design is a three-phase approach to problem solving and “design thinking” commonly used in information technology and private sector product design; however, human-centered design is beginning to spread into social services.  DCPCA fellows have completed multiple in-depth interviews with women in communities impacted by the OB closures, and they are nearing completion of the rapid-cycling design phase. We look forward to presenting our findings to DC Health and to the Committee on Health in the near future.

 

DCPCA applauds DC Health’s report of data critical to understanding where we are failing to address and improve maternal-child health. We must partner with DC Health and with women and families in communities most impacted by persistent inequity to increase awareness of existing supports and services. But while the Department’s view that prenatal services in Wards 7 and 8 are underutilized may be accurate, we also understand from our providers in the District’s east end that consistently connecting their high risk patients to appropriate care is challenging. Given that almost 1 in 3 preterm births in the District were to women with a previous preterm birth, we can and must do better to link women to early, excellent prenatal care.

DCPCA supports the establishment of a perinatal and infant health advisory committee, and we endorse implementation of a demonstration project to increase the use of 17 alpha-hydroxyprogesterone caproate (17P) to prevent preterm births.

 

Recommendation: Support appropriation for the Health Professional Loan Repayment Program (HPLRP).

 

The HPLRP is an important tool to support recruitment and retention of primary care, behavioral health, and oral health professionals in the context of safety net health care. DCPCA has just released a survey to our Ward 7 and 8 health centers to understand the physical capacity of the existing health centers, as well as what new staff centers would need to hire in order to realize that capacity. We look forward to sharing the results of the survey with the Mayor’s team engaged in planning for the new hospital, as well as the Committee on Health.

Recommendation: Include funding to implement the legislation that increases the smoking age to 21, and implement the $2 increase of the tobacco tax.

 

The previously mentioned DC Health Perinatal Health and Infant Mortality Report highlighted a finding that District women who smoke are significantly more likely to experience poor birth outcomes such as prematurity, low birth weight and infant mortality. This is only one reason why increasing the legal age for tobacco to 21 is an important public health effort. The additional tax revenue from tobacco sales is targeted in part to smoking cessation, further decreasing deleterious impacts of smoking on district residents.

 

Recommendation: Continue funding for innovation and diffusion of care grants.

 

DC Health plays a critical role in the ability of DC’s health system to respond to emerging or growing challenges, such as the crisis in opioid use disorders in the District, or the testing of behavioral health integration in the FQHC setting. DC Health funding for testing innovation and expanding access to effective interventions provides the necessary scaffolding to initiate new and needed services. Continued investment in this manner ensures that the District can be in the vanguard on emerging public health threats.

 

DCPCA appreciates the opportunity to share our recommendations on the FY19 DC Health budget. We are grateful for partnership with DC Health, Chairman Gray, and the Committee on Health as we work to build a healthier DC.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[i] https://dchealth.dc.gov/sites/default/files/dc/sites/doh/service_content/attachments/DC%20Health%20Perinatal%20Health%20%26%20Infant%20Mortality%20Report_FINAL.PDF

 

[ii] https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/adult-core-set/index.html  https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/child-core-set/index.html 

 

[iii] https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/adult-core-set/index.html  https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/child-core-set/index.html 

[iv] https://dchealth.dc.gov/sites/default/files/dc/sites/doh/service_content/attachments/DC%20Health%20Perinatal%20Health%20%26%20Infant%20Mortality%20Report_FINAL.PDF

To:       The Honorable Vincent Gray, Chair, DC Council Committee on Health

            Members of the Committee on Health

From:   Patricia Quinn, Director of Policy and External Affairs, DC Primary Care Association

Re:       Performance and Oversight, Deputy Mayor of Health and Human Services

Date:   March 5, 2018

 

The DC Primary Care Association works to build a healthier DC by strengthening safety net primary care, improving care coordination across sites of care, and improving access to health information for better health outcomes. Our partners in this work are community health centers serving 1 in 4 District residents in every ward of the city. What follows is DCPCA’s recommendation regarding performance and oversight of the Deputy Mayor for Health and Human Services.

 

DCPCA serves as the “backbone” support organization in DC PACT, a coalition of clinical, community support, and government partners focused on reframing the culture of health care delivery to address social needs. Our near-term strategic goals include standardizing social needs screening citywide and leveraging the development of the District’s health information exchange capacity to include bi-directional communication between community supports and clinical care. 

 

As DC PACT works toward our goals, we look forward to deep collaboration with the Deputy Mayor, who is uniquely situated to drive collaboration and integration of District agencies and programs focused on social drivers of health and on clinical care. In particular, we look for her support to ensure that health system behavioral health data is included in the rapidly growing District HIE. We seek her partnership to steer technology investments across departments to maximize interoperability and minimize duplication.

 

DC PACT’s vision for a seamless accountable health community that addresses unmet social needs to improve health and increase equity requires a radical rethinking of what “counts” as health care. Make no mistake; the work for affordable housing, healthy food, and income security is life-saving work, equal to heart surgery, cancer care, or HIV prevention.

 

The barriers to health equity in the District of Columbia require nothing short of our relentless commitment to every resident’s optimal health. The combined resources of the District’s government, non-profit, and business sectors must align for healthy housing, nutritious food, economic opportunity, and world class health care. We can make DC as known for positive health and wellbeing as we are for health coverage, but it requires fierce commitment to a common agenda, shared measures, and cross-sector accountability. DC PACT welcomes the opportunity to work in partnership with the Deputy Mayor to build a Collective Impact initiative to realize that vision.

 

Council of the District of Columbia

Hearing on

The Oversight and Performance of the DC Department of Health Care Finance

February 23, 2018

Committee on Health

The Honorable Vincent Gray, Chairman

By

Patricia Quinn

Director of Policy and External Affairs

District of Columbia Primary Care Association

 

Good morning Chairman Gray and distinguished members of the Committee. My name is Patricia Quinn, Director of Policy and External Affairs for the DC Primary Care Association (DCPCA). DCPCA works toward a health system that helps everyone in the District get and stay well, no matter the color of their skin, the language they speak, where they live, how much money they have, or who they love.  Our partners in this work are community health centers who serve nearly 1 in 4 District residents in every ward. I am here today to offer testimony on the performance and oversight of the DC Department of Health Care Finance.

 

DCPCA applauds DHCF’s commitment to health information exchange, as well as its focus on behavioral health integration, including increased access to substance use disorder treatment. We appreciate the Department’s partnership in a solutions-focused dialogue regarding FQHC payment, and we are encouraged by DHCF’s engagement in DC PACT, a multi-sector coalition of clinical care providers, community support organizations, and government partners focused on building a health system that identifies and addresses social drivers of health. In addition, we support DHCF investment in care management, and look forward to working closely with the Department as we build the FQHC Clinically Integrated Network, a new joint venture that represents an unprecedented collaboration on transitions of care and care management among seven of the District’s FQHCs. That said, we must highlight significant challenges in the FQHC billing system that result in excessive administrative burden for health centers and that divert resources away from critical efforts to improve patient health. We also urge a move to yearly recertification for Alliance beneficiaries and expansion of telehealth.

Health Information Exchange

DCPCA partners with DC Department of Health Care Finance to build provider capacity to utilize the full array of available HIE and HIT tools implemented by DHCF in the past year. Those tools include:

  • Dynamic Patient Care Snapshot: An ‘on-demand’ web based document, accessible by providers and members of their care teams, that provides an aggregated display of both clinical and non-clinical data for a selected patient, including demographic information, patient care relationships and clinical encounters.
  • Analytical Patient Population Dashboard:  A population-level dashboard that facilitates patient panel management.
  • Electronic Clinical Quality Measurement Tool and Dashboard: An electronic clinical quality measurement (eCQM) tool that aggregates and analyzes data captured through Continuity of Care Documents (CCDs) submitted to the HIE to assess provider performance against quality metrics standards for their empaneled patient population.
  • Obstetrics/Prenatal Specialized Registry: An electronic form that enables District providers to collect data associated with prenatal screenings and assessments for submission to the District’s OB/Prenatal Specialized Registry.
  • Ambulatory Connectivity and Support: Engage with District providers to support their connection to the DC HIE, including delivery of technical assistance aimed at the advanced use of HIE services.

DHCF’s aim in developing these tools is to provide technology solutions that will bolster clinical care, improve health-related service utilization throughout the continuum of care, and increase the exchange and integration of data associated with population health and social determinants of wellbeing.

In 2017, DCPCA expanded its relationship with DHCF through a multi-year contract award to deliver HIE-HIT technical assistance and outreach services to providers eligible for participation in the District’s Medicaid EHR Incentive Program (MEIP).  Under this contractual relationship, we have worked with health centers and small ambulatory practices throughout the District to enroll their eligible providers in MEIP so that they are able to fully benefit from DHCF’s HIE - HIT program investments.  As DHCF’s partner, DCPCA is able to offer on-going Meaningful Use technical assistance and attestation services to health center providers at no cost.  We are also able to offer technical support that is focused on helping health center staff effectively use the expanded HIE tools listed above that were launched at the end of 2017. 

As challenging as building a Health Information Exchange from disparate parts is, DHCF leadership in this endeavor is exemplary. The Department has successfully engaged partner capacity across the District to effectively coordinate an HIT/HIE approach to meet the needs of providers and patients for coordinated, effective information exchange. DHCF thinks creatively and innovatively, regularly seeking input and feedback at the implementation level to give the emerging District HIE the best chance to reach its potential to improve health outcomes.

Recommendation:

  1. DHCF should grow the District’s HIE capacity, increasing interoperability and continuing to balance innovation with investment in utilization training and analysis. Improved health outcomes and cost containment depend on this HIE capacity.
  2. DCPCA welcomes the opportunity to return to this committee in the coming months to share progress on the impact of new investments in HIE tools.

Behavioral Health Integration

DCPCA recognizes DHCF’s commitment to integrated and coordinated behavioral health in order to address the crushing inequity in health outcomes in the District. DHCF has kept the focus on behavioral health across multiple departmental initiatives, and has leveraged opportunities to partner cross-departmentally to meet behavioral health needs. Importantly, the FQHC Medicaid rule that allows for same-day payment of medical, behavioral, and dental visits became final in September 2017. DCPCA and our FQHC partners have identified some additional payment policy barriers related to behavioral health CPT billing codes and drafted a request and rationale to the District’s Medicaid agency that is currently under consideration.

SUD treatment requires some additional strategic thinking and planning. The aforementioned FQHC rule increased the list of billable behavioral health providers to include certified addictions counselors, among other additions. DHCF and DBH have agreed that FQHCs can bill DHCF directly for substance abuse treatment. This means that FQHCs that want to support patients with SUD treatment can do so without having to engage in an entirely separate billing and reporting system.  Still, FQHCs must be certified by DBH as substance abuse providers, and it is not clear how much of a barrier this may be. And health centers have yet to bill SUD for patients in the new system, particularly for those who are part of Medicaid Managed Care Organizations, so the implementation of the new policy has yet to be tested.

In addition, as health centers increase the number of primary care providers who are trained to treat SUD with Medication Assisted Treatment, we need to ensure that they can help their patients in need of immediate counseling support and connect patients to ongoing counseling, peer connection, and family education/intervention as necessary. DCPCA hopes to complete an analysis of SUD treatment capacity within FQHCs this year.

Recommendation: DHCF should maximize delivery of behavioral health services within FQHCs by all means at their disposal including:

  1. Approve use of behavioral health CPT billing codes recommended by DCPCA and our Behavioral Health Peer Group
  2. Seek to reduce any barriers to SUD treatment in the FQHC setting as they may emerge through implementation of certification and billing
  3. Expand behavioral telehealth opportunities that allow for flexibility in terms of patient and provider location
  4. Push for of the ability to access behavioral health data through the District’s HIE

FQHC Billing and Payment

             The recently approved FQHC payment rule precipitated a need to revamp DHCF’s FQHC billing process.  Beginning in the summer of 2016, the Department of Health Care Finance (DHCF,) the District of Columbia Primary Care Association (DCPCA,) the District’s Federally Qualified Health Centers (FQHCs,) and the Medicaid managed care organizations have worked in partnership to establish a payment system that would facilitate differential rates for medical, behavioral, and dental services, payment for same-day services, and timely and accurate wrap payments. We are most grateful for the Department’s spirit of collaboration and resolute problem-solving throughout the process.

                                                             

Implementation of the new system required significant, accurate, and timely re-configuration of health center billing, Medicaid MCO payment systems, and the DHCF wrap payment system. Without question, all parties substantially underestimated the scope of the necessary changes. Although all parties acted in good faith, we cannot avoid the hard truth of insufficient advance preparation, insufficient testing of the system prior to implementation, and insufficient contingency planning when problems inevitably arose.

At the heart of the new payment system is the institution of new NPI numbers and Taxonomy codes.  In particular, the new system requires each FQHC site to have a separate NPI, versus the old system which allowed health centers to bill MCOs and DHCF under a single organizational NPI. Another major change in the new system is that DHCF instituted a policy to pay wrap only on claims which could be matched to a specific MCO paid claim. FQHC finance offices have spent massive staff time to run down MCO payments, and then must also devote major resources to get wrap payments on those same claims—the perfect storm for a health center cash flow disaster.

Health centers and DHCF report light at the end of the tunnel. They see resolution of some of the most significant configuration and matching problems, and all remain hopeful that the system will cease to cause overwhelming administrative burdens to FQHCs.

Recommendations:  

  1. FQHCs should be compensated for the costs associated with that increased administrative burden. We had previously recommended a lifting of the payment rule’s administrative cap, and we are open to dialogue with DHCF on how recompense should be granted.
  2. DHCF, FQHCs, MCOs, and DCPCA may still need to consider whether a system that has such potential for double jeopardy for health centers for each and every MCO claim is sustainable or fair. If MCOs are reporting the claims and payments correctly to DHCF, we question the benefit to any party of having health centers file a secondary claim for the wrap, as opposed to paying it automatically based on MCO data. FQHCs would retain the option to appeal MCO denied claims to DHCF if necessary. DHCF has agreed to explore this option.
  3. As the work to mitigate challenges with the new FQHC billing system is ongoing and proceeding somewhat positively, DCPCA would welcome the opportunity to report further within the next two months to determine appropriate next steps.

Alliance Recertification

DCPCA believes that systemic issues that impact Alliance beneficiaries who must renew in person every 6 months result in loss of Alliance coverage for otherwise eligible residents. Even those who successfully complete the renewal process are likely to experience significant burden in terms of time and effort. Such churn regarding insurance coverage is associated with poor health outcomes, and may be part of the cause for increased cost per patient within the Alliance population.

Recommendation:  DHCF should allow yearly recertification for Alliance coverage. This change would benefit Alliance beneficiaries, as well as they many other beneficiaries of other District safety net programs. The current twice-yearly in-person recertification for Alliance beneficiaries impacts the functioning of Economic Services Administration, increasing wait times for all applicants for ESA programs.

My Health GPS

DCPCA supports DHCF’s investment in care management and care coordination, and its focus on value-based payment. Initiated in 2017, the MyHealth GPS program is an opportunity to identify what supports and interventions will best improve health outcomes and reduce utilization of high cost settings for Medicaid beneficiaries with multiple chronic conditions. It should also build knowledge about the most essential capacities and services in the provider community to achieve the best results. DCPCA and the FQHC Clinically Integrated Network welcome partnership with DHCF to engage further in value payment models. The seven DC FQHCs in the DCPCA Clinically Integrated Network (DCPCA-CIN) believe primary care should be at the center of health investment and improvement, and that their best chance to thrive as high quality safety net providers is together.

DCPCA has spent the better part of the last decade building the health information technology and analytics capacity that makes the CIN possible. That HIT, coupled with DCPCA and District investment in HIE will be leveraged to reach the following targets:

  1. Reduce LANE ER visits by 10% over 2 years
  2. Reduce hospital re-admissions by 25% over 2 years
  3. Reduce hospital admissions by 5% over 3 years

 

 

The primary interventions are:

  1. Expanded clinic access: 24/7 nurse triage, coordinated access to same day and next day appointments, and mass communications patient education campaign on primary care network services.
  2. Hospital-based transitions of care: Nurse-led transition of care program for priority group focused on discharge follow-up with PCP and specialists, transmission of discharge plan, home health coordination, and medication reconciliation.
  3. Standardized care management for complex health and social needs: Clinic-based teams that implement standardized assessment and care plan approach. This includes a Housing-to-Health pilot targeted to high utilizers with intervention-sensitive social determinants.

Recommendation:  DCPCA and the DCPCA CIN look forward to partnership with DHCF, particularly to address the needs of Medicaid Fee-for-Service patients, targeting those with evidence of poorly managed care. In addition, the CIN intends to engage with Medicaid MCO partners to achieve its stated goals.

TeleHealth

The District of Columbia Primary Care Association supports expansion of telehealth in the District because of its potential to:

• empower patients as key partners in their health care

• reduce disparities in access to care

• improve the timeliness and quality of care

In particular, we support asynchronous store and forward services and remote patient monitoring for their potential to provide care for patients when, where, and how they need it.

We also support payment for originating sites when telehealth services are facilitated directly from one provider location to another. Including a transaction fee for originating sites when appropriate could increase the use of telehealth to meet patient needs.

The DC Department of Health (DOH) notes in the 2017 Health Systems Plan (HSP)

“While gaps may exist in medical specialty care and possibly outpatient surgical services, the gaps are focused on low-income residents who are insured by Medicaid, the DC Healthcare Alliance, or are uninsured. Findings show that there are inequities in service distribution and barriers that prevent full engagement in appropriate care for some segments of DC’s population.”

The HSP identifies the need to increase availability of high-quality medical specialty services for low-income individuals and families. Telehealth can efficiently improve access and quality of care for underserved patients by providing consultations and specialty care.

Additionally, the HSP highlights that services in DC are often fragmented and uncoordinated, and that factors implicated include information flow, referral practices, barriers to access (including transportation, cost, and language/culture), and limited collaboration between providers. Telehealth is an important tool to address these systemic issues. This modality, in its many variants, should be leveraged to tackle persistent inequities that deepen along racial and socio-economic lines in the District.

Recommendations: DCPCA supports elimination of barriers to telehealth and promotion of flexible service models that increase patient access and engagement in care. We encourage expansion of telehealth to reduce health systems challenges, enhance patients’ experience of care, and improve health outcomes. We look forward to working with the Committee on Health, DHCF, DOH, and our FQHC members to build world-class telehealth services in the District of Columbia.

 

Social Determinants of Health

DCPCA supports the “health beyond health care” philosophy critical to impacting entrenched health inequity in the District. Providers across all systems of care acknowledge the need to align clinical and community supports to reach beyond the four walls of traditional clinical settings and focus on place-based care as close to home as possible. As with the need to resource provider capacity-building in HIT and care management, we must work together to identify resources and opportunities to align across multiple governmental and community entities to provide care.

Recommendations:

  1. DHCF should continue to work with DC PACT to standardize screening for social determinants of health.  
  2. DHCF should ensure that any HIE investments in community resource inventory be produced in an open, standard, interoperable format made publically accessible and adaptable by other resource inventories
  3. DHCF should consider investment in a bi-directional resource platform accessible to health and social support organizations with capacity for participating entities to communicate and track referrals   

In closing, DCPCA is focused on expanding capacity for all partners to function as a seamless accountable health community over time and across sites of care through increased cross-sector collaboration, clinical practice transformation, expanded HIT capacity and HIE connectivity, and responsive and supportive patient engagement.  In DHCF, we are fortunate and grateful to have a partner that shares that vision. We express our genuine appreciation to DHCF for the strong spirit of partnership and shared commitment to do our best for the people of the District who rely on all our work in order to get and stay well.