As part of The Commonwealth Fund’s mission to promote delivery system improvement and innovation, the Program on Vulnerable Populations supports efforts to ensure that low-income, uninsured, and racial and ethnic minority populations are able to obtain care from high-performing health systems with the capacity to meet their special needs. To achieve this mission, the program makes grants to:
Equity is a core goal of a high performance health care system. In the United States, however, vulnerable populations—low-income people, the uninsured, and disadvantaged racial and ethnic minorities—experience greater difficulty obtaining health care, receive worse care, and experience poorer health outcomes than other groups. They also are more likely to have special needs arising from their personal, social, and financial circumstances, any of which may negatively affect health and hamper efforts to obtain care. The health care systems where vulnerable populations seek treatment must be equipped to address these needs.
While the traditional safety-net health system is critical for providing care to vulnerable populations, many members of vulnerable groups do not rely on it as their main source of care. That’s why improvements in health care delivery must be made not only within the safety net but across the broader health system as well. All patients should have access to high-performing health care systems capable of providing care that is patient-centered, population-based, comprehensive, high-quality, accountable, and integrated across the continuum of health services.
Establishing a Policy Framework for Equity in Health Care
The Affordable Care Act provides a number of opportunities to improve the health of vulnerable Americans, primarily by expanding insurance coverage and bolstering the health care safety net. Much work remains to be done, however, to ensure that these opportunities are fully realized. In October 2011, The Commonwealth Fund Commission on a High Performance Health System issued a framework for achieving equity in health care and ensuring that vulnerable populations receive care from well-functioning health systems. The report puts forward three strategies: 1) ensure that health coverage provides adequate access to care and financial protection; 2) strengthen the care delivery systems serving vulnerable populations; and 3) coordinate medical care with other community-based services, including public health.
Promoting Sustainable Funding for Safety-Net Hospitals
With continuing weakness in the economy, the number of people relying on publicly funded health care has grown, while the revenue states have available to support that care has shrunk. Simply put, safety-net providers are being forced to do more with less. Public hospitals and other providers serving large numbers of low-income and uninsured patients play a central role in the health care delivery systems that treat vulnerable populations. Several provisions in the Affordable Care Act—including the expansion of Medicaid and the
reduction of disproportionate share hospital (DSH) payments, which help cover the costs of uncompensated care—will alter traditional revenue streams for safety-net hospitals. It will be critical to develop funding mechanisms that not only sustain the operations of safety-net facilities in a post-reform environment, but also promote delivery of high-performance health care.
Under the direction of Deborah Bachrach, J.D., Manatt Health Solutions analyzed current revenue streams of safety-net hospitals and how they are expected to change under health reform. The resulting report, issued by the Fund’s Commission on a High Performance Health System in March 2012, offers policy options that target existing funds so that hospitals serving the most vulnerable patients would continue to thrive once the Affordable Care Act is fully implemented.
Funded by a combination of patient care revenue, local and state taxes, and supplemental payments from DSH payment programs, public hospitals contend with wide fluctuations in their funding streams and near-constant financial uncertainty. Under the leadership of Harvard University’s Nancy Kane, D.B.A., researchers have collected audited financial statements from approximately 150 large, urban public hospitals to analyze their funding and financial sustainability, with the goal of setting a baseline for monitoring the viability of these institutions over the next decade as Affordable Care Act reforms take hold.
Safety-Net Providers’ Role in Health Reform Implementation and Accountable Care
For safety-net providers, health reform implementation presents unique challenges, given the financial constraints and the complex needs of their low-income and uninsured patients. Under a Commonwealth Fund grant, Catherine Hess of the National Academy for State Health Policy (NASHP) convened a workgroup of state and federal officials, health care providers, and health policy experts to examine the impact of health reform on the safety net and develop policy recommendations for including these providers in reform implementation plans and policies.
One area of focus for the workgroup was the role of safety-net providers in integrated health care delivery systems. Public hospitals and community health centers operating within integrated systems—which offer greater access to specialty services, more continuity in provider relationships, and better-coordinated care than smaller independent practices or hospitals typically do—appear best equipped to handle the needs of vulnerable patients efficiently, the participants agreed. An issue brief published jointly by NASHP and the Fund in August 2012 explores key considerations for incorporating safety-net providers into integrated delivery systems and discusses the roles of state and federal agencies in supporting and testing models of integrated care delivery.
Accountable care organizations (ACOs) represent a model of integrated care delivery with the potential to provide comprehensive, coordinated, and efficient care that meets the needs of vulnerable populations. There are concerns, however, that ACOs may unintentionally exacerbate existing inequities in health and health care—for example, many safety-net providers may not have the resources needed to participate in these new organizations. Under the direction of Valerie Lewis, Ph.D., Commonwealth Fund–supported researchers at the Dartmouth Institute for Health Policy and Clinical Practice conducted an analysis of the particular challenges facing would-be safety-net ACOs and suggested policy options for overcoming these obstacles. The Dartmouth team also will assess the extent to which ACOs are forming in socioeconomically disadvantaged communities and undertake a case study of a safety-net ACO—work that will inform policy options to maximize the benefits and minimize the risks of ACO formation for vulnerable populations.
Monitoring and Tracking to Inform Planning and Policy. States have a large role to play in ensuring that vulnerable patients have access to high-performing health care systems. To understand the extent to which states are embracing this role—and how they are going about it—The Commonwealth Fund is developing a scorecard of state performance on health care access, utilization, and equity for vulnerable populations, as well as state policies, resources, and programs that address their needs.
Promoting High-Performing, Integrated Delivery Systems. The Affordable Care Act’s expansion of Medicaid eligibility in 2014 for up to 17 million additional low-income Americans presents an opportunity for new accountable care organizations serving Medicaid patients to transform the way care is delivered to vulnerable populations. The Commonwealth Fund will make grants to advance the development of ACOs in Medicaid. For example, support to the Center for Health Care Strategies and Tricia McGinnis has enabled creation of a multistate Medicaid ACO learning collaborative.
Another grant, to the Camden Coalition of Healthcare Providers, in Camden, N.J., will support creation of a “hotspotting” toolkit that will enable high-risk communities to identify the biggest users of emergency department and inpatient hospital care and devise targeted interventions to improve care coordination and quality and reduce costs.
Meeting the Varied Needs of Vulnerable Patients. Inadequate transportation, language interpretation, and outreach services are some of the many nonmedical causes of poor health outcomes in underserved communities. Over the next year, the Fund will support efforts to improve coordination among medical care, behavioral health, and community-based social service providers.
Leveraging Medicaid’s Role in Driving Delivery System Reform. Fund–supported researchers are also investigating ways that Medicaid can help drive transformation of the health care systems serving vulnerable populations. A November 2012 report by Deborah Bachrach and colleagues with Manatt Health Solutions examined how state Medicaid agencies can align with and build on the Medicare Shared Savings Program, which supports the development of ACOs for Medicare beneficiaries, to catalyze cost containment and quality improvement in their programs.
Laura Summer and Jack Hoadley of the Georgetown Health Policy Institute are examining possible changes in care delivery spurred by Medicaid managed care plans, which states are increasingly turning to as a means of controlling public health care costs. The findings will inform policymakers, state Medicaid administrators, and plan sponsors about the plan designs that are most likely to promote high-value—not just low-cost—care for vulnerable populations.
A health system that delivers high performance care to all Americans, including the most vulnerable among us, requires trained, dedicated physician leaders capable of addressing the health and social needs of disadvantaged minority populations and low-income individuals. Since 1996, the Mongan Commonwealth Fund Fellowship Program in Minority Health Policy (formerly the Commonwealth Fund/Harvard University Fellowship in Minority Health Policy) has played an important role in developing these leaders.
Based at Harvard Medical School under the direction of Joan Reede, M.D., M.P.H., M.S., M.B.A., Dean for Diversity and Community Partnership, the year-long fellowship offers intensive study in health policy, public health, and management for physicians committed to transforming delivery systems for vulnerable populations. Fellows also participate in leadership forums and seminars with nationally recognized leaders in health care delivery systems, minority health, and public policy. Under the program, fellows complete academic work leading to a master of public health degree at the Harvard School of Public Health, or a master of public administration degree at the Harvard Kennedy School of Government.
Beginning with the July 2012 class, the fellowship program includes an optional second year of practicum experience to supplement the fellows’ academic and leadership development training. Fellows chosen for the practicum spend one year in a health care delivery system setting, federal or state agency, or policy-oriented institution acquiring real-world experience in bringing high performance health care to vulnerable populations. The practicum is a competitive program open to first-year fellows, with a variable number of placements available per year.
For more information on the fellowship and how to apply, visit the Mongan Commonwealth Fund Fellowship Program in Minority Health Policy page on www.commonwealthfund.org.