The ACA: can mandates to improve health improve SUD management?

Transcription

1 The ACA: can mandates to improve health improve SUD management? Integrating Research, Education and Services to Reduce Behavioral Health Disparities in Hispanic and Latino Populations National Conference, October 8-9, 2014 William A. Vega Provost Professor of Social Work, Preventive Medicine, Psychiatry, Gerontology and Psychology Executive Director, Edward Roybal Institute on Aging University of Southern California Los Angeles, CA 1 Aims of Presentation Understanding the ACA as a rationale approach to remedy health disparities - it will need many mid-course corrections The scope of ACA assumptions and implementation strategies it s about improving population health by lowering the burden of disease How do we meet this challenge for aging Latinos and other vulnerable groups? We can t make attaining the perfect healthcare system the enemy of establishing a good healthcare system 2 Creating a Society of Respect and Health Equity: A Twenty-Year Train Ride 2 1

2 Multi-level social determinants conceptual model 4 Societal Determinants of Health Conditions in the social, physical, and economic environment in which people are born, live, work, and age. They consist of policies, programs, and institutions and other aspects of the social structure, including the government and private sectors, as well as community Healthy People 2020: an Opportunity to Address Societal Determinants of Health in the U.S., factors. Objectives for 2020, July 11, Underlying Determinants of Health and Chronic Disease: The Social Environment Education On average, a high school graduate lives 6 to 9 years longer than a dropout. 1 Chronic diseases are more prevalent among those with lower educational attainment. 2 1 Wong,, et al. NEJM, 2002; 2 Woolf, S, et al. Price of a Lost Education: How Education Compared with persons not completing high school, college graduates have lower risks of chronic conditions, ranging from 11% lower odds of decreased kidney function to 37% lower odds of cardiovascular disease. 3 Affects Hunger, Housing, Health and Wealth. VCU Center on Human Needs Issue Brief. Dec Choi, A, et al. Association of educational attainment with chronic disease and mortality: the Kidney Early Evaluation Program (KEEP). Am J Kidney Dis Aug; 58(2):

3 The ACA Challenge Whereas we always think of public health and medical care as a duality if not oppositional they are now mandated to link at the policy and program levels How do we optimize health until the socioeconomic position of Latinos improves? 7 Median Net Worth of Households, by Race/Ethnicity, 1984 to The Best News You Never Heard: Trends in the Leading Causes of Death, Los Angeles County, Cause of Death Percent Change Coronary heart disease % Stroke % Lung cancer % COPD % Alzheimer s disease % Pneumonia/influenza % Diabetes % Colorectal cancer % Liver disease % Breast cancer (females) % HIV/AIDS % Homicide % Rate (per 100,000) Age adjusted to year 2000 U.S. standard population 9 3

4 Death Rate: Latinos vs All Persons Data based on death certificates Cities/Communities with Lowest and Highest Childhood Obesity Prevalence, 2008 City/Community Name Top 10 * Obesity Prevalence (%) Rank of Economic Hardship (1 128) Manhattan Beach Calabasas Hermosa Beach Agoura Hills Beverly Hills Malibu Palos Verdes Estates San Marino Rolling Hills Estate La Canada Flintridge Average 10 lowest 6.2% Ave Median Household Income $99,555 City/Community Name Bottom 10 * Obesity Prevalence (%) Rank of Economic Hardship (1 128) West Athens South Gate Florence Graham West Whittier Los Nietos West Carson Vincent East Los Angeles Hawaiian Gardens South El Monte Walnut Park Average 10 highest 32.7% Ave Median Household Income $37,747 *Table excludes cities/communities where number of students with BMI data < 500. Source: California Physical Fitness Testing Program, California Department of Education. Includes 5th, 7th, and 9th graders enrolled in LA County public schools; 2000 Census 11 Mortality by Cause: Latinos vs All Persons: per 100,000 Mortality Latino s All Persons All Causes Specific causes Diabetes Obesity Cancer: Stomach Cancer: Liver Cancer: Female cervical HIV/AIDS Liver Disease Homicide

5 Comparison of the Leading Causes of Premature Death by Race/Ethnicity, Los Angeles County 2009 Race/ethnicity #1 cause #2 cause #3 cause #4 cause #5 cause White Coronary heart disease Hispanic Homicide Coronary heart disease Black Asian/Pacific Islander Los Angeles County Total Coronary heart disease Coronary heart disease Coronary heart disease Drug Overdose Suicide Lung cancer Liver disease Motor Vehicle Crash Liver disease Drug Overdose Homicide Diabetes Lung cancer HIV Lung cancer Suicide Stroke Colorectal cancer Homicide Motor Vehicle Crash Liver disease Suicide 13 Mortality in Los Angeles County: Los Angeles County Department of Public Health, Office of Health Assessment & Epidemiology The Centers for Disease Control and Prevention (CDC) estimates up to 40% of cancer 80% of type 2 diabetes 80% of heart disease and stroke could be prevented, if Americans were to do three things: Stop smoking Start eating healthy Get in shape Source: Mensah G. Global and Domestic Health Priorities: Spotlight on Chronic Disease. National Business Group on Health Webinar. May 23, Available at: 14 Community Transformation Grant Objective To prevent heart attack, strokes, cancer, and other leading causes of death and disability through evidence and practice based policy, environmental, programmatic, and infrastructural changes in states, large counties, tribes, and territories. 15 5

6 CTG Priorities and Requirements Maximize reach (need large population impacts) Reduce health disparities Build on existing efforts, capacities, and infrastructure Coordinate and collaborate, and leverage other funding sources Address underlying health determinants (not direct services) No "research," but evaluation a high priority must have measurable results 16 CTG Strategy Areas Five Strategy Areas 1) Tobacco free living 2) Healthy eating and active living 3) Clinical preventive services 4) Social and emotional wellness 5) Healthy and safe environments 17 Key New Tool Health Impact Assessment (HIA) HIA is tool for systematically evaluating, synthesizing, and communicating information about potential health impacts for more informed decision making, especially in other sectors

7 Key New Tool HIA An HIA might ask: What are the health consequences of high rates of students dropping out from high schools? What elements of school site design are most cost effective in encouraging physical activity? Why use an HIA? To influence decision makers on health using evidence HIA places public health on the agenda To highlight potentially significant health impacts that are unknown, under recognized, or unexpected To facilitate inter sectoral working and public participation in decision making 19 Every system is perfectly designed to achieve exactly the results it gets. -- Donald Berwick IOM Disparities Model Source: Institute of Medicine. (2002). 21 7

8 Proposed Framework Detecting Define health disparities Define vulnerable populations Measure disparities in vulnerable populations Consider selection effects and confounding factors Understanding Identifying determinants of health disparities at the following levels: Patient/ Individual Provider Clinical encounter Health care system Reducing Intervene Evaluate Translate and disseminate Change policy Source: Kilbourne, et.al How Do We Consider the Role of Organizational Factors in: Latinos being less likely to enter SUD treatment? Latinos being more likely to drop out of SUD treatment before completing treatment? To improve quality the ACA requires workforce diversity, and cross cultural training and education Will it be enough? What missing?? 23 PARADOX of Providers: Limited evidence that ethnic matching improves treatment - but language matching does improve outcomes. However, the SUD managers culturally sensitive beliefs are associated with shorter client wait times and higher treatment retention What Do These Results Suggest is the Active Agent? Could It Be Leadership? Could there be unmeasured effects in total clinic environments, perhaps a combination of relatively weak steps that are cumulative? 24 8

9 Latino Ethnic Subgroups Have Somewhat Different Client Profiles Mexican clients are younger, with shorter addiction histories, fewer co-occurring mental health problems, drug of choice is preference Cuban and Puerto Rican clients are older and have higher educational attainment. Cubans reporting cocaine and Puerto Ricans heroin as drugs of preference Multiple drug use and early initiation are predictors of poor treatment outcomes HEADLINE 25 Intensity of Drug Use, Illegal Drug Preference, Multiple Drug Use, and Homelessness are Major Barriers to Treatment Effectiveness How can systems of care respond more effectively to the social determinants underlying the highest risk clients? Need for comprehensive provider to community engagement with wrap-around services now only available to some individuals with chronic mental illnesses HEADLINE 26 The Role of Organizational Environment Will the ACA emphasize medical therapies with less emphasis on cultural competence or nonpharmaceutical EBI s? Too early to judge, yet programs with professional accreditation are easer to mobilize and a better prospect of affording SUD and mental health care to clients that need it What will happen to community SUD providers that provide maintenance therapies? Will they survive? 27 9

10 Conquering the Prevention and Quality of Care Gap Requires Having All the Pieces Properly Connected 28 Closing Remarks Where do we make our investments in an environment of inequality An effective narrative is needed to explain social determinants The ultimate role of health promotion and disease prevention in the ACA has yet to be demonstrated especially for Latinos How can Latinos be more persuasive in fostering public investments in their future? Getting past the deservedness issue 29 10