#healthmeanswealth: Indiana Health Data and Trends. Jerome Adams, MD, MPH State Health Commissioner July 13,

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1 #healthmeanswealth: Indiana Health Data and Trends Jerome Adams, MD, MPH State Health Commissioner July 13,

2 Indiana Unwell? Wellness in Indiana? Over million smokers Enough overweight or obese to populate all of Iowa One third IN adults sedentary/ do not participate in leisure time activities Chronic disease Responsible for 7 out of 10 deaths, nationally Accounts for approximately 70% of healthcare costs Many are preventable or reversible with lifestyle modifications

3 What s the Cost? Increase in BMI means an increase on direct healthcare costs, sick days and medical claims Moderately obese individuals are more than twice as likely to be prescribed drugs to manage conditions Every pack of cigarettes sold equals $15.90 in healthcare costs, lost productivity, and premature death Health affects recruitment, productivity, safety/liability, and health care costs

4 Help us help you!!!! Worksites are crucial partners in improving population health Provide opportunities for adults to eat better, move more and avoid tobacco Employers are crucial in efforts to advocate for community health As community leaders you can make the business argument business means health!

5 State of the State

6 Indiana State Department of Health-Top Priorities #1. Reduction in Infant Mortality rates #2. Reduction in Adult Obesity rates #3. Reduction in Adult Smoking rates #4. Assuring preparedness for infectious disease #5. Combatting our National Opioid Epidemic #6. Getting people enrolled in HIP!!!

7 Infant Mortality Defined as the death of a baby before his/her first birthday The Infant Mortality Rate (IMR) is an estimate of the number of infant deaths for every 1,000 live births Large disparities in infant mortality in Indiana and the United States exist, especially among race and ethnicity Infant Mortality is the #1 indicator of health status in the world

8 International Infant Mortality Rates 2010 Source: Indiana State Department of Health, Maternal & Child Health Epidemiology Division [October 26, 2015] Original Source: CDC/NCHS, linked birth/infant death data set (U.S. data); and OECD 2014 (all other data). Data are available from

9 Infant Mortality Rates United States, 2013 Source: Indiana State Department of Health, Maternal & Child Health Epidemiology Division [October 26, 2015] Original Source: CDC/NCHS, National Vital Statistics Report Deaths: Final Data for 2013, Volume 64, Number 2

10 Infant Mortality Rates Indiana, U.S. and Healthy People 2020 Goal: Source: Indiana State Department of Health, Maternal & Child Health Epidemiology Division [February 23, 2016] United States Original: Centers for Disease Control and Prevention National Center for Health Statistics Indiana Original Source: Indiana State Department of Health, PHPC, ERC, Data Analysis Team

11 HIGHEST Infant Mortality Rates in State Daviess = 10.6 Grant = 10.5 Bartholomew = 10.0 Henry = 9.7 Kosciusko = 9.2 LaPorte = 9.0 Adams, Marion = 8.9 Delaware = 8.6 Jackson, Vanderburgh = 8.3 Lake, Wayne = 8.2 St. Joseph = 8.1 Source: Indiana State Department of Health, Epidemiology Resource Center, Data Analysis Team Infant Mortality Rates County Level, All Races Counties with the Best and Worst Infant Mortality Rates Aggregated Years Posey Gibson Lake Jasper Newton Benton Warren Verm. Vigo Knox Parke Pike Porter Clay White Greene La Porte Owen Perry Cass Fountain Montgomery Boone Sullivan Daviess Dubois Pulaski Tippecanoe Vander- Warrick burgh Spencer Carroll Clinton Orange Fulton Hendricks Marion Putnam Martin Starke Morgan Lawrence St Joseph Marshall Jackson Elkhart Kosciusko Wabash Miami Howard Grant Johnson Shelby Harrison Clark Noble Whitley Henry Rush Wells Ripley De Kalb Allen Adams Jay Tipton Delaware Madison Randolph Hamilton Washington Hancock Monroe Brown Bartholomew Crawford Floyd Scott Lagrange Huntington Decatur Jennings Blackford Jefferson Steuben Wayne Fayette Union Franklin Dearborn Ohio Switzerland

12 Infant Mortality Rates by Race Indiana Source: Indiana State Department of Health, Epidemiology Resource Center, Data Analysis Team

13 Factors Contributing to Infant Mortality in Indiana Obesity (ISDH #2 priority) Obese=25% chance prematurity Morbidly Obese= 33% prematurity Indiana is 7th most obese state in US 32% of females of childbearing age are obese Smoking (ISDH #3 priority) 15.1% pregnant mothers smoke (2 x US avg) 25% Medicaid Moms smoke!!! Indiana has 7th highest adult smoking rate in US 26% of females of childbearing age currently smoke

14 Factors Contributing to Infant Mortality in Indiana Limited Prenatal Care Only 67.5% pregnant mothers in Indiana receive PNC in 1st trimester White = 70.1%; Black = 55.9% Unsafe Sleep (6.0% of deaths 2014) Elective deliveries before 39 weeks gestation Limited breastfeeding Delivering at risk-appropriate facilities?

15 Indiana s Plan: Promote Good Health in Women and Infants Statewide Infant Mortality Campaign Raising awareness about problem and resources Labor of Love (laboroflove.in.gov) MOMs Helpline Statewide Public Health Home Visiting Program Collaboration with Nurse-Family Partnership and Goodwill

16 Indiana s Plan: Address Disparities If Indiana lowered the black infant mortality rate in 2014 from 14.7 per 1,000 live births to the white infant mortality rate of 5.9 per 1,000 live births, we would ve saved over 90 infants

17 Indiana s Plan: Indiana Perinatal Quality Improvement Collaborative Early Elective Deliveries: July 2014, Medicaid stops paying for non-medically indicated inductions before 39 weeks Neonatal Abstinence Syndrome (NAS): December 2015, four Indiana hospitals are piloting programs to identify and report on NAS 17P: June 2015, development of recommendations for utilization of progesterone therapies to prevent prematurity Birth Certificate: QI project that made system improvements to Indiana Death Registry System, including provision of training, feedback mechanisms, and recommendations for next phase of QI Source:

18 Vision Statement: All perinatal care providers and all hospitals have an important role to play in assuring babies born in Indiana have the best start in life. All babies will be born when the time is right for both the mother and the baby. Through a collaborative effort, all women of childbearing age will receive risk-appropriate care before, during and after pregnancy. Indiana s Plan: Perinatal Levels of Care Percent of VLBW Born in Level III Hospitals

19 Laurie Adams, CEO/Executive Director Baby and Me Tobacco Free Program, Oct 16, 2013 Researched from , NY State Department of Health, Bassett Research Institute Baby and Me, Tobacco Free Baby and Me, Tobacco Free (BMTF) is an evidenced-based smoking cessation program for pregnant women, through her child s first birthday Program Components Individualized education from BMTF certified facilitator 4 sessions prior to baby s birth Monthly postpartum visits until baby turns 1 Biochemical testing at every visit Provides up to 12, $25 diaper vouchers

20 Baby and Me, Tobacco Free October 2013 March ,532 Program Enrollees* 1,620 Vouchers distributed 369 Infants born nicotine-free 92% born 37 weeks gestation 95% born 5 lbs. 8 oz Data 15.1% pregnant Hoosiers smoke County rates range from 2.7% to 38.5% For women on Medicaid, the number jumps to 25.3% Includes March of Dimes and Anthem affiliated Indiana sites Data Source: 2014 Indiana Natality Report

21 Safe Sleep Cribs for Kids sites throughout Indiana provide safe-sleep education by distributing a Graco Pack n Play portable crib, pacifier, and safe sleep information to families who cannot otherwise afford a safe place for their babies to sleep. Messages: Focus on the ABC s of Safe Sleep practices recommended by the American Academy of Pediatrics and National Institutes of Health: Babies should sleep Alone On their Backs In a Crib or bassinette Since July 2014 approximately 6000 cribs went out to families across the state

22 (Re)Launched on March 1 st, 2016! Provide information, referrals and resources relating to maternal and child health care services. Connect mothers and pregnant women with a network of prenatal and child health care services within local communities, state agencies and health care organizations around the state.

23 Labor of Love

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27 Prevalence of Adult Obesity by State 2014 BRFSS Rank of 7 th Highest Source: 2014 BRFSS Percent

28 Obesity in Indiana Over two thirds (66.5%) of Indiana adults are overweight or obese*. 32.7% obese; 33.7% overweight Obesity rates are higher in minority populations and rural areas. Why? We re eating more & we re moving less -Easy access to fast food Fast, less nutritious food on every corner -Lack of access to fresh, affordable healthy options. Low income and/or low access -Increased screen time Less opportunity to engage in physical activity *2014 BRFSS

29 Prevalence of Adult Obesity by Race/Ethnicity Indiana 2014 BRFSS Source: 2014 BRFSS

30 Costs to Indiana Hoosiers pay $3.5 billion in obesity related medical costs Healthcare costs for obese individuals are on average $1,400 higher per year. In Indiana, 36.9% of obesity related costs are financed by Medicare and Medicaid Obese children miss more school than their normal weight peers Obese adults experience more absenteeism and presenteeism than their normal weight peers Costs employers over $6 billion/year in the US

31 Adult Current Smoking by State 2014 BRFSS Rank of 7 th highest Source: 2014 BRFSS

32 Smoking during pregnancy Indiana overall: 15.1% vs 8.7% for US -12,655 births, $4.8 mil County rates overall: 2.7 % to 38.5% Medicaid Members: 25.3% 2014 Indiana Natality Report Gibson Lake Newton Benton Warren Verm. Vigo Sullivan Knox Jasper Parke Pike Porter Clay Daviess White Greene La Porte Owen Dubois Pulaski Tippecanoe Fountain Montgomery Putnam Martin Starke Carroll Clinton Boone Cass Hendricks Morgan Monroe Lawrence Orange Crawford St Joseph Marshall Fulton Miami Marion Brown Howard Tipton Jackson Elkhart Hamilton Johnson Washington Kosciusko Wabash Shelby Grant Madison Hancock Bartholomew Floyd Scott Clark Lagrange Noble Whitley Huntington Henry Rush Decatur Jennings Blackford Delaware Wells Ripley Jefferson Steuben De Kalb Allen Adams Jay Randolph Wayne Fayette Union Franklin Dearborn Ohio Switzerland <10% 10-20% 21-29% 30+% Posey Vanderburgh Warrick Spencer Perry Harrison

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34 Emerging Infectious Diseases Zika!!! Flu Ebola HIV Measles, Mumps, MERs, oh my!!! H5N1 (bird flu) TB Antibiotic Resistant Organisms/ CRE

35 Zika 10 cases in IN, all with travel history No confirmed local transmission in US, IN considered low risk Primary mosquito vector is present in lower 2/3 rd of state. Secondary vector in more of state, but not thought to be as good at spreading virus. Mosquito control (repellent, screens, no standing water), avoid travel if pregnant or trying, avoid unprotected sex for 6 months and ISDH websites have regular updates)

36 Tackling the Prescription Drug and Opioid Abuse Epidemic

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38 Prescribing correlates with IDU, unsafe injection practices Expanding epidemic of injection drug use heralded by dramatic increase in acute HCV infections Suryaprasad Clin Infect Dis; 2014, 59(10):

39 Number Number of Deaths: Motor Vehicle Accidents and Accidental Drug Poisonings Indiana Residents, Motor Vehicle Accident Drug Overdose 1,400 1,200 1, Year Source: Indiana mortality data

40 Scott County HIV Outbreak Rural injection of Rx oral opioid = largest ever HIV outbreak in IN, largest IDU HIV outbreak in US 200 HIV cases in a rural county that never had more than 3 in one year Almost all cases report injection of the opioid analgesic oxymorphone (Opana ER and generic ER) Male = female, all white, significant poverty (19.0%), unemployment (8.9%), lack of education (21% no high school), and lack of insurance

41 HIV Infection: Tip of a High-Mortality Iceberg HIV Infection Overdose, Bacterial infections 200 diagnoses 5 deaths during contact tracing Hepatitis C virus Infection 282 total, 95% coinfected Injection Drug Use Substance Use Disorder Network of over 525 PWID Paying attention Now? Adapted from and with permission of Phil Peters, CDC

42 Slowing transmission Epidemic Curve C a s e C o u n t Specimen Collection Date

43 Number of Patients HIV Care Continuum May15, 2015 July 7, 2016

44 Outbreak Control Interventions Very few insured: established one-stop shop No HIV/HCV care: state provided resources (IU), HRSA, PREP Little HIV awareness: multiple educational efforts including billboards, infographics, webinars, TV/radio, newspaper, Jeannie White Ginder community event at Austin HS. #URNotAlone* Syringe exchange illegal: executive orders followed by new law Limited addiction services (methadone moratorium): raise awareness of MAT, train and accredit providers to prescribe Suboxone, local mental health provider designated as a FQHC, SAMHSA collaboration

45 Where can you weigh in? MAT: People don t understand the concept, or the options: Methadone vs Suboxone vs Vivitrol Think we are substituting one addiction for another Drug Court/ Diversion Programs: Can t incarcerate our way out of this problem Most local jails over capacity, but lots of fear that weaker enforcement hurts the case. Need both sticks and carrots to change behavior What comes treatment? Need more housing, halfway houses, jobs Veterans win the war and come home a hero, addicts win one war and come home to another war. I ve been clean 6 months, but I know I can never go home. The best drug recovery program is a good job

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47 Healthy Indiana Plan ( 1.0 ) First Medicaid plan with strong consumer-directed features (2008) HDHP POWER Account Consumer choice + Provider engagement Proven Results Improves healthcare utilization Promotes personal ownership of health care High Member and Provider Satisfaction Enhanced coverage Enhanced provider reimbursement 47

48 State of the Uninsured in Indiana (pre- HIP 2.0 ) Coverage Gap TOTAL UNINSURED = 881,291 (13.6%) 1. SHADAC Health Insurance Analysis. (2011). American Community Survey data. Retrieved from 48

49 HIP 2.0 vs. Medicaid Expansion Health Improvement Access Medicaid Coverage 49

50 HIP 2.0 Eligibility Who is eligible for HIP 2.0? Indiana residents ages 19 to 64 income under 138% of the federal poverty level (FPL) who are not eligible for Medicare or otherwise eligible for Medicaid Includes individuals previously enrolled in: Healthy Indiana Plan (HIP 1.0) Hoosier Healthwise (HHW) 50

51 HIP 2.0: Three Pathways to Coverage HIP Plus Initial plan selection for all members Benefits: Comprehensive coverage with enhanced benefits, including vision, dental, bariatric, pharmacy Cost sharing: Monthly POWER account contribution required Contribution is 2% of income with a minimum of $1 per month ER copayments only HIP Basic Fall-back for members with income <100% FPL who do not make POWER account contribution Benefits: Minimum coverage, no vision or dental coverage Cost sharing: Must pay copayment ranging from $4 to $75 for doctor visits, hospital stays, and prescriptions HIP Link Employer plan premium assistance paired with HSA-like account Enhanced POWER account to pay for premiums, deductibles and copays in employer-sponsored plans Provider reimbursement at commercial rates 51

52 HIP Plus: POWER Account Contributions POWER account contributions are approximately 2% of member income Minimum contribution is $1 per month* Maximum contribution is $100 per month (individual enrollee in a 9 person household earning $62,000/year) Employers & not-for-profits may assist with contributions Employers and not-for-profits may pay up to 100% of member PAC Ideally, payments are made by individual directly to member s selected managed care entity PAC amount based on family income If spouses both enrolled, they split the monthly PAC amount *Approximately 20% of HIP eligible population will have an income the corresponds with the minimum $1 PAC 52

53 HIP 2.0 turns one! Since announcing the approval of the HIP waiver on January 27, 2015, enrollment in our program has grown to ~ 400,000 members. Since HIP began, almost 70 percent of enrolled individuals have elected to make contributions to their POWER account. Of this group, 83 percent are earning below the poverty level, some making at least a $1 permonth contribution. 53

54 HIP 2.0 turns one! Once HIP members start making contributions, our data tells us that 94 percent continue making them. Nearly one-third of HIP members report asking their doctors about the cost of their health care. 52 percent of HIP members check the balance of their POWER account Just over one-third check that balance at least once a month 54

55 HIP 2.0 turns one! According to analyses performed by two MCEs, HIP members who transitioned from the traditional Medicaid program Hoosier Healthwise to HIP 2.0 have had over a 40% reduction in Emergency room utilization. In the last year, we ve added over 5,300 new providers to serve both Medicaid and HIP members. 55

56 HIP 2.0 turns one! 86 percent of HIP Plus members were satisfied or very satisfied with the program 94 percent of all HIP members would re-enroll 83 percent would pay more to be in the program 55 percent of providers surveyed indicate they have seen a decline in the number of people without insurance Almost 40 percent have seen a decline in the requests for charity care 56

57 HIP Link Premium Assistance Program HIP Link Overview HIP Link helps employees pay for the costs of their employer coverage. HIP Link members get a $4,000 POWER account. Members receive a monthly check to help cover the cost of employer premiums. Like HIP, HIP Link members contribute 2% of their income towards the costs of coverage. POWER account also helps cover member cost sharing. Members can use their HIP Link card to pay for copayments, deductibles and coinsurance. 57

58 Employer Participation Why should employers participate in HIP Link? More employees may be able to enroll in the employer s group health plan. An increase in employees may help to meet industry and marketplace participation rates or lower group premium rates. Employees can better manage health care costs with their HIP Link POWER Account and Health Reimbursement Account (HRA), if offered by employer. Potential to expand employee base and increase retention by being listed as an approved HIP Link Employer. Possible tax benefits for small employers using the Health Insurance Marketplace. HIP Link does not disrupt the current group health plan offered or cost sharing structure and can be incorporated at any time. 58

59 In summary: HIP 2.0 Is Indiana-specific solution Establishes our own priorities Builds off of successful program Expands coverage AND improves access Consumer-directed (ownership) Price transparency Patient/provider partnership Focus is on healthy outcomes 59

60 Help us get the word out! HIP.IN.gov is your primary resource About HIP Am I Eligible? Includes eligibility and income calculator How to Enroll? Links to Find a Navigator Provider links health plans, pharmacy Helpful Tools (to download) Brochures, articles, graphics, training slides GET-HIP-9 60

61 Contact Information Jerome Adams, MD, MPH State Health Jennifer Walthall, MD, MPH Deputy State Health Commissioner Joan Duwve, MD, MPH Chief Medical Officer Eric Miller Chief of Staff