With the proliferation of value-based payment initiatives and implementation of the Affordable Care Act’s (ACA’s) coverage expansions, states have had many opportunities in recent years to improve the health of vulnerable populations through health promotion, prevention, and care coordination. We believe value-based payment models can and must support accountable health care delivery systems in partnering with community-based “messengers” to engage vulnerable individuals in health education and promotion. We explore one such messenger program, ACCESS, a Brooklyn-based project of the Arthur Ashe Institute for Urban Health, which trains barbers and hairstylists to help formerly incarcerated men learn to recognize and act upon their own health risk factors. Value-based payment offers an opportunity to support programs such as this.
Credible Messengers And Social Determinants Of Health
“Messengers,” as we define them here, are community health workers—those who serve “as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.” Unfortunately, there are few dedicated funding streams available to support the messenger role. Fee-for-service payment arrangements do not reimburse these activities. Value-based payment, on the other hand, not only highlights the need to support messengers but also potentially provides funding to do so.
Value-based payment programs hold the health care delivery system accountable for meeting health goals for entire enrolled or attributed populations, which requires more than just providing better medical care. Shortfalls in medical care are responsible for only an estimated 10 percent of early mortality in the United States, while individual health-related behavior is responsible for 40 percent. Even the finest delivery system can only expect to see a modest improvement in the health of its community if it focuses only on the very thing it has been designed to do—providing medical care to sick people. Value-based payment requires delivery systems to redefine nothing less than their product, place, and providers. The product must be health; the place must be where people live and work; and the providers must include credible, community-based messengers.
Credible messengers can bring to delivery systems important knowledge about social determinants of health that impact individuals’ ability to access and act upon health-related information. We focus here on one social determinant—incarceration. Individuals formerly incarcerated have become eligible for Medicaid in large numbers and, as such, participate in a variety of value-based payment initiatives. New York State, where the ACCESS program has been implemented, is moving aggressively toward value-based payment in Medicaid. In 2015, the state announced its intention to shift 80–90 percent of its Medicaid managed care provider payments from fee-for-service to value-based arrangements by 2020.
Delivering Health Information To Formerly Incarcerated Individuals
In the United States, nearly 700,000 state and federal prisoners are released annually, and more than 11 million cycle through local jails. Incarcerated individuals have poorer physical health status than the rest of the population, a high burden of mental health and substance abuse disorders, and, once they are released, are more likely than the general population to be uninsured. However, under the ACA, more than one-third of inmates released annually from state and federal prisons are estimated to be Medicaid-eligible. If this pattern holds true for those released from local jails as well, there are potentially millions of formerly incarcerated individuals newly eligible for Medicaid—and for the value-based payment initiatives that may come with it.
The burdens of incarceration are distributed unevenly. Sixty percent of New York State prisoners come from New York City, and two-thirds of the 28,000 people released each year return to the city. Some Brooklyn neighborhoods have especially high incidences of incarceration and concomitant prison spending, earning them the dubious honorific of “million-dollar blocks,” even though they are among the poorest neighborhoods in Brooklyn.
At the Arthur Ashe Institute for Urban Health (AAIUH), we found a striking overlap between Brooklyn’s million-dollar blocks and areas where we were already engaged in health-promotion activities. Founded in 1992, the AAIUH is an independent, nonprofit organization that collaborates with community members to incubate, test, and replicate neighborhood-based interventions to improve health conditions disproportionately affecting minorities. Arthur Ashe, a world-renowned African American tennis champion and social justice advocate, founded the AAIUH in partnership with the State University of New York Downstate Medical Center. Using community-based participatory research, the AAIUH navigates disparate worlds—the institutional universe of academic medicine and day-to-day life in multi-ethnic, multi-linguistic neighborhoods.
Among other projects, the AAIUH has a long history of training barbers and hairstylists to deliver health education related to breast cancer, cardiovascular disease, asthma, and diabetes in women, and HIV/AIDS and prostate cancer in men. When we began the ACCESS program in 2009, exploratory work revealed that more than 80 percent of barbers working in our ongoing projects had themselves spent at least one night in jail. This made them particularly credible messengers for our priority population of formerly incarcerated men and the supportive women in their lives. Guided by input from a community-based advisory board, we conducted focus groups of barbers, stylists, and customers to determine the best way to discuss incarceration and health, and which health issues would be most important to the community. Based on that input, the program emphasized cardiovascular disease, stress, and HIV/AIDS. We developed a health curriculum to increase awareness of these conditions, emphasizing prevention and the importance of “knowing your numbers”—that is, understanding health indicators such as blood pressure and cholesterol levels. The curriculum included a resource guide for community health and social services related to the priority conditions and services for the re-entry population.
We trained barbers and stylists to deliver the curriculum in six establishments in the Bedford-Stuyvesant and Crown Heights areas of Brooklyn, emphasizing that health messages must be delivered in a way that could be useful to any member of the community who might know someone who had been incarcerated, instead of focusing solely on the formerly incarcerated themselves. In addition to the health messages and the resource guide, ACCESS included an HIV-focused health education video played several times a day in participating salons and barbershops and 12 AAIUH-sponsored Health Resource Days held at these establishments.
The project evaluation consisted of pre- and post-intervention surveys of patrons. The pre-intervention survey assessed patrons’ familiarity with risk factors, prevention, and resources related to the priority conditions. For example, patrons were asked multiple-choice questions such as: “What are some of the warning signs of a heart attack? What is a normal blood pressure reading?” The post-intervention survey of the same individuals sought to determine whether they had been exposed to the intervention and whether their knowledge regarding any of the previously asked questions had changed. Survey respondents’ ability to identify ways to assess their cardiovascular disease risk increased from 44 percent to 62 percent, and understanding that condom use can decrease the spread of HIV increased from 77 percent to 88 percent.
We view ACCESS as a pilot program that helped us understand the health and social needs of formerly incarcerated individuals, the challenges in creating and maintaining relationships with this vulnerable group, and innovative ways to reach the population with credible health messages. The next phase of the program will focus on health literacy.
Policy Opportunities To Support Credible Messengers
ACCESS illustrates the power of using a community’s own assets—its credible messengers—to engage and connect with members of a vulnerable population before they become patients. Such programs are ideally suited to partner with delivery systems under value-based payment programs that hold the system accountable for meeting population health goals. This type of partnership is an important element of the New York State Delivery System Reform Incentive Payment (DSRIP) program, a type of Medicaid Section 1115 demonstration waiver. Under this program, the state will restructure the Medicaid delivery system, with a goal of reducing avoidable hospital use by 25 percent over five years. Hospital-led entities called performing provider systems may receive financial rewards for achievements in system transformation, clinical management, and—importantly—population health. Many such projects require performing provider systems to partner with community-based organizations to help engage, educate, and link to care low- or non-using Medicaid recipients.
All three performing provider systems located in Brooklyn asked the AAIUH to partner with them; the AAIUH serves on the advisory board of one and recruited uninsured participants to complete its patient activation measure survey. AAIUH staff also collaborated on the implementation plan for another performing provider system and, for a third, helped develop a cultural competency and health literacy strategic plan and a plan for training and community engagement activities.
New York State’s goal of shifting Medicaid toward greater accountability for cost and quality echoes a similar one set by the US Department of Health and Human Services in 2015: Then-secretary Sylvia Mathews Burwell pledged that 50 percent of Medicare fee-for-service payments would be made through alternative payment models—such as accountable care organizations or bundled payments–by 2018, and that 90 percent of all traditional Medicare payments would be tied to quality or value by then. We believe that achievement of such ambitious goals is heavily reliant on delivery systems’ ability to engage with a strong community-based infrastructure of credible health messengers.
New York State also presents an opportunity for health plans to support messengers in community-based health promotion right now. The state’s Medicaid health homes are well positioned to engage with messengers to provide health education and promotion. Recognizing the particular challenges associated with reaching formerly incarcerated individuals, New York’s health home program includes several pilot collaborations between health care and criminal justice system partners. The partners identify eligible incarcerated individuals and engage them in the program during their transition into the community. Credible messengers such as those trained under the ACCESS program have the potential to help health homes with the important task of engagement.
Building The Business Case
With current financial support of community-based messengers based on a patchwork of public and private grants and state and local general funds, they remain an afterthought to the health care delivery system. Value-based payment provides an opportunity for accountable delivery systems to support credible messengers in a more consistent way—and, in fact, the systems’ success may depend upon doing so.
To partner in any of the existing or new value-based payment programs, ACCESS and other programs like it must continue to develop solid evidence of their return on investment for health care delivery systems. The next task for the AAIUH is to build the business case for replication of the credible messenger model—both for formerly incarcerated men and for other vulnerable populations.
By bringing health care services within reach of millions of people who previously did not have access, the ACA increased the need for delivery systems to think more creatively about reaching community members outside their walls. This mandate includes community members who have historically been underserved by the health care delivery system, with its traditional means of delivering health messages and impacting individuals’ behavior. As a result, delivery system leaders, policy makers, and other stakeholders must consciously include credible messengers in any value-based payment program designed to improve population health and reduce health disparities.