Health Enterprise Zones and Infant Mortality in Maryland

April 9, 2014

Carlessia A. Hussein, RN, DrPHDirector

Office of Minority Health and Health DisparitiesMaryland Department of Health and Mental Hygiene

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Maryland is One of the Most Racial/Ethnic Diverse States

45% minority

4 jurisdictions>50% minority

6 jurisdictions >40% minority

9 jurisdictions>33% minority

Out of 24 jurisdictions

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Disparities by Race/Ethnic Group

Selected Racial and Ethnic Health Disparities in Maryland(Shows how many times higher the minority rate is compared to the White rate)

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Unadjusted ED Visit Rates per 100,000 for Diabetes, by County, Black vs. White, Maryland 2011

Dorcheste

r

Queen Anne's

Worce

ster

Wico

mico

Carolin

e Kent

Talbot

Baltimore City

St. Mary's

Anne Arundel

Baltimore

Calvert

State Of M

aryland

Harford

Cecil

Charles

Frederic

k

Carroll

Wash

ington

Somerset

Montgomery

Prince

George's

Howard

Allegany

Garrett

0

200

400

600

800

1000

1200

1400

1600

Black White

Maryland

Both Place and Race Matter to this rate

Hospital Admission Rate Disparities Black vs. White

• For Ambulatory Care Sensitive Conditions (or AHRQ Prevention Quality Indicators) for Maryland:

• Kid’s Asthma: Black rate is 3.1 times higher• Adult Asthma: Black rate is 2.7 times higher• Adult Hypertension: 4.5 times higher• Adult Congest Heart Fail 2.6 times higher• Various Diabetes metrics 2.6x to 4.6 x higher• (data from AHRQ State Snapshots as presented in the

MHQCC Health Disparities Workgroup Report)

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Cost of Disparities in Maryland

• Minority Health Disparities cost Maryland between 1 and 2 Billion Dollars per year of direct medical costs.

• Excess charges from Black/White hospitalization disparities alone were $814 Million in 2011.– These are just the hospital charges, NOT including

physician fees for hospital care, emergency department charges, or any outpatient costs.

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Maryland Health Disparities Workgroup

• Convened by Maryland Health Quality and Cost Council in 2011 (Council chaired by Lt. Gov Brown and Sec Sharfstein)

• Workgroup Chaired by Dean Reece of U of MD School of Medicine, included diverse experts on minority health

• Maryland Office of Minority Health and Health Disparities staffed workgroup and co-drafted Final Report in 2012

• Report Recommendations:• Health Enterprise Zones (HEZs)• Maryland Health Innovation Prize• Racial and Ethnic tracking of health care delivery performance

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Report Implementation

• Legislature passed Maryland Health Improvement and Disparities Reduction Act of 2012 based on the Report

• Administration funded HEZ program with $ 4 million per year for four years beginning in 2013

• State Health Department and the Community Health Resources Commission oversee implementation

• Five HEZs were designated in January 2013

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Maryland Health Improvement & Disparities Reduction Act of 2012

• Health Enterprise Zones• Racial / ethnic data from insurers (MHCC)• Racial / ethnic data for incentive programs: • Hospital incentives (HSCRC)• Patient-Centered Medical Homes (MHCC)

• Hospitals report efforts to reduce Disparities• Health education institutions report efforts• Cultural competency workgroup of Health

Quality and Cost Council9

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Health Enterprise Zones: Definition and Eligibility

• A Health Enterprise Zone was defined in law as– A contiguous area of one or more zip codes– Experiencing documented poor health outcomes

and health disparities– Experiencing documented economic disadvantage

• Operationalized eligibility as– Bottom 50% on one of two poverty metrics, AND– Bottom 50% on one of two poor health metrics

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Health Enterprise Zones:Provider Incentives

• HEZ enabling legislation provides various statutory incentives for providers in the Zones:– State income tax credits– Hiring tax credits– Grants for equipment purchase or lease– Loan repayment assistance programs

• These are contingent on– Participating in cultural competency training– Accepting Medicaid and uninsured patients– Participating with the Coordinating Organization 12

Health Enterprise Zones:Community Intervention

• HEZ enabling legislation provides grants for community-level public health interventions:– Deploying community health workers– Increasing availability of fresh fruits and vegetables– Improving access to safe physical activity– Transportation assistance programs– Mobile crisis teams for mental health– Providing cultural competency training– Supporting community coalitions

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Health Enterprise Zones:Principles for Proposals

• HEZ call for proposals contained 13 principles that doubled as proposal review criteria.

• Several key principles were:– Cultural, linguistic, and health literacy competency– Workforce diversity– Outreach and targeting of minority populations– Racial, ethnic & language data collection/reporting– Addressing social determinants of health– Balance between provider and community focus

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Health Enterprise Zones:Progress and Future

• Five HEZs designated in January of 2013• To date, 43 new health providers of various

types hired in the zones• Cultural competency training assistance

• Programmatic technical assistance

• Quarterly reporting on productivity and quality

• External evaluation contract to be established15

Infant Mortality in Maryland: DEMO Programs

• MHHD is currently funding 3 pilot Minority Health Disparities Reduction Demonstration Grant (DEMO) sites for minority infant mortality in FY 2014

• DEMO Programs utilize: – Minority Perinatal Navigators, CHWs, and health promoters; – Community coalitions and taskforces; – Increased community outreach and education;– Enhancement of clinical services;– Infrastructure for Program Sustainability;– Inter-county collaboration.

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Infant Mortality in Maryland: General Background

• Racial and Ethnic Breakdown of births and infant deaths, Maryland 2012

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2012 Births % total Deaths % total Death rate *

White 42,791 59% 174 38% 4.1

Black 24,306 33% 251 55% 10.3

Hispanic 10,201 14% 56 12% 5.5

Asian 5,430 7% 21 5% 3.9

Amer Ind 164 0% 1 0% 6.1 **

* Infant deaths per 1000 live births, the Infant Mortality Rate**American Indian rate varies greatly year to year due to small numbers

Infant Mortality Reductionin Maryland

2005 2006 2007 2008 2009 2010 2011 2012 20130.0

5.0

10.0

15.0

20.0

25.0

Maryland Infant Mortality Rates, 2006-2012, by Race, Maryland Vital Sta-tistics Administration

Maryland Black Linear (Maryland Black)Maryland White Linear (Maryland White)

Deat

hs p

er 1

,000

Live

Birt

hs Black

White

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Racial/Ethnic Population in Delaware

33.7% minority

2 jurisdictions>33% minority

Out of 3 jurisdictions

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Racial or Ethnic Minority Population, by Jurisdiction, Delaware, 2010

% Minority

New Castle 37.5%

Kent 33.4%

Sussex 23.5%

Delaware 33.7%

Infant Mortality in Delaware: General Background

• Racial and Ethnic Breakdown of births and infant deaths, Delaware 5-Year Average, 2006-2011

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2006-2011 Births % total Deaths % total Death rate *

White 7,818 68% 46 51% 5.9

Black 3,140 27% 42 46% 14.2

Other Race 598 5% 3 3% 5.2

* Infant deaths per 1000 live births, the Infant Mortality Rate

Infant Mortality Reductionin Delaware

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2003 2004 2005 2006 2007 2008 2009 2010 2011 20120.0

5.0

10.0

15.0

20.0

25.0

Delaware Infant Mortality Rates, 2004-2011, by Race, Delaware Vital Statistics Administration

Delaware White Linear (Delaware White)Delaware Black Linear (Delaware Black)

Deat

hs p

er 1

,000

Live

Birt

hs

White

Black

Disparities Reduction PrinciplesHEZs DEMO Program

Community coalitions Community coalitions and taskforces

Community health workers and workforce diversity

Minority Perinatal Navigators, CHWs, and health promoters

Outreach and targeting of minority populations

Increased community outreach and education

Addressing social determinants of health Linkage to community resources

Provider Incentives (tax credits, loan repayment)

Enhancement of clinical services

Evaluation and Sustainability Infrastructure for Program Sustainability

Chronic Disease Utilization Chronic Disease and Infant Mortality

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Linkages to Maryland HEZsDEMO PROGRAMS

Shared logic model and common operational design features

HEZsLow Birth Weight is used in designation of HEZs & HEZs may choose to target Infant Mortality

INFANT MORTALITY

Programs develop locally-targeted strategies for reducing infant mortality within a community

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Recommendations

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• Use HEZ/DEMO model to target infant mortality in clusters of zip codes• Identify specific small population groups by geographic areas where

infant mortality rates and numbers are higher than the state average• Where small groups of individuals with infant mortality that is higher

than acceptable, target communication in a culturally competent manner

• Distribute infant mortality data trends information (rates and numbers) by small areas within counties

• Activate a coalition of diverse interest groups ( health, citizens, elected officials, faith-based, etc.) to focus on reducing infant mortality as a community

• Engage in innovative communication: movie theater ads, Man/Boys support groups, sports and entertainment personalities, grandma/senior citizen groups, etc.

Important LinksHealth Disparities Planhttp://dhmh.maryland.gov/mhhd/Documents/Health%20Disparities%20Plan%202010.pdf

Health Disparities Workgroup Final Reporthttp://www.governor.maryland.gov/ltgovernorn/documents/disparitiesreport120117.pdf

Cultural Competency Workgroup Reporthttp://dhmh.maryland.gov/mhgcc/SiteAssets/SitePAges/meetings/Cult%20Comp%20Full%20Report%2012.13.pdf

Maryland Chartbook of Minority Health and Minority Health Disparities Datahttp://dhmh.maryland.gov/mhhd/Documents/Maryland-API-Data-Report-2013.pdf

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Contact InformationOffice of Minority Health and Health Disparities

Maryland Department of Health and Mental Hygiene201 West Preston Street, Room 500

Baltimore, Maryland 21201Phone: 410-767-7117

Fax: 410-333-7525

Website: www.dhmh.maryland.gov/mhhdFacebook: www.facebook.com/MarylandmhhdTwitter: @MarylandDHMHEmail: dhmh.healthdisparities@maryland.gov

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