Policy to Expand Access to �Outpatient COVID-19 Care for All

Team members

Lilia Cervantes, MD ◆ Bert Johansson, MD PhD

Maria Lame, MD ◆ Alisha Parada, MD ◆ Emma B Olivera, MD

Policy Coach Susana Morales, MD

Problem and Impact

• Pandemic has highlighted disparities in healthcare, in particular that due to access
• US Congress included funding for the treatment of uninsured patients with COVID-19 as a part of the 2020 Coronavirus Aid, Relief and Economic Security (CARES) Act including $175 Billion in the Provider Relief Fund
• This model does not offer insurance to patients which has led some states to adopt Emergency Medicaid authorizations to cover uninsured patients with SARS-COV-2 infection

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Problem and Impact

• Under the Emergency Medical Treatment and Active Labor Act (EMTALA), hospitals must assess and stabilize all patients who present to their emergency departments without regard to their insurance status
• Patients with COVID-19 who require emergency department services or an inpatient hospital admission can receive treatment in all 50 states, and that treatment can generally be covered by Emergency Medicaid for emergency department services (and, in some states, for inpatient services)
• Once patient is stabilized, EMTALA no longer applies
• 12 states have amended their Emergency Medicaid-qualify conditions
• The majority of states have not expanded access to outpatient services

Policy Strategy

• Work with the Senator Bennett and other members of Congress who urged Congress to expand Emergency Medicaid to cover COVID-19 testing, treatment and vaccinations at no cost
• Highlight the cost-benefit of the states who have expanded emergency Medicaid that aids patients upon discharge to get medications and treatments related to their infection

Recommendations

• Facilitate access to Medicaid and/or CHIP Coverage
• Expand LTSS eligibility and benefits
• Supporting providers across service type and authority by increasing payment rates and making retainer payments
• Increase beneficiary access to medications
• Increase access to telehealth

Recommendations

• Facilitate access to Medicaid and/or CHIP Coverage
• Expand LTSS eligibility and benefits
• Supporting providers across service type and authority by increasing payment rates and making retainer payments
• Increase beneficiary access to medications
• Increase access to telehealth

Policy Recommendations

• Federal CMS applies pressure to local state Medicaid agencies to make a sub regulatory language change to include outpatient COVID-19 services under Emergency Medicaid
• Federal government allocates funding to state Medicaid agencies that make this change as a reward and to cover the costs of covering this patient population

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MAXIMIZING OUR POTENTIAL: ADVOCACY TO INCREASE RESIDENCY & FELLOWSHIP TRAINING POSITIONS FOR LATINOS

ANA CEPIN, MD

RICARDO CORREA, MD, ED.D

PILAR GUERRERO MD

KEILA N LOPEZ MD, MPH

DORA MARTINEZ MD

DAVID PARAJON MD, MPH, MBA

ADVISOR: KATHERINE FLORES MD, MPH

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WORKFORCE DATA

• US Census data: Latinos account for 19% of the population
• AAMC data: 6% of physicians identify as Latino
• Current data shows Latino physician:patient ratio will continue to worsen through 2050
• Latinos make up only 3.2% of academic medical faculty
• Latinos are more underrepresented today than in 1990

across all ranks & specialties

• Cultural/language concordant care improves patient outcomes

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https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018

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IOM-Unequal Treatment: What Healthcare Providers Need to Know about Racial and Ethnic Disparities in Healthcare

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0207274

IDENTIFIED GAPS

• Data lacking in the number of MD/DO/IMG Latinos that go unmatched in all specialties
• Lack of representation in academic medical faculty = less mentorship/sponsorship
• Lack of Latino physician representation in medical, surgical, or other subspecialties
• Insufficient residency and fellowship slots: No increased residency slots 1997-2020
• 12/2021- Consolidated appropriations act: 2023-2028: 1000 slots to be added (200/yr)
• Build Back Better Act 2021; GME cap flex act 2021; Resident physician shortage reduction act 2021: Building on Consolidated Appropriations Act 2021
• Slots not specifically dedicated to increasing URM physicians
• Data is lacking for recruitment and retention strategies at all physician levels

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/DGME

POTENTIAL POLICY SOLUTIONS

• Improve data collection, transparency, and dissemination regarding all URM physicians
• Loan forgiveness for URM physicians, who commit to serving Latino communities
• Partnership with NHMA-GME to create and fund scholarly programs geared to prepare Latino MD/DOs and IMGs to successfully match into residencies and fellowships
• Create GME pipeline programs for URM med students dedicated to underserved areas
• Ensure dedicated residency/fellow training slots for URMs in proposed GME bills
• Increase leadership training for mid-career URM MD/DOs and IMGs= sponsorship

PRIORITIZED POLICY SOLUTIONS

• Improve data collection, transparency, & dissemination regarding all URM physicians
• Understand the incoming pipeline to understand the largest leaks (ACGME, NMRP, AAMC)
• Create a medical school-NHMA partnership to assist unmatched Latino medical students
• POTENTIAL POLICY IMPACT: INCREASE STATE/FEDERAL FUNDING TO IMPROVE URM PIPELINE
• Loan forgiveness for URM physicians, who commit to serving our communities
• At the institutional medical school level and at the federal level (grants)
• POTENTIAL POLICY IMPACT: REDUCE $ BURDEN TO INCREASE URM PHYSICIANS WHO:
• PROVIDE CONCORDANT CARE IN AREAS OF NEED
• IMPROVE PATIENT ACCESS AND OUTCOMES

PRIORITIZED POLICY SOLUTIONS

• Ensure dedicated residency/fellow training slots for URMs in proposed GME bills
• Diversify Latinos across primary care, medical, surgical, and other specialties
• POTENTIAL POLICY IMPACT: WILL INCREASE LATINO REPRESENTATION IN RESEARCH, EDUCATION, QI, CLINICAL MEDICINE, ACADEMIA, AND IN CREATING HEALTH POLICY
• Increase leadership training for mid-career URM MD/DOs and IMGs
• For institutional and academic medicine leadership
• For state and federal level policy leadership
• POTENTIAL POLICY IMPACT: INCREASING SPONSORSHIP AND MENTORSHIP FOR:
• LATINO PHYSICIANS COMING UP THE PIPELINE
• LATINO PHYSICIAN LEADERS TO IMPACT HEALTH POLICIES

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Health Policy Analysis:�Improving Hispanic Behavioral Health & Wellbeing Now & Beyond

Frank A. Crespo MD, CHCQM, FACOG

Marlene Martin, MD

Lucille Torres-Deas MD

Maria Verduzco, MD

Faculty Preceptor: Hector Colon-Rivera MD

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Problem Statement

• What strategies can the U.S. Department of Health and Human Services and Department of Education employ to increase preventative behavioral health services and improve the behavioral health outcomes of Hispanic youth?

Background

• Childcare centers, schools, after-school programs, and recreational activities closed
• Disconnecting ~60 million children and youth from essential resources and supports. 

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• Many families faced job loss, economic hardship, and food insecurity 🡪 impacting MH and wellbeing of children and youth

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• Disproportionate impact on LatinX

COVID-19 pandemic disparities

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2021 Household pulse survey⁴

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COVID-19 pandemic disparities

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2021 Household pulse survey⁴

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Multi-tiered framework

• Modeled after Health Impact Pyramid ¹³
• Aims:
• Having 1 full time mental health professional in schools
• Reduce suicide rates among adolescents
• Increase SBIRT
• Target high percentage Hispanic counties

�Behavioral Health Pyramid

In the Schools

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Increase access to health care among Hispanics

• 18.7% Hispanics are uninsured
• Expand Medicaid to all states
• Politically challenging
• Barriers unique to Hispanics: unauthorized immigrant status, language barriers, income

Increase community programs

• Community programs focusing on exercise, diet, lifestyle, and possibly professional development
• After school programs
• Benefit of coping strategies and promotion of health
• Barriers: Limited resources and funding

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Next Steps

• HS Secretary Xavier Becerra, Education Secretary Miguel A. Cardona Announce a Joint Effort to Develop and Share Resources to Ensure Children Have Access to School-based Health Services
• Attend webinars
• Advocate to target resources/programs to high percentage Hispanic counties

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Thank you!

Under this model, behavioral health equity among Hispanic youth will be reached.

Target US Counties

References

1. Centers for Disease Control and Prevention. Vital Signs: Hispanic Health. https://www.cdc.gov/vitalsigns/hispanic-health/index.html. Published May 5, 2015. Accessed February 6, 2022.
2. Office of Minority Health. Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64. Published October 12, 2021. Accessed February 6, 2022.
3. Office of Minority Health. Mental and Behavioral Health- Hispanics. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=69. Published May, 20, 2021. Accessed February 6, 2022.
4. Centers for Disease Control and Prevention. Anxiety and Depression. https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm. Published October 20, 2021. Accessed February 6, 2022.
5. Substance Abuse and Mental Health Services Administration. Project AWARE State Education Agency Grants. https://www.samhsa.gov/grants/grant-announcements/sm-20-016. Published April 29, 2020. Accessed February 7, 2022.
6. McGregor B, Belton A, Henry TL, Wrenn G, Holden KB. Improving Behavioral Health Equity through Cultural Competence Training of Health Care Providers. Ethn Dis. 2019;29(Suppl 2):359-364. Published 2019 Jun 13.
7. Congress.gov. Every Student Succeeds Act. https://www.congress.gov/114/plaws/publ95/PLAW-114publ95.pdf. Published December 10, 2015. Accessed February 7, 2022.
8. Guide to Community Preventive Services. (2019). Mental Health: Universal School-Based Cognitive Behavioral Therapy Programs to Reduce Depression and Anxiety Symptoms. https://www.thecommunityguide.org/findings/mental-health-universal-school-based-cognitive-behavioral-therapy-programs-reduce-depression-anxiety-symptoms. Published February 2019. Accessed February 7, 2022.
9. Castillo EG, Ijadi-Maghsoodi R, Shadravan S, et al. Community Interventions to Promote Mental Health and Social Equity. Curr Psychiatry Rep. 2019;21(5):35. Published 2019 Mar 29.
10. Heboyan V, Douglas MD, McGregor B, Benevides TW. Impact of Mental Health Insurance Legislation on Mental Health Treatment in a Longitudinal Sample of Adolescents. Med Care. 2021;59(10):939-946.
11. Cunningham NR, Ely SL, Barber Garcia BN, Bowden J. Addressing Pediatric Mental Health Using Telehealth During Coronavirus Disease-2019 and Beyond: A Narrative Review. Acad Pediatr. 2021;21(7):1108-1117.
12. Wiecha JL, Nelson TF, Roth BA, Glashagel J, Vaughan L. Disseminating health promotion practices in after-school programs through YMCA learning collaboratives. Am J Health Promot. 2010;24(3):190-198.
13. Barfield WD, Warner L, Kappeler E. Why We Need Evidence-Based, Community-Wide Approaches for Prevention of Teen Pregnancy. J Adolesc Health. 2017;60(3S):S3-S6.

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Water Equity via Community Education and Empowerment

Climate Justice Policy Group

NHMA Leadership Fellowship

Jose Cucalon Calderon, MD

Esmeralda Morales, MD

Sonia Rebeles, MD

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Policy Coach: Emilio Morante, MPH

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Environmental Justice

• “Fair treatment and meaningful involvement of all people regardless of race, color, national origin, or income with respect to the development, implementation and enforcement of environmental laws, regulations and policies”¹

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• Latino communities disproportionately impacted by environmental hazards to health

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Environmental Protection Agency. (n.d.). EPA. https://www.epa.gov/environmentaljustice

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Water Inequities

• Area specific cases
• San Joaquin Valley, CA¹
• Corpus Christi, TX²
• Small community, rural areas³
• 12, 972 community water systems of local government–owned utilities that served populations of 10000 or more²
• Studied over 4 years
• Communities at or above 40% of the federal poverty level and with a higher % of Hispanics or Blacks had a significant increase in the number of predicted drinking water violations

1. Flores-Landeros, H et al. 2021. Community Perspectives and Environmental Justice in California's San Joaquin Valley. Environmental Justice. https://doi-org.stanford.idm.oclc.org/10.1089/env.2021.0005

2. Switzer, D. and Teodoro, M., 2017. The Color of Drinking Water: Class, Race, Ethnicity, and Safe Drinking Water Act Compliance. Journal - American Water Works Association, 109, pp.40-45.

3. McDonald, Y. and Jones, N., 2018. Drinking Water Violations and Environmental Justice in the United States, 2011–2015. American Journal of Public Health, 108(10), pp.1401-1407.

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Switzer, D. and Teodoro, M., 2017. The Color of Drinking Water: Class, Race, Ethnicity, and Safe Drinking Water Act Compliance. Journal - American Water Works Association, 109, pp.40-45.

Regulation of Safe Drinking Water

• Safe Water Drinking Act (SWDA): Environmental Protection Agency (EPA) sets national standards for drinking water safety/quality¹

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• Drinking Water State Revolving Fund (DWSRF): Financial assistance program to help state water systems to meet quality standards set by the SWDA²

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1.US EPA. 2022. Safe Drinking Water Act (SDWA) | US EPA. [online] Available at: <https://www.epa.gov/sdwa>.

2. US EPA. 2022. Drinking Water State Revolving Fund (DWSRF) | US EPA. [online] Available at: <https://www.epa.gov/dwsrf>

2021 Bipartisan Infrastructure Law

• $50 billion to EPA for investment in clean water projects

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• 49% of funds provided through the Drinking Water State Revolving Fund (DWSRF) General Supplemental Funding and DWSRF Lead Service Line Replacement Funding dedicated to disadvantaged communities

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• Not less that 25% of funds provided through DWSRF Emerging Contaminants Funding required to be for disadvantaged communities or public water systems serving <25,000 people

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Epa.gov. 2022. [online] Available at: <https://www.epa.gov/system/files/documents/2022-03/bil-srf-memo-fact-sheet-final.pdf>

Policy Recommendation

Fund community engagement/education initiatives in highest risk communities to address water inequities (active engagement rather than passive)

• Engage with Environmental Protection Agency (Office of Water, Office of Environmental Justice, Office of Enforcement and Compliance Assurance)

Fostering Meaningful Involvement �in Highest Risk Communities

• Community education

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• Directly engage community leaders to implement education and receive feedback from the community

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• Ease of access to information regarding water quality reporting

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