Public Health Agency Approaches to Improving Access to Care

Introduction In the last decade, the number of Americans lacking access to basic medical care grew to over 100 million people.1 Access to care is key to ensuring the nations’ ability to prevent and respond to infectious and chronic diseases.2 Through partnership with the health care delivery system, payors, community-based organizations, and academic institutions, public health leaders can catalyze significant improvements in access to care. The Association of State and Territorial Health Officials’ (ASTHO) Access to Care technical package offers policy and program recommendations for state and territorial health officials (S/THOs) to increase access. These strategies focus on enhancing safety net services, expanding digital health in underserved areas, strengthening the workforce pipeline, improving Medicaid coverage and quality, and promoting data interoperability between Medicaid and public health systems. An ASTHO technical package is a summary of a select group of related interventions that, taken together, help achieve and sustain improvements related to risk factors or health outcomes. ASTHO technical packages are based on programmatic subject matter experts’ assessment of evidence-based interventions, expert recommendations, overviews of current public health activities, and a review of federal funding guidance (eg, Centers for Medicare and Medicaid Services, Health Resources and Services Administration (HRSA), and Centers for Disease Control and Prevention (CDC)). They are not intended to be comprehensive and can be iterative. ASTHO acknowledges that there are other policy interventions that broadly address access to care, which are not reflected in this technical package. Additionally, this package will be updated as new federal policies, and guidelines are introduced. Methods ASTHO used the following sources to develop the framework for the technical package: The Foundational Public Health Services, ASTHO Profile Survey, HRSA program data, post-COVID public health and health care reports, ASTHO telehealth needs assessment survey, and ASTHO workforce assessment of state/territorial primary care offices (PCOs). The recommendations were refined through meetings with HRSA and CDC subject matter experts, national Medicaid policy thought leaders, focus groups with S/THOs, and input from ASTHO’s Population Health and Informatics Policy Committee and Clinical Service Leader Peer Network.3 The final recommendations were assessed to be impactful, trackable, and appropriate for public health’s role in improving access to care. A summary of ASTHO’s Access to Care technical package is outlined in Table 1. TABLE 1 - ASTHO Access to Care Technical Package Objective to Improve Access to Care State-Level Action Required Mechanisms S/THO Authority or Influence Establish an executive leader within the public health agency responsible for public health and health system alignment Create an executive role for leading public health and health system alignment, foster relationships with state/territorial clinical and policy leaders, and operationalize agency-level initiatives to increase access to care Dedicate FTE or create an executive position reporting to the S/THO responsible for public health and health system alignment (eg, Health Innovation Officer and Chief Medical Officer) Direct authority over hiring and public health agency organizational structure Support development and sustained deployment of CHWs across a range of public health, health care, and community settings Assess opportunities to use public health grant funding to employ CHWs or to contract with community-based organizations that employ CHWs Standardize hiring CHWs within the agency Working with CHWs, set a consistent, agency-wide definition of CHWs Direct authority over hiring and contracting Working with CHWs, set and maintain standards for CHW training and certification, in a way that aligns with current and emerging public health and clinical practice Convene with CHWs and CHW organizations to consider appetite and process for CHW training and certification opportunities (in alignment with standards set by the CHW Core Consensus Project4) Maintain a registry of practicing CHWs in the jurisdiction Conduct a workforce study to document CHW deployment across the jurisdiction Dedicate FTE or establish an Office of CHWs within the agency to serve as a relationship manager with CHWs and allies Educate health care and insurance sector on the business case of incorporating CHWs into multidisciplinary care teams Direct authority over establishment of health department policy, programs, and organizational structure Ability to educate policymakers on the impact of CHWs and work with them to implement policies to support CHW training, standards, and certification Ensure access to health care providers in rural and underserved communities through workforce development programs or digital solutions Build a robust, strategic state/territorial PCO to manage health care workforce recruitment and retention programs and offer robust data to inform policy on physician/facility access5 Legislation/appropriations to initiate expansion of investment in both physical and behavioral health care workforce pipeline programs (eg, state loan repayment programs, scholarship programs)6 Secure dedicated or matched funding by the public health agency to ensure sufficient staffing of the PCO beyond the limited coverage supported by the HRSA PCO cooperative agreement Ensure data sharing agreements and processes are in place that allow PCOs to access the licensure and claims data required for their work Influence over state general funds allocated to the public health agency Ability to educate legislators on the impact increased investment would have on the health care workforce and associated population health outcomes Direct authority over public health agency organizational structure (eg, PCOs and legislative liaisons) Direct authority over instituting data sharing agreements with external entities, such as Medicaid and licensing boards Make direct investments in workforce pipeline initiatives for a range of provider types who commit to serving in rural and underserved communities Secure dedicated funding to supplement HRSA grant dollars supporting state-based loan repayment and scholarship programs. Consider opportunities to expand existing programs to include additional provider workforces Convene state/territorial agency, academic, and industry stakeholders to share data (eg, HPSA, SLRP, immunization, and Medicaid utilization and quality) Forge partnerships and facilitate discussion with health systems, health center-controlled networks, health plans, foundations, business, and other entities about policy and braided funding opportunities to support provider pipeline initiatives Influence over state general funds and ability to educate legislators on the value of dedicating resources to provider pipeline initiatives Direct authority over public health agency organizational structure Coordination (internally and with external partners such as government agencies, academic medical centers, or broadband office) on policies or programs that increase access to broadband and uptake of telehealth Legislation or leveraging federal or state funding to expand broadband access Legislation or regulations that remove geographic restrictions and/or allow audio only services to be reimbursable Expansion of patient and provider education about telehealth Grants to providers to expand capability to do telehealth Development of programs that offer telehealth access points (eg, library sites) Ability to educate legislators on the impact of broadband access on population health and telehealth’s impact on access to care Direct authority over internal agency workgroup development and programs Expand access to providers through interstate licensure compacts that allow providers to serve patients via telehealth across jurisdictions7-9 Legislation joining an interstate licensure compact for various provider types (eg, Interstate Medical Licensure Compact, Nurse Licensure Compact, Psychology Interjurisdictional Compact, and Emergency Medical Services Compact) Ability to educate legislators on the impact of joining an interstate licensure compact on access to care Increase Medicaid coverage, thereby improving financial accessibility of care by encouraging Medicaid agencies to expand eligibility categories, covered services, and enrolled providers Adopt Medicaid continuous coverage policies (eg, expanded Medicaid postpartum coverage for up to 12 months, multi-year continuous eligibility for coverage of children, reentry under the age of five, coverage of justice involved reentry waivers to support community reentry for people who prior to release to facilitate reentry who are incarcerated) and HRSN policies (eg, housing and nutrition)10-12 Development and submission of 1115 waiver for continuous coverage, HRSN services, coverage of justice involved persons9 Development and submission of Medicaid State Plan Amendment for expanded postpartum coverage for up to 12 months13 Development of managed care contract requirements that require Medicaid MCOs to provide HRSN services and CHW services14,15 Development and submission of In Lieu of Services in managed care contracts to provide HRSN services16,17 For S/THOs with oversight of their state Medicaid program: leverage authority of Medicaid program and managed care plans For S/THOs without oversight of their state Medicaid program: collaborate with state Medicaid partners and managed care plans Coverage of multidisciplinary, community-based provider types (eg, CHWs, doulas, peer support specialists, hospital-based violence interventionists, home visitors, and peer support providers)10,18-21 Development and submission of Medicaid State Plan Amendment to cover CHWs, doulas, peer support specialists, hospital-based violence interventionists, home visitors, and other provider types (eg, pharmacists) Development of standing orders or standing recommendations to allow multidisciplinary, community-based provider types to provide services20,22 Development of managed care contract requirements that require MCOs to hire CHWs to provide services for plan members Align quality and performance improvement strategies across Medicaid and public health programs to incentivize evidence-based practices in Medicaid and prioritize efforts to improve care delivery Leveraged public health program quality metrics in Medicaid managed care contracts Collaboration between public health program leaders (eg, WIC Directors, Title V & X Directors, SNAP Directors, Immunization Program Directors, and Ryan White/HIV/AIDS Program Directors) and state Medicaid agency to align public health program and Medicaid managed care contract quality measures, including mandatory Medicaid measures23 Inclusion of a public health input process during MCO request for proposal development Joint membership on quality committees For S/THOs with oversight of their state Medicaid program: leverage authority of Medicaid program and managed care plans For S/THOs without oversight of their state Medicaid program: collaborate with state Medicaid partners and managed care plans Establish data interoperability between Medicaid and public health to facilitate the cross-agency exchange of data and leverage Medicaid data analytics to enhance public health surveillance6 DSAs or Inter/Intra Agency Agreements established between Medicaid agency and public health agency (including Title V, immunization and Ryan White HIV/AIDS programs) Work with state Medicaid agency partners to develop DSAs or IIAs For SHOs with oversight of their state Medicaid program: leverage authority of Medicaid program For SHOs without oversight of their state Medicaid program: collaborate with state Medicaid partners Abbreviations: ASTHO, The Association of State and Territorial Health Officials’; CHWs, community health workers; DSA, data sharing agreements; FTE, full time employee; HPSA, health professional shortage area; HRSA, Health Resources and Services Administration; HRSN, health-related social needs; IIA, Inter/Intra Agency Agreements; MCOs, managed care organizations; PCOs, primary care offices; S/THOs, state and territorial health officials; SHO, state health official; SLRP, State Loan Repayment Program; SNAP, Supplemental Nutrition Assistance Program; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children. Medicaid Partnership (Policy, Quality, and Data) Public health and Medicaid agencies are essential pillars of state government population health services. Successful alignment and integration of the skills and knowledge embedded in these agencies are required to effectively promote health and deliver quality care. Establishing partnership structures for these agencies to maximize coverage of community-based providers and services, developing clinical and social service quality improvement initiatives, and establishing the cross-agency exchange of data to enhance public health surveillance and conduct analyses for population health improvement can increase access to care. Support the Professional Development and Sustained Deployment of Community Health Workers Community health workers (CHWs) can increase access to care among populations who share their life experience and who may be disconnected from or inequitably served by the health care delivery system.24,25 CHWs’ role can include cultural mediation, care coordination and system navigation, coaching and social support, and advocating for individuals and communities, among others.26 S/THOs can encourage sustained hiring of CHWs into the public health workforce, adopt a consistent statewide definition of CHWs, and act as an administrator or champion for CHW certification or training programs.27 Ensure Access to Health Care Providers in Rural and Underserved Communities Every state health agency has a PCO that oversees HRSA-funded programs aimed at identifying shortages of health care providers and facilitating resources to expand access to care, such as federal scholarship and loan repayment programs that are offered to providers that work in an underserved or rural community for a defined number of years. S/THOs can support this work by directing additional resources to PCOs to increase their capacity to facilitate partnerships between the health agency and health care entities, support widespread use of PCO data in the agency’s strategic planning (16 PCOs reported enhancing their HRSA PCO cooperative agreement funding through state general funds).28 S/THOs can also encourage legislative action to invest in state-specific health care provider loan repayment and scholarship programs or to expand the number of provider types eligible to participate in such programs.29 In addition, over the last 4 years, S/THAs have used telehealth to augment treatment and response to infectious disease outbreaks and maintain or expand access to the safety net and primary care services provided by both public health and state health care delivery systems and providers. S/THOs can continue to support access to care by developing and implementing policy that allows broad telehealth use across all populations, such as by encouraging participation in interstate licensure compacts that allow health care providers to engage via telehealth with patients living in other states.30 States can also pursue legislation or regulation that remove geographic restrictions or allow audio only services to be reimbursable, which could be complimented by public health’s patient and provider education about telehealth policies in their jurisdiction. Conclusion S/THOs can play a pivotal role and take strategic actions to improve access to care. Public health agencies’ strength lies in the capacity to influence and leverage their expertise working in concert with other divisions and agencies (eg, state Medicaid agency, Office of Health Equity, Office of Behavioral Health, Office of Aging Services, and Office for Disability Services), state broadband and telehealth offices, other insurance payers, academic institutions, and federal partners. S/THOs can utilize their influence to advocate for changes in insurance practices and health care policies, effectively addressing market drivers behind rural hospital closures, specialty access issues, and the continuation of health care deserts. Through strategic partnerships, creating awareness and championing best practices, S/THOs can extend their impact beyond traditional boundaries, catalyzing significant improvements in access to care.