2018 Canada – United States COMMUNITY HEALTH CENTRES

SUMMIT

SETTING THE

STAGE

Joseph Gallegos

Bruce Gray

Scott Wolfe

September 27, 2018

Victoria, British Columbia, Canada#CACHC18

The Canadian ContextSETTING THE

STAGE

Scott Wolfe

Executive Director

Canadian Association of

Community Health Centres

Toronto, ON

#CACHC18

CDN CHCs: A Sum of Parts

CHCs have different origins across Canada, very often in isolation from each other (within and across provinces). No linear history (i.e. unlike http://chcchronicles.org/histories in U.S.).

Emerge as responses to the imperfect offering of CDN “Medicare”. Two key drivers at local level:

• Lack of health services (eg, rural communities)• Inadequacy of existing health services (eg, inappropriate to local

needs; too medicalized; no health equity approach, etc)

CDN “Medicare”: An Imperfect Offering

Yay!!!“Universal” single-payer healthcare

But wait…• “Hospital and doctor services” only• 13 provincial healthcare systems• Underplayed/valued federal role• Dominance of FFS, medical model• Gaps: dental, vision, Rx, and others• Disconnected from SDOH• No clear consideration of equity

CHC Landscape

200+ CHCs

1. Provides interprofessional primary care

2. Integrates services & programs in primary care, health promotion and community wellbeing

3. Community-centred

4. Actively addresses social determinants of health

5. Committed to health equity and social justice

CDN Definition: Community Health Centre

Additional Challenge: A Fraught

Social/Political Environment

• Austerity• Populism = isolationism = anti-elitism = racism• Complexity vs soundbites• Broken “first past the post” electoral system

CHCs are currently affected by a highly divisive and polarized social context – a global trend, it seems.

Opportunities

CHCs can and must lead• Control what we can control: document impact, demonstrate value• Civic leadership: engagement/education; community building; acting as

connective tissue between different communities• CHCs = solution to multiple complex challenges faced by governments

Complete the unfinished business of Medicare • National Pharmacare, public dental care, community-centred PHC

Leverage our national and global networks (IFCHC, CACHC/NACHC)

Priority: Strengthening our CHC

Movement Across Canada

• Increase CHC association capacity at federal & provincial levels

• Increase coordination of federal and provincial CHC association

efforts

• Better document our impact, tell the CHC story

• Show how CHCs are solution to multiple complex challenges

Canadian Advocacy Agenda: Priorities

• Investment in Community Health Centres

• Universal, single-payer National Pharmacare

• Investment in public dental care

• Investment in affordable housing + support for homeless

• Improving health and opportunity for refugees

Other: harm reduction / opioid crisis, democratic engagement

The U.S. ContextSETTING THE

STAGE

Joseph Gallegos

Senior VP, Western Operations

US National Association of

Community Health Centers

Albuquerque, NM

#CACHC18

2017 Uniform Data System Report

2017 Uniform Data System Report

Historic Changes in Health Care

Key Health Care Trends in U.S.

• Payment reform amidst spending limitations: shift to global payments | Volume / Encounters => Value / Outcomes

• Therapeutic advances

• Access to health care technologies (telehealth, noninvasive bio-monitors, wellness/disease management apps)

• Moving “Upstream”: Social determinants of health

Historic Changes in Health Care

Key Health Care Trends in U.S.

Changing US demographics & dynamics• Age - impact on Medicare and health providers

• 60% more 65+ in 2025 than 2010

• Ethnicity (e.g. growing Latino population). Need for cultural competency and culturally-relevant providers

Attitude toward health, wellness & well-being

Increased emphasis on partnerships & collaboration: Accountable Care

• fully integrated vertical/horizontal levels of care

• avoid “lone wolf” approach to delivering care

Our 2018 Legislative Agenda:

5 Key AreasFederal Grant Funding

FY19 Appropriations; Long term stability for cliff

MedicaidState-federal connection; Protections for overall program and CHC PPS

Behavioral Health/SUD Treatment

Targeted grant funding; Adding billable providers; opioids

340B Drug Pricing Program

Maintaining health center access

Telehealth

Reimbursing CHCs as distant and originating sites

**Workforce issues included throughout agenda**

Policy Priorities

Workforce – Supports CHC Model of “patient-centered care” through team-based approach; Ability

to Recruit & Retain; Provider of Choice/Employer of Choice (National Health Service Corps,

Teaching Health Centers, CEO/CFO, Boot Camp)

Financial Sustainability – Protect CHC grant funding; Protect Medicaid and Children Health

Insurance Programs (CHIP) and other public funding sources, Payment model for CHCs – Medicaid

Prospective Payment System)

340B Pharmacy Benefits – Provide low-cost pharmaceutical supplies for uninsured patients)

Leveraging Tele-Health especially in rural areas – Reimbursement by 3-party payers; Malpractice

coverage; initiating/receiving site; broad band in rural areas

Civic Engagement and Advocacy at local/state/federal level

Behavioral Health & Substance Use Disorder Treatment – Targeted Funding to CHCs; Adding

Billable Providers

Opportunities

CHCs have broad support from policy makers – CHCs viewed by Congress as “front-line”

providers and leaders in community health. Continue to educate members of Congress, state

legislators, federal/state agency officials; city/county officials on value proposition of CHCs

From Triple Aim to Quadruple Aim – CHCs have a long history to impact the following:• Improving the patient experience of care (including quality and satisfaction);

• Improving the health of populations; and

• Reducing the per capita cost of health care

• Focus on Provider/Staff Engagement, Recruitment and Retention – Employer of Choice

CHCs increase access, improve quality of care and reduce overall cost of care

CHC Model – Expertise in addressing Social Determinants of Health (SDOH) – Health Plans are

taking note of the value of CHCs in addressing SDOH

Collaborate with other sectors on SDH – housing; transportation; food safety; employment/training

Challenges

Lack of National Immigration Policy - Increased fear and anxiety for immigrant families, especially children. Fear of deportation due to increased immigration enforcement. Patients not accessing care except for acute/emergency treatment. Dis-enrolling from any form of public assistance

30% Rate of Uninsured – Even after Affordable Care Act (ACA). Threat of Repeal of ACA

Workforce Shortage - Across the Spectrum: Physicians, Physician Assistants, Nurse Practitioners, Behavioral Health Therapists, Dentists, Hygienists, Pharmacists

“CHC model” being challenged to play broader role in public/community health

(i.e., spread of communicable disease-Zika virus in Puerto Rico, Dade County, FL, TX; water contamination in community water systems – Flint, MI; Expand Mental Health Services – lack of gun control; Opioid Use Disorder treatment)

Financing of Health Care – Moving from “Volume” to “Value”

Pressure on CHCs to balance “Mission” with “Margin” – Long Term Financial Sustainability at risk

Challenges, cont.

• Uncertainty continues

• Tax bill zeroed out the individual mandate penalty starting in 2019

• Congressional attempts to address marketplace instability, but no agreement on best path forward; likely no action before elections

• Action has moved to the states – waivers to allow for reinsurance programs to stabilize and reduce premiums

Advocacy & Civic Engagement:

Key to Our Success

Army of 200,000 Health Center Advocates

facebook.com/HCAdvocacyTwitter: @HCAdvocacy

Sign up for text alerts!Text HCADVOCATE to 52886

Sign up for the weekly Washington Update, calls to action, and other

important advocacy communications at

www.hcadvocacy.org/join

The Case for CollaborationSETTING THE

STAGE

Bruce Gray

Chief Executive Officer

Northwest Regional

Primary Care Association

Seattle, WA

#CACHC18

Can-Am CHC Collaboration:

The RIGHT Thing to Do

The “big picture”: ecologies that transcend borders– Similar physical environment

– Common industries and regionalized economies

– Cross-border travel and population movement

– Public health risk factors in common (e.g. increasing chronic disease, Substance Use Disorders)

The shared vision – Providing comprehensive, integrated, holistic, patient-centered & community-based primary

health care Addressing the Social Determinants of Health (SDOH) through “enabling” services

– Offering innovative, team-based workforce models

The value proposition – Sharing promising practices & strategies (knowledge-exchange)

– Building mutually beneficial peer-to-peer networks

– Engaging in collaborative action based on shared vision

Can-Am CHC Collaboration:

The SMART Thing to Do

Evolving Regional Political Frameworks:

The Pacific Coast Collaborative (PCC) example

• Formed in 2008. Forum for cooperative action, leadership and information

sharing by Govts of British Columbia, California, Oregon and Washington.

• Cities of Vancouver, Seattle, Portland, San Francisco, Oakland, and Los

Angeles have since officially joined, with AK in official observer status.

• Pacific Coast of North America => the world’s fifth-largest economy, 55

million people, combined GDP of $3 trillion.

• Primary shared goal: reducing greenhouse gas emissions at least 80 percent

by 2050 through regional action to transform power grids, transportation

systems, buildings, and economies.

Can-Am CHC Collaboration:

The SMART Thing to Do, cont.

PCC & Public Health

• 10th anniversary meeting of PCC March 2018 - Statement of

Cooperation (SOC) on responding to the overdose crisis:

– “The jurisdictions are committed to ending the stigma and discrimination

associated with addiction and substance use disorders, and, to that end, to

identifying and defining areas of future cooperation that will enable an

effective and compassionate response to the overdose crisis.”

Local political frameworks (e.g. Rotary International)

• District 5060 (central BC & WA) and District 7010 (ON & MI)

• Joint meetings and membership on both sides of border

Can-Am CHC Collaboration:

The NECESSARY Thing to Do

Strategy: Leverage pricing

and licensure protections to

ensure a key part in service

delivery.

Strategy: Integrate data and

information in new ways to

better link supply and demand.

Combined net worth: $14.6B.

Current state vs future state for CHCs – analogy of taxis vs ride sharing

• Massive geographic reach and a background in logistics

• Deep experience serving Medicaid patients

• Relationships with State government

• Ability to lever profitability in additional service lines (PBM)

• Unlimited capital to invest

• Deepest experience applying technology to logistical challenges

• Massive existing user base and a highly sticky engagement model

• A focus on innovation

• Incubated through Alphabet’s Sidewalk Labs, w $20 mil in vc

• Political connections through a high profile Board of Directors

• Offering primary care, behavioral health, social services

• Technology to integrate within underserved communities

• Intend to serve underserved communities. From CEO: “CHCs are

facing really significant challenges and aren’t moving as fast as they

need to be toward value-based payments.”

Can-Am CHC Collaboration:

The NECESSARY Thing to Do, cont

Can-Am CHC Collaboration:

The NECESSARY Thing to Do, cont.

A shot across the bow at CHCs and our mandate

Sidewalk Labs & Waterfront Toronto

• Waterfront established in 2001 by Govt of Canada, Province of Ontario and City of Toronto to lead renewal of city’s waterfront.

• Sidewalk Labs won Waterfront Toronto’s RFP.

• Sidewalk Toronto joint effort by the two entities to create new kind of mixed-use, complete community on Toronto’s Eastern Waterfront (325 hectares/800 acres).

• Alphabet plans to move Google’s Canadian headquarters to the Eastern Waterfront.

“The future’s already here. It’s just not very evenly

distributed.”

- William Gibson

Canada – U.S. Survey SETTING THE

STAGE

Scott Wolfe

Executive Director

Canadian Association of

Community Health Centres

#CACHC18

Overview

• Survey report online at: https://infogram.com/2018-canada-us-community-health-centres-survey-1h7j4dn7djed6nr?live

• Survey conducted from Aug – Sept 2018 with CHCs in 5 Canadianprovinces and 14 U.S. states

• 153 responses (Canada = 73, U.S. = 80)

• Goals: identify trends related to services and populations served by CHCs in both countries, with some special attention to opioid crisis; identify areas for collaboration between CHCs and their associations (national, state/provincial, and regional) across borders.

What’s Included in the Report

Sections:• CHC Service Sites, Geographies and Catchments• Populations Served by Canadian and U.S. CHCs• CHC Services and Programs - Clinical• CHC Services and Programs - Clinical comprehensiveness

➢ 15+ Club: CHCs providing services/programs in 15 or more of 22 clinical areas listed in survey

• CHC Services and Programs - Social/Community• CHC Services and Programs - Social comprehensiveness

➢ 8+ Club: CHCs providing services/programs in 8 or more of 13 social/community service areas listed in survey

• The Opioid Crisis - CHC Observations• The Opioid Crisis - CHC Responses• The Opioid Crisis - Comprehensiveness of CHC Responses

➢ 8+ Club: CHCs providing services/programs in 8 or more of 10 service and organizational dev’t areas listed in survey

• The Opioid Crisis - CHC Comments• Participating Community Health Centres

Urban Rural Suburban

Canada 74% 32% 15%

United States 40% 58% 34%

74%

32%

15%

40%

58%

34%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Chart Title

Canada United States

Locations of Communities Served by CHCs

Relative Strengths of CHCs

CANADA: Comprehensiveness of social/community programs

UNITED STATES: Comprehensiveness of clinical services

See Full Survey Findings

https://infogram.com/2018-canada-us-community-health-centres-survey-1h7j4dn7djed6nr?live

2018 Canada – United States COMMUNITY HEALTH CENTRES

SUMMITThank You!www.ifchc.org/victoriasummit2018

September 27, 2018

Victoria, British Columbia, Canada#CACHC18