Redesigning Preconception HealthService Delivery to Achieve Health Equity

Michael C. Lu, MD, MPHDepartment of Obstetrics & GynecologyDavid Geffen School of Medicine at UCLA

Department of Community Health SciencesCenter for Healthier Children, Families and Communities

UCLA School of Public Health

Third National Summit on Preconception Health & HealthcareTampa FL

June 14, 2011

Redesigning Preconception HealthService Delivery to Achieve Health Equity

• Medical home for women’s health• Women and children’s accountable care

organization (ACO)• Best Babies Zone

The definition of insanity is doing the same thing over and over and expecting different results

Benjamin Franklin

Prenatal Care 1.0

Receptionist & Clerks

Medical Assistant

UltrasoundTechNurse Manager

Lu MC. Healthcare reform and women’s health: A life-course perspective. Curr Opin Obstet Gynecol 2010;22:487-91

Prenatal Care 2.0

Oral Health

TeratogenInformationServices

Primary &Specialty Care

Family Support

Social Services

WIC

ReceptionistMedical

Assistant

Ultrasound TechNurse Manager

High RiskOB

Mental HealthLu MC. 2010;22:487-91

Redesigning Preconception HealthService Delivery to Achieve Health Equity

Medical Homefor

Women’s Health

Prenatal Care 3.0

Genetic Counseling& Prenatal Diagnosis

UltrasoundCenter

OBHospitalist

Oral Health

Mental Health

Dietitian & WIC

Primary &PreventiveServices

Health Education

Family Planning

Family Support

& Social Services

High RiskOB

Specialty Clinics

Preconception &Interconception

Care

Prenatal Care

Lu MC. 2010;22:487-91

Women & Children’sAccountable Care

Organization

Redesigning Preconception HealthService Delivery to Achieve Health Equity

Women and Children’s ACO• Reduce costs

• Averted NICU admissions• Averted maternal morbidities• Averted disease & disability in children• Averted heart disease, diabetes, and cancer in adults?

• Improved care • Solo or small group practices to share resources & savings

with the medical home

• Promote population health• Not only from care coordination, but from optimization of

fetal (and preconceptional) origins of health & disease

Women & Children’s ACO

Genetic Counseling& Prenatal Diagnosis

UltrasoundCenter

OBHospitalist

Oral Health

Mental Health

Dietitian & WIC

Primary &Preventive

Care

Health Education

Family Planning

Family Support

& Social Services

High RiskOB

Specialty Clinics

Preconception &Interconception

Care

PrenatalCare

OB

OB

OB

OB

OB

OB

OB

OB

What Can Medicaid Do to Improve Perinatal Outcomes?

• Single largest payer of perinatal healthcare in U.S.• Pays for > 40% of all births• Spends $39 billion a year on perinatal healthcare

• $21 billion for pregnancy and delivery• $18 billion for newborn care

Andrews RM. The national hospital bill: The most expensive conditions by payer, 2006. Healthcare Cost and Utilization Project. Statistical brief #59. September 2008

Women and Children’s ACO Demonstration• Coverage for pre- and inter-conception care

• States with family planning demonstration or state option• Start-up costs

• CMMI or HRSA should provide start-up costs in under-resourced communities• Risk-sharing

• Minimize risk-sharing• Assignment rule

• Assignment should not exclude FQHC’s that provide care through team approach rather than direct physician care

• Performance measurement• Develop perinatal quality measures incl service coordination in ambulatory settings

• Collaborative learning• Support center to facilitate collaborative learning, improvement & innovation

• Integration with Kids ACO• Design in collaboration with Kids ACO demonstration

Best BabiesZone

Redesigning Preconception HealthService Delivery to Achieve Health Equity

HealthDevelopmentEducational

Development

CommunityDevelopment

Economic Development

Best BabiesZone

Best Healthcare • “Accountable care neighborhood” for women’s health

• Preconception and interconception care• Quality improvement in prenatal & intrapartum care  • Comprehensive women’s health services across life course

continuum• Integrated with public health & social services programs in

the community (e.g. Nurse Family Partnership, Healthy Start)• Cost savings are reinvested in the community

Best Education

Too Much, Too Late?

Public Expenditures Children 0-17,

Sweden, 1995

Best Opportunities

• Opportunity Incubator• Macroeconomic policies • Microfinance• Business incubator & job training• Financial literacy & asset development for families• High-function safety net programs

Best Community• Healthy Community

• Clean air and water (environmental justice)

• Healthy foods & physical activities• Fatherhood & Family• Social capital• Racial equity

BBZ Incubator• Assessment• Blueprint• Capacity-Building

• Community engagement• Transformative leadership• Improvement & innovation• Measurement, mapping & evaluation• Policy & advocacy• Design thinking

• Development• Evaluation

AccountableCare

NeighborhoodPromise

Neighborhood

ChoiceNeighborhood

ByrneCriminal Justice

Innovation

Best BabiesZone

“If you want 1 year of prosperity, grow grain. If you want 10 years of prosperity, grow trees. If you want 100 years of prosperity, grow people.”

Chinese Proverb

"We must become the change we want to see.”

- MOHANDAS GANDHI