Health Enterprise Zones: "I Believe We Can Eliminate Health Disparities"

Dec 12, 2012, 12:25 PM

The state of Maryland recently passes legislation to address health disparity issues through “health enterprise zones.” The legislation allows local non-profits, health agencies, and local health providers to work together to address this critical issue through innovative public health strategies including tax incentives, financial awards and capital improvement funding for physicians and health care organizations.

Lt. Governor Anthony Brown of Maryland played a key role in establishing the zones, and spoke about them in session at yesterday’s GOVERNING Summit on Healthy Living. Lt. Governor Brown gave some important background on his personal push to establish the health enterprise zones, explaining that his father was a doctor who “taught a lesson of service.” For decades, he said his father saw and cared for patients in some of the poorest neighborhoods in New York. “I saw the file cabinets of unpaid invoices. My father taught me we have a responsibility to serve and care for our neighbors.”

Brown told the audience that, “as we look at health reform, there are real opportunities to address disparities in health. As we expand access, we need to increase quality and equity. I believe we can eliminate health disparities.” NewPublicHealth had the opportunity to speak with Lt. Governor Brown about health enterprise zones.

NewPublicHealth: Is this the first time that a health enterprise zone has been implemented?

Lt. Governor Brown: Yes. Maryland has introduced and now established the health enterprise zone program. As far as we know, and we have searched the literature and looked at practices around the United States to address health disparities, there is no other state that has a program similar ours. The health enterprise zone is an innovative approach to add incentives to the delivery of primary care in targeted communities that are underserved and are experiencing higher rates of chronic diseases, which lead to health disparities. The thinking is that if we can incentivize providers to deliver more resources into the communities that need it most, we can reduce health disparities.

NPH: How did it come about that you chose health enterprise zone as a vehicle to address disparities?

Lt. Governor Brown: The concept is not new, only new in the area of health care and health disparities, but it has been tried and tested already. For example, in economic development, we have economic enterprise zones. In some communities in the U.S. facing economic distress and a high unemployment rate, jurisdictions have offered a package of incentives to companies to provide jobs in those areas and they call them economic enterprise zones. The Harlem Children’s Zone is located in an area of New York City where you have underperforming schools in distressed communities. The community was targeted with resources to improve performance in school. So that is the same concept for addressing disparities that we are looking at for improving health disparities in Maryland. If it works in school and works in economic development then it will work with health disparities.

NPH: What was effective in persuading policymakers to adopt this program in Maryland?

Lt. Governor Brown: In my discussions with them, I started by saying that eliminating health disparities is a moral imperative. There is no reason why an African American girl should be two and a half times more likely to die before her first birthday than a white girl. There is no reason why Maryland should have, and we do, the second highest number of primary care providers per capita compared to any other state yet when it comes to geographic health disparities we rank 35. We are better than that. But then what I did was go to a second step.

If you aren’t convinced about the moral imperative, there certainly is a business case to be made. We have excess admissions of African American patients in our hospitals. What I mean by excess admission is this: African Americans make up a certain percentage of the population in Maryland yet if you look at the admissions in our hospitals, the percentage of admissions for African American patients is a higher percentage than they represent in the population. That additional percentage cost us 820 million dollars in 2010. And in Maryland, because of our all-payer system of reimbursing hospitals, everyone pays for that additional care—particularly when the patient is on Medicaid or if they don’t have insurance at all. So if you don’t think there is a moral imperative there is certainly a financial case to be made that we can save dollars by addressing health disparities.

NPH: How will you measure success?

Lt. Governor Brown: Some of it will be quantitative. In the zones that are created, we will look at hospitals and admissions and readmissions for those conditions that are being addressed. So, for example, if an applicant for a health enterprise zone says my strategy and my focus is reducing asthma or diabetes or hypertension in this zone, we will look at the number of admissions and readmissions for those conditions. We will measure them and we believe we will see a reduction in hospital admittance. Another example could be emergency department visits for preventable conditions where prevention services would reduce the number of emergency department visits.

But some intangible ways in which we will measure the success is the extent to which we bring additional resources including primary care and community resources into targeted communities; create partnerships; create better outreach to the communities that are being served. Because the best way to administer a program is to assure that the community is involved in the program.

Regarding specific metrics, each applicant in a health enterprise zone is also responsible for setting forth what their proposed metrics and criteria are for success. So this is not the state dictating but working collaboratively with applicants to agree on what a set of metrics ought to look like.

NPH: What are some of the other thing you are doing in Maryland to eliminate health disparities?

Lt. Governor Brown: When developing our health enterprise zone, we also established a mandate in other areas. We are requiring our health plans to deliver culturally appropriate educational materials regarding healthcare to their members. Number two is we are developing criteria and eventually curriculum for continuing education for health providers in the area of multicultural healthcare. Number three, we are going to require all state-funded institutions of higher education that teach health professionals, whether it is doctors, nurses, dentists or pharmacists, to take action. We want to see in their curriculum and in their program, effort to reduce health disparities. And finally, we are developing a standard of measurement to measure racial and ethnic variations in health outcomes that will be measured in our hospitals. That information will be available to our health insurance companies so that we can use the data to learn better about what better health disparities. For example, we know things like what percent of African American patients have asthma or have diabetes. We understand and have some data on the disparities, but we need better data in terms of how we deliver care and who we deliver it to.

We know that in our hospitals there are over 50 complications that we believe are preventable. And they are preventable if we adopt certain protocols that, if followed, statistically you are going to eliminate a particular complication—such as changing IV lines and bed pans on a regular basis, and asking certain questions of every patient that comes in. We don’t currently measure that by race or ethnicity, so we don’t know if we asking the same questions of African American patients that we do of other patients. Are we changing bedpans regularly for every patient regardless of race or ethnicity? And since most of these protocols are billable codes that we send to insurance companies, if we could put a racial or ethnic identifier on it, we will be able to better track how we are delivering care in our hospitals. And it will give us more data to determine whether or not there are changes in protocols or practices that need to occur.

We have a significant problem here that has gone unaddressed and that is reducing health disparities. We have to look beyond what we have been doing traditionally.

>>Bonus Link: Read about the success of the Harlem Children’s Zone in a recent NewPublicHealth interview with Angela Glover Blackwell, founder and CEO of PolicyLink, national research and action institute whose goal is to advance economic and social equity.

This commentary originally appeared on the RWJF New Public Health blog.