Building Equity Through Integration Three Integrated Practices at

Building Equity Through Integration: Three “Integrated” Practices at Mount Sinai Hospital? Katherine Garvey and Michael Miller Human Rights and Social Justice Program Symposium Icahn School of Medicine at Mount Sinai April 26, 2018

Outline - Current status of segregated care at Mount Sinai Project: Interviewing three “integrated” departments at Mount Sinai Takeaways and next steps

Definitions: Segregated Care Patients with different insurance statuses (public vs. private) receive different access to and/or quality of care. Segregation by insurance status is de facto segregation by race.

At Mount Sinai Hospital Faculty Practice Associates (FPA) Center for Advanced Medicine (CAM)

Definitions: Integrated Care All patients are seen by the same physicians, in the same location, at the same time.

Barriers to Integration - Financial Space Racism Transition

Goals Understand the structure of “integrated” departments and how they have navigated the aforementioned barriers to integration.

Approach - - Identify “integrated” departments within Mount Sinai - Susan and Leonard Feinstein Inflammatory Bowel Disease Clinical Center - Ruttenberg Treatment Center/Dubin Breast Center (Oncology) - Institute for Liver Diseases Conduct semi-structured interviews with these departments

Interview Questions Transition Clinic Structure Post-Integration Experience - When did this practice - How is the clinic structured? - How, if at all, did the transition to an integrated When are commercially insured impact the care or experience model? patients seen? When are those of your patients? Of your - What prompted this transition? insured with Medicaid seen? providers? - How was this transition? How - Who staffs this clinic? - Are there any challenges with long did it take to complete? - If applicable, why are Medicaid how the clinic is run currently? patients seen on different days with different providers?

Transitions

Transitions Timeline Dubin Breast Center 2010 IBD Clinical Center 2016 2011 Ruttenberg Treatment Center 2017 Institute for Liver Diseases

Common Themes - Decision to integrate was financially motivated Transitions were difficult, but no perceived drop in productivity

340 B Drug Discount Program Source: https: //chartpack. phrma. org/programs-chartpack/medicines-in-340 b/how-340 b-discounts-work

Clinic Structure

Same Physicians? Physicians Inflammatory Bowel Disease ✘ Oncology ✔ Liver ✘ - IBD and Liver: Fellows only see patients with Medicaid

Same Location? Location Inflammatory Bowel Disease ✔ Oncology ✔ Liver ✔ - Patients in all three departments are seen in the same physical space

Same Time? Time Inflammatory Bowel Disease ✘ Oncology ✔ Liver ✔ - IBD: Patients insured by Medicaid are seen on Fridays by Fellows and Attendings; those with commercial insurance are seen Monday-Thursday by Attendings only Liver: ?

Summary Physicians Location Time Inflammatory Bowel Disease ✘ ✔ ✘ Oncology ✔ ✔ ✔ Liver ✘ ✔ ✔

Post-Transition Experience

Common Themes - No evidence that providers or patients were dissatisfied with new clinic structure Perception that “integrated” practices were generating more revenue Perception that wait-times have improved for publicly insured patients

Takeaways - - - Transitions were difficult but doable without noticeable dips in productivity or revenue - Due to 340 B, integration has been profitable All departments noted no patient or physician dissatisfaction with integration - General consensus that this was a positive for all involved Even “integrated” departments do not meet our definition of integration

Next Steps - - Collaborate with Health Equity Task Force to define integration and link 340 B incentive to meeting the requirements of this definition - Next practice to integrate: Rheumatology (Fall 2018) More rigorous data collection pre- and post-integration

Thank you! Special Thanks To - Connor Fox & Brielle Cardieri (Last Year’s Dyad) - Jorge Rodriguez - Dr. Cam Hernandez - Sonia Pagan-Pastor, Practice Manager for IBD - Melissa Bellino, VP for Oncology - Alyson Harty, Clinical Nurse Manager for Liver - Orlando Morel, Practice Manager for Liver

Questions?