DSmith_Increasing Prevention Utilization among African Americans_The_6_18_Approach

Denise Smith HSM 544 Course Project Page 1

Increasing Prevention Utilization among African Americans: The 6|18 Approach

Denise O. Smith, BHCA, CHW, PN

February 20, 2016

DeVry University

Professor Danita Erickson, PhD

HSM 544 Health Policy and Economics


TABLE OF CONTENTS

Executive Summary 3

Problem Statement 4

Literature Review 4

Individual Level Intervention 4

Provider Level Intervention 6

System Level Intervention 10

Problem Analysis 13

Possible Solutions 15

Solution and Implementation 16

Justification 21

References 24


EXECUTIVE SUMMARY

African Americans have experienced centuries of disparate health outcomes in all

current measures of chronic disease, morbidity and mortality for centuries. Influencing factors

are myriad and involve historic inequitable access to health care coverage and quality care,

social factors including low health literacy, poverty and limited access to public health

prevention which prevent motivated individuals from complying with available treatments.

Barriers have also been identified within provider education on best practice treatments and

misaligned reimbursements which do not promote dissemination of evidence-based

interventions.

Soaring expenditures and poor health outcomes have motivated researchers, payers

and providers to identify promising solutions in individual, provider and system levels. While

challenges are present at each level, system levels, such as that advocated by the Centers for

Disease Control and Prevention’s 6|18 Initiative is presented in this paper as the most

comprehensive, evidence-based approach to increase prevention interventions among African

Americans. Strengths of this Initiative include public and private payer alignment of goals,

metrics and reimbursements, coordination of public health prevention resources to reduce the

negative impacts of social factors and rapid application of upstream, lower cost, evidence-

based prevention interventions with targeted low income, minority populations who

experience or are at risk for chronic disease.


PROBLEM STATEMENT

African Americans in the United States experience higher rates of morbidity and

mortality from preventable diseases including HIV/AIDS, heart disease, stroke, cancer and

diabetes as compared with their White counterparts (Collins Airhihenbuwa, 2006) (pg 488). The

under use of preventive care among African Americans in the United States is a significant

contributor to disparate rates of morbidity and mortality and high treatment expenditures.

Increased utilization of evidence-based prevention services among African Americans

requires a system level coordination of public health and clinical care that improves access to

evidence-based, culturally appropriate interventions, acknowledges and responds to the

social determinants of health and reduces downstream healthcare expenditures.

LITERATURE REVIEW

This paper reviews articles describing a range of approaches to improve prevention

engagement and health outcomes among African Americans. Articles are organized from

downstream to upstream approaches implemented at the individual, provider and system

levels and represent writers and researchers from academic, government and private sectors.

Individual Level Intervention

In “Behavioral Changes for African Americans”, author and public health professional

Dashiel Geyen attributes the lack of prevention within the African American community as a

problem of individual behavioral change, indicating that African Americans have barriers


resulting from their “inability or unwillingness to perceive the value in, and place a premium on

understanding the misconceptions and purely behavioral threats to maintaining a healthy

lifestyle” (Geyen, 2012, pg 11). Geyen’s article begins with brief summaries of data on the

prevalence of diabetes, stroke, cardiovascular disease and other preventable diseases, pointing

next to cultural lifestyle choices, such as eating “historic and less healthy soul or comfort food”

and “an ego-driven disdain among African American females to exercise for fear that their hair

may become unkempt”, which according to the author are largely responsible for increased

disease risk factors and require individual behavior change. In the remainder of his article,

Geyen advocates for the implementation of behavior change theories including the Health

Belief Model and theory of Planned Behavior as the best practice to reduce poor health

outcomes and reverse cultural habits which are barriers to healthy choices (Geyen, 2012, pg

12).

The Theory of Planned Behavior and other models have been studied with the context

of specific chronic disease. In “Theory of Planned Behavior, Self-Care Motivation, and Blood

Pressure Self-Care”, Rosalind found that attitudes and beliefs regarding the goal of keeping

blood pressure within normal limits were found to determine studied African Americans’

motivation to engage in the multiple behaviors necessary for control” (Peters, 2013, pg 1).

While providing a definition of the theories of planned behavior and self-care, the article also

indicates that little study has been done on self-care and behavior modification among African

Americans. The author stresses that self-care behaviors are “the result of a person’s self-care

ability” along with the presence of “available resources to take the necessary action steps”


(Peters, 2013, pg 3) coupled with a person’s value of the goal-belief; that the goal will be

effective and should be believed in and thus behavior changed to adhere to the goal.

Limitations to individual behavior change approaches are articulated in the “Oxford

Journals 2003 Epidemiologic Reviews” which recommends consideration of the social

determinants of health rather than prevention interventions which are oriented in “simplistic

assumptions that changing people’s awareness about the problem alone would change their

behavior”(Gielen, 2003, pg 67) and provider surveys such as Health Care’s Blind Side

acknowledge the many social barriers to achieving health for their patients (Robert Wood

Johnson Foundation, 2011, pg 6). Peters’ article also cautions that a critical implication of her

“Theory of Planned Behavior, Self-Care Motivation, and Blood Pressure Self-Care” study, is the

extent to which providers are aware of underlying assumptions in these models that patients’

trust the provider’s agency in selecting the appropriate instructions for behavior change. Far

from “mutual goal-setting”, providers are called upon to influence behavior change.

Provider Level Intervention

The utilization of providers as agents to promote high value prevention interventions

within African American communities is being developed by the Centers for Medicare and

Medicaid Services (CMS) through the value-based payment design model. As a payer of

publically funded healthcare coverage for a disproportionate number of African Americans,

CMS has great influence over high value treatment implementation which could impact

prevention access for 5 million African Americans who receive Medicare and 10.4 million

receiving Medicaid (Government Relations and Policy Department, 2016, para 19)


In “Principles for Consumer-Friendly Value-Based Insurance Design”, Families USA, a

public policy and advocacy organization, promotes the benefits of value-based payments to

incentivize both the provider to utilize high value care with patients who have certain chronic

conditions (Centers for Medicare and Medicaid, 2016, para 1), for their “potential to improve

patients’ health and lower healthcare costs” (Mitts, 2013, pg 2) providing that they can be

“driven by high-quality evidence and consumer-friendly principles” (Mitts, 2013, pg 2) which do

not create or sustain additional barriers to care for those who need it most.

There are however, concerns regarding equity in value-based care, identified in

“Incorporating Clinical Value into Coverage Design” published by the Institute for Clinical and

Economic Review (ICER), a policy group who examines “clinical effectiveness and cost

implications of care options” (Institute for Clinical and Economic Review, 2016, para 1). ICER

cites a “lack of consensus on what is the definition of value is and the lack of research being

conducted on value based treatments that are proven to benefit African Americans” among the

challenges of this provider level intervention (Stein, 2016, pg 5). The Center for Medicare and

Medicaid Services, who will begin piloting value-based insurance design in seven states in 2017

through their Medicare program (Centers for Medicare and Medicaid, 2016, para 3), allows

each state to establish their own definitions of value, so goals, metrics and results from the

project will likely be difficult to compare, scale or adapt to varied communities. ICER

recommends establishing a uniform definition of value and the development of “a common

language and model of the components of value across life science companies, payers,

providers and consumers and patients” and increased “public discussion of value” (Stein, 2016,

pg 3, 9).


Uniformity of goals, metrics and interventions is a key strength of the “6|18 Initiative:

Accelerating Evidence into Action”, a conceptual framework developed by the Centers for

Disease Control and Prevention which has researched and identified six (6) high burden,

preventable conditions that 1) affect large numbers of people, 2) are associated with high cost

and 3) are evidence-based interventions that can both reduce cost and improve health”

(Hester, 2016, pg 5) which are candidates for rapid adoption by providers. The six conditions

selected all disproportionately impact African Americans citizens and are all preventable

(Hester, 2016, pg 5). Like the CMS value-based pilot, the CDC 6|18 Initiative engages Medicare

as a partner, but also the Medicaid programs, public health officials, private payers and clinical

providers to begin system level alignment of priority health conditions of targeted population

groups with reimbursements and interventions (Hester, 2016, pg 8). Given that the 6|18

Initiative targets patients covered by Medicaid and Medicare (Centers for Medicare and

Medicaid, 2016, para 3), millions of African Americans stand to benefit.

However, value based payments which incentive evidence-based prevention and

treatments are of no benefit if African Americans cannot access them. With both innovations,

medical providers, especially primary care providers, must be knowledgeable about these 6

targeted conditions and trained to implement these 18 evidence-based interventions in the

presence of historic access barriers experienced by African Americans which often prevent

treatment compliance and block positive health outcomes.

“Prevention for the 21st Century: Setting the Context through Undergraduate Medical

Education”, explores the current status of initiatives to enhance knowledge of effective and

culturally competent prevention within medical schools. The article analyzes medical school


curriculum and concludes that current programs are still insufficient with respect to evidence-

based population health, cultural competency or prevention strategies training. “While many

schools indicate their desire to improve teaching prevention, gaps still exist in population

health education and most schools struggle with even tracking their dissemination of these

education concepts and evaluating their effectiveness” (Pomrehn, 2000, pg 1).

This article recognizes that curriculum changes recommended by the Association of

American Medical Colleges (AAMC) and American Public Health Associations recommendations

in 1945 including “community placements and interdisciplinary training” along with directives

“to ensure that students attend to the preventive and curative concerns of their patients” and

“understand the family, community, and cultural contexts in which their patients live”

(Pomrehn, 2000, S7) will improve providers’ awareness of health disparities and social factors

that impact health, but this may not be enough to transform the system of care. Further

research reveals an additional and more deeply hidden gap in the ability of providers who are

currently treating patients to respond to patients’ needs.

This gap is well documented in the Robert Wood Johnson research study “Health Care’s

Blind Side”, in which 85% of providers acknowledge that “unmet social needs – things like

access to nutritious food, reliable transportation and adequate housing – are leading directly to

worse health for all Americans, 76% of providers wish that the health care system would pay for

the costs associated with connecting patients to these services and 80% of providers are not

confident to address their patients’ social needs” (Robert Wood Johnson Foundation, 2011, pg

5-6). The current American landscape, in which one out of every four African Americans

experiences food insecurity, unemployment is double the rate of White adults, and over 25% of


African Americans are living in poverty (Feeding America, 2016, para 2, 4) prevents many

African Americans from adhering to their providers’ treatment plans and increase morbidity

and mortality rates.

Results of the Health Care’s Blind Side study confirm that more than new, targeted,

evidence-based interventions and high value treatments, providers want the power to write

prescriptions in response to social needs such as fresh food or a mold-free apartment, “such

prescriptions would represent approximately 1 out of every 7 prescriptions that they write”

(Robert Wood Johnson Foundation, 2011, pg 7). These providers comments point to their

desire for a more upstream approach and prevention interventions in response to the social

determinants of health.

System Level Intervention

Challenges with individual behavior change and provider agency along with social

factors which present barriers for both in successful implementation of evidence-based

interventions has resulted in a greater focus further upstream in the healthcare system, with

recommendations of a conglomerate of interventions, innovations and policies encompassed

within an integrated systems approach.

In “Breaking Barriers to Care: A Community of Solution for Chronic Disease

Management”, authors and medical providers James Sanders, Solberg and Gauger present an

evidence-based model emanating from experience providing clinic level health care to

impoverished African American patients in Milwaukee (Sanders, 2013, pg 312) where they

documented high cardiovascular, diabetes and stroke death rates among African Americans and


“end-organ damage nothing less than a national tragedy”(Sanders, 2013, pg 312). The authors

credit the success of their CCDM (community-based chronic disease management program) to

broad community partnerships, patient-centered engagement with low income residents and

training medical students, nurses and residents about social factors that create barriers to

treatment adherence and how to deliver culturally appropriate and respectful service.

CCDM identified “innumerable barriers to ongoing care with which patients had to

contend” including high pharmaceutical costs, preventive monitoring supplies and lack of

health literacy education. Notable in their intervention was the inclusion of Community Health

Workers to increase education, skills and referrals to services between the community and the

clinic.

This intervention, while successful, impacted only hundreds of patients. Effective

response to urgent and growing chronic disease morbidity and mortality rates in African

Americans communities requires a scalable intervention and system support that may be found

through collaborative implementation with the national network of 9,000 Community Health

Centers (CHCs). African Americans comprise 25.8% of patients who receive care at CHCs

(Terrell, 2011, para 3) and currently provide “a comprehensive array of primary and preventive

health care services, and provide needed financial, social and enabling services to tackle even

the most persistent barriers to care” (National Association of Community Health Centers, 2012,

para 2).

In “Health Wanted: The State of Unmet Need for Primary Care in America”, community

health centers advocate for their relevance amidst a climate of federal funding cuts and


position as the solution for those with “elevated health care needs, limited access or no access

to a timely, continuous and regular source of primary care”. Much of this need is concentrated

in urban and rural communities of color where, according to the report, the percentage of low

income populations reaches as high as 100% and where uninsured rates reach 42.8% in

predominately African American cities like Hartford, Oakland, Louisiana and Detroit (National

Association of Community Health Centers, 2012, pg 12). CHCs seek to address poor health

outcomes, primary care shortages, and the need for culturally competent and patient-centered

care for disparate health outcomes such as low birthweight, highest among Black Americans at

14.9%, high rates of HIV infection (National Association of Community Health Centers, 2012, pg

19) highest among African Americans at “44% for new infections and 44% of all people in the

U.S. living with the disease, 8 times that of whites and twice that of Latinos” (The Henry J.

Kaiser Foundation, 2014, para 3,4).

While CHCs have proven their niche as a provider of diverse health services for low

income, uninsured and culturally diverse communities, CHCs have one significant weakness;

they are dependent upon federal funding, which is altered by the President and Congress in

their various budget proposals resulting in “at least 25% of U.S. counties in greatest need”

without a center (National Association of Community Health Centers, 2012, pg 3).

In “Policy Options in Support of High-Value Preventive Care” the authors support

advancement of a multi-level approach which “engages clinicians and the community as

partners” (Stange, 2008, pg 4) similar to recommendations offered in the Breaking Barriers to

Care and Health Wanted articles, and address cost by shifting dollars currently spent on


treatment services for advanced stage diseases to clinical and public health prevention

resources (Stange, 2008, pg 5).

Authors of Policy Options concede that there are still too few providers trained to

implement upstream prevention practices, a topic addressed previously in both provider

education and promotion of value-based insurance design, and thus recommend the furthering

of both, emphasizing that “the focus of the healthcare system must shift from one of crisis care

to upstream interventions which reduce fragmentation in primary care and public health

service delivery and increase patient engagement through education and reduction of patient

barriers” (Stange, 2008).

Policy Options organizes its policy recommendations into five realms (individual and

family, healthcare delivery system, primary care practice, community and financing, stressing

that true implementation requires integration of the five into a sixth realm). Individual behavior

change is highlighted as an important component of achieving health outcomes, but this paper

expands beyond individual choice, emphasizing that “prevention must occur in multiple sectors

and across individuals’ entire life span and embrace screening at-risk populations, management

of disease and targeted health promotion activities” (The National Center for Chronic Disease

Prevention and Health Promotion, 2009, pg 8).

Problem Analysis

African Americans have experienced disparate health outcomes since the early 1700s

when Dutch settlers brought a small group of Africans in chains to American shores where they


were forcibly sold into slavery in the United States slave trade (The History Channel, 2016, para

2). After the Emancipation Proclamation in 1865, physical violence, psychological trauma,

perilous living conditions and poor nutrition persisted in African American communities as

many moved north. In the 1890’s, W.E. B. DuBois collected data on “excessive death rates”

among impoverished African Americans living in Philadelphia “due to bad ventilation, lack of

outdoor life, poor protection against dampness and cold added to hereditary predisposition

and the lack of nearly all measures to prevent the spread of disease” (Dubois, 1899, pg 165),

indicating that disparity in social determinants, health care access and health outcomes for

African Americans has a long history. Desegregation of health facilities such as emergency

rooms and physician offices was not required until 1965, just 51 years ago (National Institutes

of Health, 2013, para 5).

Despite the impact of science and technology over the last century on improved health

for American Whites, African Americans still experience high rates of preventable deaths, for

which “there exist effective treatments such as diabetes, infectious and respiratory disease,

cancers and hypertension” (RWJF Health and Society Scholars Program, 2009).

Most literature agrees that health outcome inequalities experienced by African

Americans in our healthcare system have crippling societal impacts, totaling “over $341.8

billion in excess medical costs” for Black males alone (Maruniak, 2014, para 1,2) and that

prevention is a critical component of a healthy life. Solutions on approaches to improve

prevention care among this population vary in evidence base, cost, timeline for implementation

and intervention level. Increasingly, researchers, payers, providers and patient advocates have

considered an integrated approach in which public health and clinical care coordinate the


delivery of high-value, evidence-based interventions and target high cost, preventable chronic

disease to reduce needless expenditures. Additionally, reports and studies show that these

interventions must incorporate strategies that respond to the social determinants of health,

those “life-enhancing resources, such as food supply, housing and transportation, economic

and social relationships” which disproportionately determine the ability of African Americans to

have access to and comply with prevention interventions (James, 2002).

POSSIBLE SOLUTIONS

1. Prevention for the 21st Century: Training providers in prevention education and public

health interventions including techniques and best practice in the integration of primary

care and public health services is cost effective as curriculum can be developed based

on existing research from government and private foundations and incorporated into

the medical training program. Programs may have additional hiring costs for specialist

instructors who are paid $99,210 to $126,130 or more depending on the geographic

area and prominence of school (Hearst Newspapers, LLC, 2016, para 2) and additional

costs for community placements and supplied may also be incurred.

2. Value-Based Payment Design: CMS will begin piloting this program in seven states in

2017, allowing Medicare plans to offer reduced cost sharing to enrollees with certain

chronic diseases if they engage in high value, evidence-based treatments. Medicare

expenditures comprise “14% or $597 billion of the U.S. federal budget and 22% of

national healthcare spending” (The Henry J. Kaiser Family Foundation, 2015, para 1).

Expenditures will shift from downstream chronic disease expenditures (hospitalizations,


prescription drugs and surgeries) to more upstream and cheaper increased prevention

and reduce chronic disease rates and related service costs.

3. CDC’s 6|18 Initiative: This initiative, comprised of 6 high burden, preventable, chronic

disease focus areas and 18 evidence-based interventions “prioritized to improve health

and save control health costs” (Hester, 2016, pg 6). This initiative is designed to advance

the application of best practice among current providers, acknowledge and incorporate

community supports to prevent social determinant barriers and increase partnerships

across public and privately funded health care coverage programs. Expenditures are

predicted to be reduced due to prevention of chronic disease.

SOLUTION AND IMPLEMENTATION

To increase utilization of evidence-based prevention services among African Americans

the Centers for Disease Control and Prevention 6|18 Initiative should be implemented to target

preventable and costly chronic disease and facilitate access to evidence-based and culturally

appropriate interventions through partnerships with providers, public and private payers and

African American community members.

This Initiative is advantageous over interventions discussed above because: 1) The

intervention addresses the urgent need for rapid dissemination of population focused,

evidence-based interventions to providers and medical schools, 2) The intervention aligns payer

and provider goals and metrics with population-based reimbursements for interventions that

work with targeted chronic disease patients who have high health care expenditures and 3) The

intervention is built on strong collaboration between public health and clinical care which


supports a focus on community partnership, prevention, response to the social determinants of

health and culturally appropriate practices.

The 6|18 Initiative targets 6 chronic disease conditions which disproportionately impact

morbidity and mortality rates in African American communities: 1) tobacco use, 2) high blood

pressure, 3) health-care infections, 4) asthma, 5) unintended pregnancies and 6) diabetes

(Hester, 2016, pg 5) with 18 effective interventions, 3 for each preventable condition, selected

for their efficacy and positive impact on lowering cost. African Americans have the highest

levels of obesity, diabetes and high blood pressure, high cholesterol and associated health

problems such as asthma, as well as historically high rates of smoking (Mandal, 2013) and black

teens are “twice as likely as whites to become pregnant” or have an unwanted pregnancy

(Wiltz, 2015, para 3).

The 6|18 Initiative requires system level implementation and is a collaboration between

public and private payers, medical providers and health care systems (like hospitals and

provider groups) and public health programs at the state and local level. Through contractual

agreements, public and private payers can design reimbursement incentives for clinical

providers to promote and utilize one or more of the 6|18 Initiative targets with corresponding

interventions. Public and private payers should immediately begin to transform their plan

designs to facilitate access to the evidence-based interventions, using the 6|18 matrix as an

assessment tool to align their resources to best practice. Through CMS policy development, all

Medicare and Medicaid patients who are at risk or are diagnosed with these chronic diseases

can be required to have access to these prevention and intervention initiatives. Payers and

providers can analyze patient electronic health record data to confirm eligibility and can


implement any of the 6|18 combinations at one time, building their practices until all

interventions are present in their practice and available to their patients.

Provider training on the 6|18 Initiative, implementation and electronic health records

systems will require time and financial resources. Training should become a part of provider

required continuing education units and be made available at conferences, in-house trainings

and online, as well as be adopted into medical and nursing school curriculum. Public and private

payers can be responsible for upfront costs, as their costs over time will be reduced by fewer

patient expenditures and claims for hospitalizations, specialists and prescription drugs.

Dissemination of the 6|18 matrix of interventions into the public health workforce and

programs should begin immediately, facilitated as collaborations between the Centers for

Disease Control and Prevention and experts at regional Offices of Minority Health and state and

local public health departments and made available through conferences, continuing education,

through online training platforms and adopted into graduate public health program curriculum.

The 6|18 interventions are implemented at varying levels. Payers will coordinate

reimbursement design for 6|18 interventions such as contraceptive services and screenings or

other devices such as self-measuring blood pressure machines and diabetes testing kits (Hester,

2016, pg 7), removing cost sharing and copay barriers for African American patients so that

providers can prescribe and distribute these tools in their practice. Providers will

simultaneously promote other 6|18 interventions, such as tobacco cessation programs, asthma

self-care programs and screenings for blood glucose and obesity as part of cardiovascular risk

assessments (Hester, 2016, pg 7) in collaboration and through referrals to public health


programs and services. Some interventions will incur no cost for payers, as they are already

paid for through public health grant funded programs at the state and local level, such as

diabetes prevention programs and community health worker asthma home visit programs.

Complications and cost barriers during implementation of the 6|18 Initiative may

present in payers’ redesign of provider contracts and patient insurance coverage plans,

development of electronic health record (EHR) data collection systems and intervention metrics

and criteria to identify at risk African American adults for engagement as well as coordination of

training and coordination of collaborative efforts and referrals between clinical and public

health services. Expenditures saved from more downstream services such as hospitalizations

could offset the costs of development and training in EHR, however large capital investments

will be required up front. Coordinating bodies must be identified, track progress and align

metrics with payers and providers to 6|18 Initiative targets.

However, the most significant barriers may still be experienced by those in the African

American community, many of whom have historically not engaged in prevention services due

to lack of knowledge, motivation or health care coverage costs, and those who are prevented

from engagement due to social factors such as lack of transportation to get to appointments,

low health literacy to understand and act on treatment instructions and take medications

appropriately, inability to secure child care to comply with prevention education programs and

appointments, low wages which prevent purchase of needed prescriptions and food insecurity

which may result in poor overall nutrition to maintain health. For the 6|18 Initiative to be

successful, state and municipal departments of public health must improve access to services in


the community that address these needs, partnering with non-profits and coordinating and

training community health workers to identify, engage and refer at risk African Americans.

While the 6|18 Initiative is collaborative, providers are utilized as highly influential

agents on patients’ behalf during implementation, and thus must ensure ethical treatment and

equitable access to services. Providers who are no longer taking patients, are out of a payers’

network or are not culturally competent and respectful may negatively impact quality and

access to services. Historic mistrust of health systems and providers among African Americans

and limited health literacy to engage in self-advocacy in these areas result in other barriers.

Both payers and providers should ensure robust, easy to understand and accessible grievance

policies and procedures are available to all patients.

The 6|18 Initiative is strongly endorsed by the “U.S. Preventive Services Task Force, the

Agency for Healthcare Research and Quality and CDC subject matter experts” (Hester, 2016, pg

4), and the Centers for Disease Control and Prevention is already sharing their interventions,

model and recommendations for implementation with its partners. Even in the presence of

above mentioned barriers, the implementation of the 6|18 Initiative holds promise to increase

utilization of evidence-based prevention services among African Americans through a system

level coordination of public health and clinical care that improves access to evidence-based,

culturally appropriate interventions, acknowledges and responds to the social determinants

of health and reduces downstream health care expenditures, due to its evidence base,

readiness for rapid dissemination, potential to reduce healthcare expenditures and

coordination of population health targets, metrics and partnerships to achieve success. “The

successful adoption of some 6|18 strategies is a critical first step as a proof of concept for a


new way of working together. CDC and its partners need to build on the model, improving it

and expanding it into new themes. Ideally, the broader public health community at the state

and local level will follow CDC’s lead and explore how to create effective partnerships” (Hester,

2016, pg 8).

JUSTIFICATION

African Americans have experienced poor health outcomes for over 350 years due to

debilitating social factors including poverty, low health literacy and historic mistrust of a

healthcare system which often denied access to respectful and equitable quality health care.

The 6|18 Initiative can effectively respond to African American health disparities

because its underlying structure acknowledges health economic, clinical and public health

evidence on how our current health system operates and how it can be transformed.

Health economic production functions depicting the relationship of healthcare inputs to

health outputs shows a marginal return which eventually flattens out at higher levels of care,

indicating that at some point, healthcare inputs have less impact and perhaps even a

diminishing impact on the health of its recipients (Folland, 2010, pg 88). This fact is confirmed

through studies which indicate that 80% of health outcomes are influenced by social and

economic factors (40%), health behaviors (30%), environmental factors (10%), leaving only 20%

of health impacted by clinical care (Booske, 2010, pg 1).

This reality of the distribution of the underlying factors that impact health outcomes

must be primary in analysis; elimination of social and economic barriers will allow for increased

sustainability of evidence-based provider interventions and positive individual behavior change


resulting in 90% of health influences (40% social and economic + 30% health behaviors + 20%

clinical) being addressed across the individual, provider and system levels of health.

Solutions which only focus on individual behavior change or provider level interventions

are insufficient for the population level goal of increased engagement of African Americans in

prevention and reduced chronic disease and health care expenditures. Individual behaviors are

important, but as the data confirms can at best influence only 30% of health outcomes on their

own. Low literacy of individuals, lack of motivation and personal barriers will further reduce the

impact that individual behavior change can have.

Interventions that operate only at the provider level are reliant upon medical schools

and provider continuing education, whose curriculums does not yet mirror the evidence-base

and current payer barriers which have not yet aligned provider reimbursements to targeted

interventions proven to work with African Americans.

“Critics of the U.S. health care system often wonder what Americans are getting for

their money” (Folland, 2010, pg 3) and cite racial disparities in healthcare, estimated at “$35

billion in excess health care expenditures, $10 billion in illness-related lost productivity and

nearly $200 billion in premature deaths” (Ayanian, 2015) as evidence of a wasteful system ill-

equipped to prevent morbidity and mortality. In this context, system level interventions are the

most promising approach to increasing the engagement of African Americans into prevention

services as they acknowledge the need for public and private payer alignment, a shifting of

financial resources to evidence-based medicine, collaboration with and promotion of public


health to reduce risk and lower cost and rapid distribution of interventions at work into care

delivery now, to prevent morbidity and mortality.

Beyond high expenditures, our current healthcare system is inefficient because it does

not distribute services equitably based on need, which can be defined as “the expenditure

required to effect the maximum possible health improvement” (Folland, 2010, pg 375). The

6|18 Initiative improves efficiency in payer, provider and intervention aligned goals, metrics

and targeting of high risk, low income and minority populations while promoting increased

quality in service delivery and coordination of prevention services. Additionally,

implementation of the 6|18 Initiative among African Americans who suffer chronic disease and

are high utilizers of their federal Medicare and Medicaid coverage programs, can lower federal

Medicare and Medicaid expenditures, allowing those tax dollars to be allocated to another

resource-strapped federal program.

Finally, greater efficiency and reduced cost in our healthcare system is achieved through

the 6|18 Initiative because it disseminates evidence-based interventions to clinical providers,

whose practice is subject to small area variations due to lack of uniform training in productive,

validated procedures, resulting in varying health outcomes for African Americans. In the

traditional medical model in the United States, an asymmetric information resource exists

resulting in patients often “delegating decision making to the physician”, known as agency

(Folland, 2010). Contributing to the prevalence of asymmetric information are low health

literacy rates which prevent African American adults from “obtaining, processing and

understanding basic health information and making appropriate health decisions” (Office of

Disease Prevention and Health Promotion, 2008).


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Documents

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