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New Disparity Data Released 6 | Health Literacy 8 | Health Policy Summit 2013 23 | OSEDA's Dr. Tracy Greever-Rice 24

Impact Center for Health Policy

University of Missouri

Climate Change:

Ready or not?

Are health care systems and patients prepared to adapt?


Impact Vol. 9, Issue 2 Published by the Center for Health Policy Karen Edison, MD Director Stan Hudson, MA Associate Director Nick Butler, MS Project Director Shannon Canfield, MPH Project Director LaRita Emanuel, MBA Administrative Associate Fiscal/Human Resources Candy Fincher Office Support Staff III Jill Lucht, MS Project Director Ioana Staiculescu, MPH Research Specialist Dave Zellmer Project Development Specialist Amy Dunaway, MPH, MA Jon Stemmle, MA Editors Contributors: Teresa Shipley, Shraddha Sankhe, Tara Robertson Photography from the Center for Health Policy, Flickr User AlexIndigo, Glen Cameron/HCRC, MorgueFile, Deposit Photos, Tracy Greever-Rice, PhD, MS/ OSEDA. Impact is published twice a year by the University of Missouri Center for Health Policy. The University is an affirmative action, equal opportunity employer.

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Dear Friends and Colleagues, Have you noticed that change seems to be the new normal? While in the past change was inevitable, it seems like the pace of change is no longer measured in a day or a week, but now in minutes and seconds. And it’s everywhere I go, from our clinic to my office. With new technology in health care delivery, patients can now monitor their own health with a simple wristband at home and at work. Data can be transmitted back to health care providers who can determine whether someone’s blood sugar has spiked or if someone’s heart is out of rhythm. With new regulations in health care law, the U.S. Supreme Court upheld some provisions of the ACA, like the individual mandate, but Medicaid expansion was not upheld as a guaranteed change. States that had planned on changes around that individual mandate suddenly had to question whether they should expand Medicaid to more of the uninsured. More recently, the Department of Health and Human Services announced that for now state-run insurance marketplaces set to launch in October will not have to verify consumers’ health care status. Only at a later date, will these marketplaces need to verify whether a consumer has employersponsored health care. These examples illustrate how quickly change can happen in health care and health care policy. In this edition of Impact, we examine some of these changes from a macrolevel (see page 14), including the way our climate is affecting health and

health care delivery in Missouri, and how hospital systems here at home and across the nation are preparing for the new normal of varying and often dramatic weather conditions. Likewise, we also highlight microlevel changes in health care data as discussed in a profile piece on our close collaborator, Tracy Greever-Rice, PhD, MS (see page 24). Dr. Greever-Rice is Director (Interim) of the Office of Social and Economic Data Analysis (OSEDA) and is a long-time partner on the MU MO HealthNet Data project. Through this project, we have recently been able to collectively examine health care delivery and better understand the prevalence of deadly skin cancer among young women in Missouri. As summer winds down, I am reminded of these and other changes that influence how we care for our patients, our communities and ourselves. It is true that there are many more changes ahead, and we will still face growing pains, but I am comforted in knowing that with change, there come successful models of adaptation. These paths to success are happening across our state and we will highlight some of them in the next issue of Impact. Until then, please share your stories of change and success with us. You can connect with us on Twitter @CHPMissouri or via e-mail chp@ In good health,

Karen Edison, MD Center Director

summer 2013



14 News Briefs



Cambio de Colores presentation | 4 LGBT health disparities discussed | 5 New health disparity data released | 6 Honoring Mom-Friendly Businesses in Sedalia | 7 Health Literacy update | 8 Medicaid Funding | 9 ACA updates | 10 Expanding Telehealth in Serbia | 12

Changing Climate, Changing Health A look at the way weather & shifting climate patterns are affecting health in the Show-Me state | 14

Publications | 21 Presentations | 22 Summit 2013 | 23 Collaborator Spotlight: OSDEA's Dr. Tracy GreeverRice | 24

Center for Health Policy | 3

News Briefs

Focusing on newcomers and provider perspectives at Cambio de Colores If a family loses almost a third of their household income, what happens to their health? That question and its answers were discussed at the Twelfth Annual Cambio de Colores Conference in St. Louis.

Economist William R. Emmons from the Federal Reserve Bank in St. Louis confirmed that between 2007 and 2010, the median wealth of a Latino family declined 32 percent.

Organized by the University of Missouri’s Cambio Center, Cambio de Colores took place at the University of MissouriSt. Louis between June 12 and 14, and featured presenters included the Center’s Shannon Canfield, MPH, and Ioana Staiculescu, MPH who shared findings from the Missouri Health Equity Collaborative (MOHEC). MOHEC’s presentations highlighted the group’s research of newcomer populations’ experiences around pathways and barriers to access to health care as well as related research on providers’ perspectives on caring for newcomer groups, such as refugees and immigrants. “While the two studies looked at very different


populations, each shared the challenges that come with communication and how critical effective communication is to caring for patients and their families, both in acute situations and across the lifespan,” MOHEC project Director Shannon Canfield explained. “But it was also clear from presenting at the conference that our findings are consistent with other groups and research today. Many providers and advocates at the conference agree that much more needs to be done to help bridge the communication gap between patients and good health outcomes.” Read more about the conference on

Newcomers are individuals or groups who enter the United States, and they may be asylum seekers, immigrants, refugees, legal or illegal aliens, migrants, international adoptees, and others. —L.S. Smith, “Health of America’s newcomers” Journal of Community Health Nursing, 2001

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News Briefs

LGBT health disparities discussed in Columbia This spring, the Center’s Missouri Health Equity Collaborative (MOHEC) co-hosted a community event with the Center Project, the Missouri Foundation for Health (MFH), PROMO, and SAGE Metro St. Louis highlighting the health disparities faced by lesbian, gay, bisexual and transgender (LGBT) Missourians. Community and health advocates gathered in Columbia for one of four community forums being held throughout the state to inform communities about why LGBT health matters and what the latest health disparity findings are. “Many health care providers and community health advocates just aren’t aware of what LGBT Missourians experience in the state,” said Shannon Canfield, MOHEC project director. “LGBT populations are less likely to receive needed health care because of a variety of reasons. These community forums are intended to raise awareness and discuss some of these barriers so we can begin to improve health and health outcomes for all Missourians.” Recent reports from MFH and other state data sources have found that sexual and gender minorities are 1.5 times more likely to be uninsured than the general population, and more than 1-in-3 have not disclosed their sexual orientation to their health care provider(s). Moreover, LGBT families are more likely to be poor, underemployed and multi-racial. A.J. Bokelman, PROMO executive director, said that his organization focuses on LGBT-related policies in Missouri. “Under the new federal administration, there [is] a lot more data coming out about the community,”

Bokelman said. “Until the current administration, the federal government forbade research into gender orientation and sexual orientation.” During the forum, panelists discussed these findings and protections in the Affordable Care Act (ACA) for LGBT groups. Key ACA provisions that help to address these health disparities include: • Inclusion of LGBT individuals in the Patient’s Bill of Rights. • Increased access to preventive care screenings for millions of LGBT individuals. • Improved access to health care. As of 2014, preexisting conditions will no longer be an accepted reason to deny coverage. • Requirements for sexual orientation and gender data collection for national health surveys. And while these new health provisions are steps in the right direction, organizers reiterated awareness is critical, even among LGBT populations. “We’re trying to build a movement to empower the community about their own health,” Bokelman said. “Overall, we’re pretty uneducated about our health. Of gay men who are out, only 40 percent are out to their docs.” Wayland continued the sentiment on raising health care providers’ awareness. “What I’m finding is that most [providers] have the intent to treat us competently, but many are taken aback simply because it’s the first time they’ve had someone come out to them. We need to take responsibility for ourselves.” Additional forums are planned for other regions in Missouri. Stay tuned to for details. Center for Health Policy | 5

News Briefs

MFH releases new data on African American & Hispanic health outcomes in Missouri Why do some Missourians continue to experience poorer health outcomes than others? This was a question circling the minds of participants at the June 4 Health Equity Forum, cosponsored by the Missouri Foundation for Health and the Missouri Health Equity Collaborative. The event had over 90 attendees at the Hampton Inn in Columbia and featured distinguished guest speakers including Cynthia Dean, CEO, Missouri Bootheel 6 | Impact | Summer 2013

Regional Consortium, Fatherhood First Program; Katherine Mathews, MD, MPH, MBA, Casa de Salud; Jason Purnell, PhD, MPH, Washington University; Michael Weaver, MD, St. Luke’s Hospital, Kansas City; and Ryan Barker, MSW, MPA, Missouri Foundation for Health. The Center’s own Director Karen Edison, MD, and MOHEC Project Director Shannon Canfield, MPH, also spoke at the event. Speakers highlighted gains that local communities

were making and responded to new data presented at the meeting on minority health disparities in Missouri. (Download reports from or “The forum was a great networking and data sharing event. We often forget how big Missouri is, and while it may seem like great work is not happening in local communities, the opposite is true. There are many people

concerned about health outcomes for African Americans, Hispanic/ Latinos and others. This event reminded us of that and also ushered in the release of new information about our health care disparities. Having that kind of information can really help focus resources and attention where most needed,” said Canfield. Videos and slides from the event are available online.

Businesses help more moms & babies in Pettis County Breastfeeding is good for new mothers and infants. The practice is linked to lower asthma and obesity rates in children, decreased rates in post-partum depression for new moms, as well as decreases in Type II diabetes. Doctors recommend breastfeeding for an infant’s first year of life. However, research has shown that many new moms will start breastfeeding but drop off after three or six months. Common barriers include problems with milk supply, lack of support and a new mom’s return to work. The Center’s Healthy Community Initiative (HCI), formed in partnership with the MU Department of Family and Community Medicine, helped to honor businesses in Pettis County that are working to address many new moms’ transition back to work. The Pettis County Breastfeeding Coalition, part of the Sedalia/Pettis County Blue Ribbon Task Force, and a key partner of HCI, honored mother-friendly businesses in the area: Katy Trail Community Health, Bothwell Regional Health Center, Pettis County Health Center and Waterloo Industries. These four businesses are the first in Pettis County to be designated as Mother-Friendly Workplaces by the Pettis County Breastfeeding Coalition. To be mother-friendly, businesses provide time and proper facilities for mothers to pump milk during work hours so that they can continue to provide their child with breast milk from bottles.

As businesses become mother-friendly, advocates say the policy change not only helps new moms and their babies, but also the businesses, too. Pat Sturges, co-chair of the Pettis County Breastfeeding Coalition and health coordinator for the Sedalia School District, explained that companies that provide support for mothers to continue to express milk during work hours see an average of $3.00 savings for every $1.00 invested. The Breastfeeding Coalition is part of the Pettis County Blue Ribbon Commission to improve health outcomes in the county. In addition to the Breastfeeding Coalition, the Blue Ribbon Panel includes Clean Air Sedalia, a coalition formed to reduce the burden of secondhand smoke; a youth group formed to reduce teen pregnancy; Healthy Living Action, a coalition to improve nutrition; and a recruitment and retention team for health care professionals. Learn more about the Healthy Community Initiative at: healthpolicy.missouri. edu.

Local leaders and health advocates from Pettis County honor mother friendly businesses.

Center for Health Policy | 7

News Briefs

Health literacy implementation grantees announced

Five health literacy implementation grantees were announced in June from the Greater Health Care Foundation of Kansas City. The grants were part of a collaborative effort being led by the Foundation, the Center for Health Policy and Health Literacy Missouri, to support the adoption and assessment of promising health literacy practices to improve health among safety net patients, and to implement these practices into routine operations of the participating safety net providers and organizations. Details at

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Board-certified health literacy training held in Philadelphia CHP’s health literacy coaches were in Philadelphia on July 25 as part of a national offering of the Center’s groundbreaking Health Literacy Quality Improvement Module. The module is part of the Center’s larger health literacy training program and is the first of its kind in the nation to train doctors to effectively communicate with patients and families. Said Associate Director Stan Hudson, “It was great to begin to expand this program outside of Missouri. Scaled up to a national level, this program has the potential to impact hundreds of thousands of patients and provide them with understandable health information. This would empower patients to act on the information they receive and make them more confident managers of their own health.”

This program is unique: Doctors spend one day learning evidence-based tools and then follow a self-directed improvement plan over the year. CHP coaches provide the data analysis, coaching and personalized video feedback files as well to help doctors implement their plan and achieve measurable results. Additional training dates are being planned. American Board of Family Medicine (ABFM), American Board of Internal Medicine (ABIM), and the American Board of Pediatrics physicians completing the program earn credits fulfilling their maintenance of certification requirements.

News Briefs

Center awarded new contract for meaningful analysis on Medicaid claims data In spring 2013, Center for Health Policy Director Karen Edison, MD, announced a new contract for nearly $300,000 to support the Center’s collaborative work on the MU MO HealthNet Data Project. The MU MO HealthNet Data Project is a collaboration between the Center for Health Policy, the Office of Social and Economic Data Analysis (OSEDA) at the University of Missouri, and the Missouri Department of Social Services, MO HealthNet Division. MO HealthNet is Missouri’s Medicaid or public health insurance coverage for low-income families

with children, senior citizens, and people with disabilities. The goal of the MU MO HealthNet Data Project is to provide health leaders and policymakers high quality, balanced, and timely information on the quality and cost of MO HealthNet services so they can best manage this underserved population of Missourians.

claims data and bring in experts from around the state when necessary. We work to create a complete picture of how the insurance is being used by doctors and patients, and how we can help provide accurate information to stakeholders so state insurance is leveraged for better health.”

Explained Project Director Jill Lucht, “The Center’s team has been working on this project for several years. Together, we work with project partners to analyze MO HealthNet

As part of the new contract, the MU MO HealthNet Data team will publish a web-based “dashboard” analysis tool that includes quality comparisons of fee-for-

service and managed care of MO HealthNet clients. The team will also research and write policy briefs or white papers that examine clinical and administrative areas in the program with the potential for cost savings and improved quality of care. Among the topics in development for these briefs and white papers are emergency department use and hospital readmissions, chronic disease management, home health and preventive care. Learn more about the MU MO HealthNet Data Project online at

Center for Health Policy | 9

News Briefs

Medicaid expansion on hold for now

While Gov. Jay Nixon supported efforts that would expand Medicaid eligibility to more Missourians, no legislation was passed in the General Assembly that would make expansion a reality in 2013. “By not taking the expansion, Missouri is giving up dollars which will go to other states,” said Dave Zellmer, project development specialist. “Hospitals in the state are also still on the hook for the disproportionate hospital share payment cuts that were set to be reduced because of agreements set forth in the Affordable Care Act (ACA). The Obama administration had recommended postponing those cuts but these were not accepted by Congress.” Read more about disproportionate care payment cuts at http://bit. ly/15vFVru. Opponents of the expansion have voiced concern over the cost of expanding Medicaid when almost 1-in-7 Missourians are currently enrolled. Policy analysts project that if Missouri were to expand Medicaid eligibility up to 138 percent of the federal poverty level, the expansion would provide health care to an additional 300,000 Missourians. While the U.S. Department of Health and Human Services has stated the additional costs would be covered through the federal government at first, some legislators are wary that the state will not be able to support expanded Medicaid enrollment in future years as federal support is rolled back.

“Health care is a rising expense. We’ve seen that again and again over time,” CHP Director Karen Edison, MD, stated. “However, in the last few years, we have seen that rising growth actually stabilize or go down. The exact reasons are hard to pinpoint and certainly rising out-of-pocket expenses individuals and families are asked to pay may be part of it. Whatever the reason, though, we know that there are many Missourians who forego care even though they’re working because they just can’t afford it. By not expanding Medicaid, we continue to face these same challenges.”

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News Briefs

Hudson discusses health care navigators on KBIA

Medicaid at the Intersection

In an interview with KBIA, Center Associate Director Stan Hudson discussed one key provision of the Affordable Care Act: the online health insurance marketplace. With over $1 million in funding for “navigators,” these new health care educators will help raise awareness and inform individuals about their health care options.

Is Medicaid expansion right for Missouri? This hotly debated theme was the topic of discussion on a spring episode of Intersection, KBIA’s local news talk show. Center for Health Policy Director Karen Edison, MD, served as a panelist with Rep. Keith Frederick (R-Rolla), and each discussed the benefits and challenges of taking the Medicaid expansion option as proposed under the federal health care law. After the Supreme Court’s ruling in June 2012, each state can decide whether or not to expand its own Medicaid program, what is called MO HealthNet in Missouri. Governor Nixon has announced his support of the expansion, while other lawmakers remain wary. In this episode, Rep. Frederick said he would introduce legislation that would ask the federal government to reinstate disproportionate share hospital or DSH payments that hospitals receive for caring for the poor. Under the current health care law, these DSH payments are being reduced as funding for Medicaid expands. Read more>>>

Get ready for October 2013 Starting in October, individuals and families can enroll in insurance through the Health Insurance Marketplace. Designed to provide one-stop insurance shopping for individuals and small businesses (less than 50 employees), the health insurance marketplace can be run by individual states, work in conjunction with another state, or have the federal marketplace serve its citizens. Missouri's marketplace will be run by the feds. The marketplace isn’t a physical building where you go to buy health insurance; rather, it is a web site citizens can visit that will be packed with information about plan prices, benefits, provider networks and other information that will allow people to compare different health plans. Enroll Missouri provides a centralized source of information for individuals, small businesses and others to learn more about the health insurance marketplace, opportunities for premium assistance to purchase health insurance and more. Learn more at

Center for Health Policy | 11

News Briefs

As part of a Mizzou Advantage grant, Center Director Karen Edison, MD, joined members of the Missouri Telehealth Network, the Health Communication Research Center, and Serbia’s National Alliance for Local Economic Development (NALED) in Serbia this past June. The trip helped to raise awareness of the role telehealth can play in providing specialty health care for rural Serbians. Said Edison, “Serbia faces many of the same challenges that local hospitals and states face in America. How do we set up a telehealth network, how do we ensure the information shared through the technology is secure. This was an exciting opportunity for us to provide technical assistance and also show how Missouri is solving some of these problems today. Over the next few months and years, we anticipate developing our partnership further.” To read more about the group’s travels in Serbia, visit the Heartland Regional Telehealth Center’s web site:

Expanding telehealth in Serbia: Center, MTN and HCRC travel to Serbia as part of Mizzou Advantage Representatives from the Center for Health Policy, the Missouri Telehealth Network (MTN) and the Health Communication Research Center (HCRC) traveled to Serbia in June to help set up the Balkan nation’s first telehealth network. Funded by Mizzou Advantage, members of the team met with Serbia’s National Alliance for Local Economic Development (NALED) for a week in June. NALED previously visited Columbia in 2012 to learn more about telehealth and how its cost-effective solutions could expand access to specialty health care in two urban hospitals and one rural clinic. Since 2012, MTN and NALED have since continued to collaborate on ways telehealth expansion can better serve Serbians. “It is thrilling to be able to help an entire nation begin to think about how they were going to increase

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access to specialty care through telehealth,” said Center Director Karen Edison. “We met with so many excited health care and nonprofit providers in Belgrade and Niis, and having worked in telemedicine for so long, I know that it takes a small group of committed individuals to help champion these innovations. In the months and years ahead, it will be exciting for us to continue this partnership and see how other nations can learn from the work we do in Missouri.” Along with Edison, delegation members also included MTN Director Rachel Mutrux and MTN Assistant Director Mirna Becevic, and HCRC Co-Director Glen T. Cameron, PhD.

Top: Karen Edison, MD, is interviewed by local Serbian journalists about telehealth’s applicability to residents. Bottom: The Missouri team prepares to be interviewed on national Serbian television.

Edison explains value of telehealth on NPR’s Talk of the Nation

Center Director Karen Edison, MD, recently served as a guest on the NPR program “Talk of the Nation.” Edison joined Dr. Ray Dorsey from Johns Hopkins Medicine, Md., in voicing support for telemedicine services. Tune in>>>

Broadband summit spotlights urban health care for rural Missourians Connecting doctors and patients anywhere is the basis of telemedicine, but that requires fast Internet speeds, which are often not available in rural areas. To discuss how to make health care more accessible, efficient and cost-effective, and how these models can apply to the current and planned provisions of the Affordable Care Act (ACA), MoBroadband Now and Broadband Illinois hosted the Broadband Telemedicine Summit in May. More than 150 health care providers, administrators, public health professionals, insurers and health information engineers attended.

Participants heard from local, state and national thought leaders, including Missouri Gov. Jay Nixon, American Telemedicine Association’s Jon Linkous and Mercy Hospital System’s Thomas Hale, MD, PhD, and Christopher Veremakis, MD. More information and selected videos from the summit can be found online: Use-it/Broadband-Telemedicine-Summit/Video-Fromthe-Event.html

Changing Health By Teresa Shipley

A look at the way weather & shifting climate patters are affecting health in the show-me state

Climate change might seem like a subject still up for debate, but in Missouri, lawmakers said as early as 1991 that climate change was not only real, but posed a threat to human society. The majority of climate scientists are adamant: Climate change is not only real, it’s here….now.

In northern latitudes, summers are warmer today than they’ve been for the last 600 years. The United Nations Intergovernmental Panel on Climate Change (IPCC), the leading body in charge of studying global warming, 14 | Impact | Summer 2013

says there is “incontrovertible evidence” that the global climate is changing thanks to man and is leading to an increase in severe weather and certain types of diseases. While global warming means potential tough times for farmers, one of the most troubling implications is its negative effect on human health. While Missouri doesn’t have to worry about the rising sea level, it will potentially have to face an increase in infectious diseases

Flickr user AlexIndigo

Changing Weather


like West Nile virus, more frequent and severe storms, and a changing plant landscape that could increase conditions like Lyme Disease, asthma, and chronic obstructive pulmonary disease. Missouri’s regional administrator for the Environmental Protection Agency, Karl Brooks, told a St. Louis CBS affiliate that climate change is producing more extreme weather and contributing to breathing problems and heart disease. The EPA’s web site also says that in the Midwest, average annual temperatures increased over the last several decades. “Heat waves are becoming more frequent and cold periods are becoming rarer…Heavy downpours now occur twice as frequently as they did

a century ago. These trends are likely to continue under future climate change: average summer temperatures are projected to increase by 3°F over the next few decades and could increase by over 10°F by the end of this century. This range would make summers in Illinois and Michigan feel like those in present-day Texas and Oklahoma, respectively.” In Missouri, one in 11 people are already living with asthma, which cost $96 million in hospital charges in 2008. Now, climate scientists are warning that climate change, specifically changing ozone levels, can lead to an average of seven percent increase in asthma emergency room visits. Right now, Missouri’s Department of Health and Senior Services

estimates that more than five in 1,000 people visit the ER because of asthma. Nationally, asthma costs society more than $50 billion per year in health care expenses, missed school and workdays, and early death. While the specific causes of asthma aren’t known, the triggers are well documented: Environmental agents like mold, mildew and pollen all exacerbate asthma. Experts say climate change is expected to affect air quality in several ways, including higher concentrations of ozone, more carbon dioxide (which can lead to more prolific pollen- and moldproducing plants) and increased frequency of droughts, which means more dust and particulates in the air.

Curious about what states are doing to address climate change and continue to grow economic opportunity? The North America 2050 Partnership for Progress (NA2050) facilitates state and provincial efforts to design, promote and implement costChanging weather effective policies that reduce greenhouse gas and storm emissions and create economic opportunities. readiness Learn more at For Missouri, another climate change-related

worry is tornadoes. Climate change has been linked to a rise in deadly tornadoes. In Joplin in 2011, major area hospitals faced a crisis when the town was blasted by a mile-wide tornado, which killed more than 150 people and injured more than 1,300, wiping out nearly one half of the city’s health care resources in the process. St. John’s Mercy Regional Hospital was almost totally annihilated and had to relocate all its patients to other centers and auxiliary buildings. Two years later, the hospital is still rebuilding the new St. John’s. Next door to St. John’s, Freeman Hospital West lost more than 17,000 square feet of its roof and was without power and utilities, including air conditioning, for 18 hours, according to Skip Harper, the hospital’s environmental health and safety officer. Freeman was also without water for 48 hours following the deadly tornado. Center for Health Policy | 15


“We did not have access to running water, sewer, electrical power,” Harper said. “With the loss of the water, you lose pretty much every utility you have: air conditioning, the ability to flush toilets. After 48 hours, there were still boil orders in place, and we couldn’t do a lot until the boil orders were rescinded.” Flooding is likely to be another side effect of climate change in Missouri. Flooding can cause a range of health impacts and risks, including contaminated drinking water, hazardous material spills, increased numbers of disease-carrying insects and rodents, moldy houses, and community disruption and displacement, according to the Natural Resource Defense Council. The diseases could be waterborne, like typhoid fever,

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cholera, and hepatitis A, or carried by insects, such as malaria, dengue fever, and West Nile Fever.

Adapting to climate change Despite the gloomy news, scientists are stressing that humans can adapt to the effects of climate change. The National Institutes of Health, which studies the effects of climate change on human health, said that implementing key strategies now will protect human health and the environment. In its 2010 report on the subject, the agency said, “Certain adverse health effects can be minimized or avoided with sound mitigation and adaptation strategies. Strategies for mitigating and adapting to climate change can prevent illness and death in people now, while also protecting the

environment and health of future generations.” States like Missouri can learn from other regions in the U.S. that have developed strong public health partnerships over time to respond in times of disaster. When Hurricane Sandy hit the East Coast last year, public health officials had a plan in place to cope with the unprecedented disaster. Dan Regenye coordinates the public health department for Ocean County, New Jersey, one of the hardest hit areas on the eastern seaboard. Soon after the hurricane hit, his office deployed a mobile health van that dispensed tetanus and flu shots and kits with sterile gloves, masks and sanitizer. The van also carried a health educator to help answer the workers’ and volunteers’ questions. As

Regenye said on the New Public Health blog from the Robert Wood Johnson Foundation, it’s important to better define and better establish public health in terms of emergency response. “We … know that no single organization can meet the needs in a response independently,” Regenye said. “It really does need to be a concerted effort and a lot of times that’s challenging when you’re bringing together multiple organizations that are based on different cultures and policies and procedures and driving factors. “I think we’ve been very good as a convener in the past, which helped us tremendously during Sandy. It’s extremely important to meet the people in as many other organizations you might

need to partner with as possible, prior to an event so when an event occurs you know who the key people are within the organizations and within your community.”

Lessons from Joplin Hospitals in Joplin are learning from the devastating 2011 tornado and implementing new building designs to strengthen their resilience to other disasters. The old St. John’s is now known simply as Mercy Regional Hospital. As it rebuilds, Mercy is devising a window system that can protect its inhabitants from 250 mph winds. Mercy also is adding a concrete roof, fortifying “safe zones” on every floor and half-burying generators away from the main building. In all, Mercy is spending about $11 million in upgrades specifically designed to harden the new hospital against natural disasters, according to the hospital’s web site. Skip Harper at Freeman Hospital System said the biggest lesson they learned was the necessity of good planning. As part of its normal preparedness plans, the hospital had Memorandums of

Understanding (MOUs) with many other businesses and health care providers in the state. “You may not be able to physically prepare for something as massive as this, but you can be mentally prepared,” he said. “Through the Missouri Hospital Association, we have MOU’s with every hospital in the state, which allows us to share resources in advance. We didn’t have to worry about filling out contracts or signing legal documents.” For Freeman, supplies and aid arrived in ambulances from a four-state area. Harper and others were communicating via Hamm radios and text messages after the storm. “People outside Joplin knew much better what was going on than we did,” he said. The relationships and contracts signed in advance of the storm were a major key to Freeman’s ability to ride out the tornado. The hospital stayed fully operational the entire time, Harper said. The Missouri Hospital Association recently released a report about the Joplin disaster and the lessons learned. It highlights several key areas health care systems

need to address in order to have an effective response to disasters, including a safe environment, continuity of operations, management of a sudden or sustained influx of patients requiring medical assessment and care, identification of the organization’s capabilities and limitations and coordination with other community and regional partners. The report stressed that emergency preparedness planning must not be an exclusive process. “All employees and medical staff must know and understand the emergency operations plan,” the report’s authors stated. “Further, regional and state coordination are essential — know your partners. Plan and exercise together. The number one lesson learned always centers on communication.” Harper said the biggest lifesaver after the Joplin tornado was not anything the hospitals did, although he said Freeman’s patients that day did have more than a 99.6 percent survival rate.

“What saved more lives than anything was triage done out in the field community-based first aid,” he said. Harper said any disaster that hits “is a community event.” To that end, he said Freeman started providing more training to staff so they understand emergency preparedness protocols. Also, Freeman provides free quarterly trainings for the whole community in addition to its staff in areas like hospital preparedness, what to do during a chemical, biological or radiation event and leadership during disasters. “We’re the only hospital that I know of that goes as Continued on pg 19 Center for Health Policy | 17

How telehealth & technology can help When it comes to adopting climate action policies, one hurdle facing Missouri is cost. Many energy reduction projects require large start-up costs, for example, especially when they include investment in new, more efficient technologies. But in health care, new technologies can often mean reduced costs for both doctors and patients. In Missouri and globally, telehealth is poised to transform the way areas practice health care in the face of a changing climate. Using telehealth as a response to the challenges of climate change is nothing new. In 1999, the United Nations established an action team to help implement telehealth in developing countries while using space technologies like satellites to aid public health workers in detecting infectious diseases earlier. Missouri policymakers could consider investing in more “hospital at home” programs, which have flourished in countries with single-payer health systems, but have only been used on a limited basis in the U.S. The

Commonwealth Fund, a bipartisan health care and health policy research group, said hospital-at-home programs are proven to be “safer, cheaper, and more effective than traditional hospital care, especially for patients who are vulnerable to hospital-acquired infections and other complications of inpatient care.” Instituting more of these programs, which are delivered primarily via telehealth, would save hospital systems money by reducing overhead costs. It would also relieve stress on hospitals faced with public health emergencies because more beds would be free. Additionally, under the Affordable Care Act, states can apply for federal funding to provide “Health Homes” to Medicaid participants with chronic illnesses. In Missouri, this project is already underway. The Missouri Health Home initiative, a program that integrates behavioral health and primary care, has seen a 16 percent reduction in per-Medicaid-beneficiary costs. As of 2012, the state had nearly 19,000 patients enrolled in the program.

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far as community training,” Harper said, adding that he’s been invited to speak all over the country about Freeman’s model of emergency preparedness.

Missouri’s Other Preparations Missouri also has some federally designated programs in place to help with responding to disasters. The CDC’s Cities Readiness Initiative (CRI) is a federal program designed to enhance preparedness in the nation’s largest cities and other “metropolitan statistical areas” where more than 50 percent of the U.S. population resides. Through CRI, state and large metropolitan public health departments have developed plans to respond to a large-scale bioterrorist event by

dispensing antibiotics to the entire population of an identified metro area within 48 hours. Missouri has two: Kansas City and St. Louis. Funding for this program comes from the CDC’s Public Health Emergency Preparedness (PHEP) cooperative agreement. The CDC provides a “snapshot” of Missouri’s public health preparedness. For example, Missouri contributed to the laboratory response in the 2006 E. coli outbreak in spinach, the largest foodborne disease outbreak in the United States since 1993. Prior to the cooperative agreement, the Missouri State Public Health Laboratory (MSPHL) did not have adequate staff, equipment, or communication systems

to rapidly respond to an event the size of the 2006 outbreak. Now, MSPHL provides a wide variety of testing 365 days per year. According to the Missouri Department of Health and Senior Services, the cooperative agreement is valuable because “it has allowed the state to hire staff, purchase new equipment, draft guidances, and prepare training and educational opportunities for its workforce.” The agency's web site reports that staff have been trained in disaster response techniques and methods that were invaluable during the response to Hurricane Katrina. While local communities such as Joplin have begun to rebuild and strengthen their emergency

response plans, at the state level, little has been done to implement recommendations from scientists and other experts. It falls short on passing much legislation specific to climate change, seeming to rely instead on independent adoption of policies on a local scale. For example, in addition to a public health preparedness plan, most U.S. states also have a “Climate Action Plan” in place. Missouri’s was written in 2002. It includes recommendations to reduce greenhouse gas (GHG) emissions in a variety of ways, including reforestation, using alternatively fueled vehicles, and rethinking solid waste management, but little in the way of methods for adapting to a warmer, stormier world. Many cities and universities in the state have taken charge in forwarding their own, often more stringent, climate action plans. At a recent symposium on climate change, the University of Missouri said it was prepared to “lead an effort” to help find ways for society to not only adapt to a different climate, but profit from it. It implemented its “climate action plan” in 2011, with the overarching goal of

Center for Health Policy | 19


carbon neutrality, greatly expanding its research focus in this area. In 2008, Kansas City adopted a city-wide “climate protection plan,” which focuses on energy efficiency, public transportation and expanding green spaces - all actions which improve air quality as well as lower GHG emissions. Just last year, Richmond Heights, a suburb of St. Louis, began implementing its own “climate action plan” with similar goals.

greater attention to public health preparedness. By incorporating more telehealth-based programs, states can potentially be better poised to respond to severe events. But whether state policy makers are responding to disaster preparedness because of “climate change” specifically may not matter; scientists agree the changes are coming whether we’re ready or not. Ω

Thanks to recent superstorms like Hurricane Sandy, Missouri and other states are paying even

>>>>Climate Change Resources: Want an up-to-date list of climate-related legislation in all 50

states? The Center for Climate and Energy Solutions (C2ES) has these lists, as well as information on Missouri’s own policies. See more at

20 | Impact | Summer 2013



Karen E. Edison, David A. Fleming, Elizabeth Lewis Nieman, Kendra Stine, Louanne Chance, and George Demiris. “Content and Style Comparison of Physician Communication in Teledermatology and In-Person Visits.” Telemedicine and e-Health. July 2013. Available from: Sherri Ulbrick, James Campbell, Carla Dyer, Gretchen Gregory, and Stan Hudson, “Interprofessional Education on Health Literacy: Session Development, Implementation, and Evaluation,” Annals of Behavioral Science and Medical Education. 2013, Vol. 19, No. 1, 3-7. Available from: viewFile/152/151.

April 25, 2014 Missouri Health Equity Conference Columbia, MO Details at

Center for Health Policy | 21


Presentations A roundup of early 2013 presentations made from Center staff. Jan. 10 Joint Commission Simulation Center, Columbia, Requirements, Presentation, MO, Karen Edison, Stan Green Meadows Clinic, Hudson, David Fleming, Jim Columbia, MO, Stan Hudson, Campbell, Diane Smith, Nick Nick Butler Butler, Ioana Staiculescu, Dave Zellmer Feb. 28 Booster Education Day, Health Literacy Mar. 28 Caring CommunitiesStrategies, Presentation, Strategies for Healthier Carondolet Health Literacy Patient/Provider Presentation, St Joseph Communication, Workshop, Medical Center, Kansas City, Randolph County Health MO, Stan Hudson Department, Moberly, MO, Stan Hudson Mar. 4 Educate you Patients and Improve Outcomes, Mar. 29 Bring Your Power Presentation, AAD Annual to the Table, Presentation, Meeting, Miami, FL, Karen Bothwell Education Center, Edison Sedalia, MO, Karen Edison, Chris Stewart, CEO Katy Trail Mar. 5 Educate Your Patients, Community Health Panel, AAD Therapeutic Safety Forum, Miami, FL, Apr. 4 Using Simulation for Karen Edison Interprofessional Education on Health Literacy, Poster, Mar. 12 Access to Health Education Day, MU School Care Services: Perspectives of Medicine, Columbia, from Patients with Mental MO, Deb Howenstine, Stan Health Issues, Poster, Hudson Diversity RX Conference, Oakland, CA, Nancie Apr. 4 Teaching Culturally McAnaugh, Steve Jeanetta, Effective Health Care, Karen Edison, Ioana Presentation, Education Day, Staiculescu, Caress Dean and MU School of Medicine, Stan Hudson Columbia, MO, Deb Howenstine, Stan Hudson Mar. 13 Disparities in Access to Health Care Apr. 25 Health Literacy Services: Perspectives from Strategies, Presentation, Refugee and Immigrant Healthy Community Initiative, Patients, Poster, Diversity Sedalia, MO, Stan Hudson RX Conference, Oakland CA, Nancie McAnaugh, Steve Apr. 25 UMHS Healthy Jeanetta, Karen Edison, Community Initiative (HCI): Ioana Staiculescu, Caress A Collaboration Model for Dean and Stan Hudson Improving Population Health, Presentation, MOCAN Mar. 25 Health Literacy Quarterly Meeting, Columbia, Maintenance of Certification MO, Kevin Everett, Shannon Training, Workshop, Canfield 22 | Impact | Summer 2013

Apr. 26 Strategies for Healthier Patient/ Provider Communication, Presentation, Clinical Oncology Symposium, Columbia, MO, Stan Hudson Apr. 30 One Health One Medicine One Community Network, Poster, Third Annual Mizzou Advantage Day, Columbia, MO, Karen Edison, Amy Lake, Stan Hudson, Molly VetterSmith, Sharon Grass, Joseph Lemaster, Melissa Maras, Shannon Canfield May 1 A Collaboration Model for Improving Population Health: UMHS Healthy Community Initiative (HCI), Poster, UMHS Innovation and Improvement Sharing Days, Columbia, MO, Kevin Everett, Karen Edison, Molly VetterSmith, David Mehr, Shannon Canfield May 1 Missouri’s Pilot Primary Care Extension Program, Poster, UMHS Innovation and Improvement Sharing Days, Columbia, MO, Molly Vetter-Smith, Shannon Canfield, Karen Edison, David Mehr, Kevin Everett May 8 UMHS Healthy community Initiative: A Collaboration Model for Addressing Population Health, Presentation, Colwill Seminar, Columbia, MO, Kevin Everett, Shannon Canfield, Karen Edison, Molly Vetter-Smith May 15 Center for Health Policy (CHP) & Childhood

Obesity, Presentation, MU Childhood Obesity Initiative, Columbia, MO, Karen Edison June 4 Center for Health Policy MOHEC Qualitative Overview, Presentation, MFH - MOHEC Health Equity Forum, Columbia MO, Shannon Canfield, Ioana Staiculescu June 7 Strategies for Healthier Patient/ Provider Communication, Presentation, Social Service Association of Missouri, Lake Ozark, MO, Nick Butler June 13 Caring for Newcomer Patients: Provider Perspectives, Presentation, Cambio de Colores, St. Louis, MO, Stephen Jeanetta, Karen Edison, Ioana Staiculescu, Shannon Canfield, Stan Hudson June 14 Caring for Newcomer Patients: Provider Perspectives, Presentation, Cambio de Colores, St. Louis, MO, Stephen Jeanetta, Karen Edison, Ioana Staiculescu, Shannon Canfield, Stan Hudson

Summit 2013

Left to right: Susan Dentzer, Stephen McHale, Daphne Miller, MD.

RWJF’s Dentzer headlines Summit 2013 It’s two months and counting until the Center’s Eleventh Missouri Health Policy Summit. This year’s summit, “Moving Beyond Politics: Meaningful Health Reform for Missouri Communities,” will be held on October 25th from 8 a.m. to 5 p.m. at the Hilton Garden Inn Conference Center in Columbia. Susan Dentzer (Robert Wood Johnson Foundation), Stephen McHale (Explorys) and Daphne Miller, MD (WholefamilyMD) are the distinguished keynote speakers. Susan Dentzer is a senior policy advisor at the Robert Wood Johnson Foundation and one of the nation’s most respected health and health policy thought leaders. A frequent guest and news commentator, Dentzer was editor-in-chief of Health Affairs, and transformed the publication into the nation’s leading journal of health policy. Stephen McHale is co-founder and CEO of Explorys, a leading health care data analysis and management firm. Explorys helps providers and health care systems use electronic health records (EHRs) to improve health

and the delivery of medicine. McHale has a deep background in health data and technology and leverages a keen understanding of the fields as providers struggle to make sense of big data. Daphne Miller, MD, is a family physician, author and health advocate who explores the frontier between modern medicine and the natural world. Uniting complementary ideas from many cultures, Miller’s work embodies the idea that health begins long before a patient steps into the doctor’s office. She founded WholefamilyMD, an integrative primary care practice in San Francisco and continues to practice there, caring for patients across their lifespan. Registrations are now open for the day-long conference. Participants can save time and money by registering in advance. Early bird registration for the conference is $150 until October 1. On Twitter? Follow #Summit13 for all the details. Additional information is available online at

Center for Health Policy | 23

Collaborator Spotlight

MU Mo HealthNet Data Project Spotlight on Mo HealthNet:

A conversation with Director (Interim) of OSEDA, Dr. Tracy Greever-Rice By Shraddha Sankhe and Tara Robertson Since her start with the Office of Social and Economic Data Analysis (OSEDA) in 1999, Tracy Greever-Rice, PhD, MS, has been fostering collaboration. In fact, she originally was brought to OSEDA to encourage human services professionals, like health care workers, social workers, therapists and others, to collaborate together. That idea is still evident in projects, such as work OSEDA and the Center for Health Policy (CHP) conduct together on the MU MO HealthNet Data Project. The MU MO HealthNet Data Project assists the state’s public insurance program administrators to make meaning of their claims data. The MO HealthNet program is Missouri’s public health coverage or Medicaid program for low-income families with children, senior citizens and people with disabilities. Through the MU MO HealthNet Data Project, research teams under direction of the Missouri Department of Social Services MO HealthNet Division provide tailored analyses to better understand program costs and quality of care issues.

24 | Impact | Summer 2013

The MU MO HealthNet Data Project collaboration was a result of work that the Center for Health Policy completed as a member of the interdisciplinary MU Medicaid Workgroup in 2005. The goal of the project is to find more efficient ways to impact more lives through improved health care. Dr. Greever-Rice says her team creates reports based on claims data for MO HealthNet. These data-driven reports, on topics such as mental health prescriptions for children, sometimes contribute to larger multi-state reports drawn from Medicaid data in Missouri and other states. This project has become even more meaningful since the enactment of the Affordable Care Act (ACA), which put a focus on meaningful data for better care delivery and resource management. From direct patient care to administrative support, it becomes critical to have evidence and accountability that supports how the state uses limited dollars to care for an estimated one million Missourians. “I think there is going to be more and more pressure on every element of the health care system in the state to quantifiably rationalize why they are choosing to do what they are doing,” says Dr. Greever-Rice. “Giving meaning to the data and answering the health care policy questions in a way that’s far more affordable is what we do in the MO HealthNet data research.” To do this work, OSEDA uses an interdisciplinary faculty of health care analysts and social science researchers who examine and interpret the state’s Medicaid claims for the Missouri Department of Social Services. Along with OSEDA, which is part of the MU College of Agriculture, Food and Natural Resources (CAFNR), Division of Applied Social Sciences, and CHP, the MO HealthNet data project is structured to pull together expertise from other groups around the state, if necessary. It is a federal program managed by the state of Missouri and a perfect example of a state-university

Collaborator Spotlight

The Office of Social and Economic Data Analysis (OSEDA) collaborates with partners in the analysis of social and economic data in ways that contribute to improvements in the well-being of people, enterprises and communities. Learn more about OSEDA's work at

partnership. Using a collaborative model to examine the data often helps in interpreting findings because of the different viewpoints and expertise involved in the analysis. The MO HealthNet program serves low-income children, pregnant women, people with disabilities who are unable to work, seniors, and very low-income parents. Although it’s a subset of the population, it is a segment that often needs the most help. One recent study involved skin cancer within the Medicaid population. Melanoma, a malignant type of skin cancer, is generally more of a male phenomenon in Missouri. However, in the data that the MU MO HealthNet Data Project studied, more young women in rural counties were affected. On the surface, the results were surprising, but given the population that MO HealthNet serves, the findings made sense to researchers and state authorities. Most importantly, the finding provided actionable data. Currently, CHP Director Karen Edison is developing a melanoma outreach and screening initiative to reach out to young women in rural areas to teach them how to protect themselves from skin cancer. “These projects can seem like they are really deep in the data weeds sometimes, but the work itself, in cases like this, can bring about an actual intervention that has an impact on people’s life in a direct way,” Dr. Greever-Rice said. The MU MO HealthNet project will continue to be critical to Missouri leaders and decision makers in the future. Currently, 1-in-6 Missourians are covered under MO HealthNet. Under federal health care reform, Missouri has a new opportunity to offer Medicaid insurance

coverage to adults, starting in 2014. Under Medicaid expansion, eligibility for Medicaid would extend from the current 19 percent of the federal poverty level to 138 percent, reducing the state’s uninsured by more than one-fourth. That would provide coverage for more than 250,000 previously uninsured Missourians, and bring an estimated $1.56 billion in new federal health care matching funds into the state’s economy in 2014. Medicaid expansion was not passed in the 2013 legislative session by lawmakers, however, new expansion legislation is anticipated for the 2014 session. As legislators and staffers begin to write anticipated legislative bills, the MU MO HealthNet Data Project may prove to be an invaluable resource. “We’ve been doing this work for so long,” says Dr. Greever-Rice, “and we have a very good handle on the trends and the recent history of what’s going on with Missouri Medicaid. The project provides important policy information on two different levels: One, it literally helps how the Missouri Medicaid program is functioning, but it also tells us what’s going on with the population in poverty in Missouri.” Before moving on to another meeting, Dr. Greever-Rice reflected on OSEDA’s and CHP’s model of collaboration and reaffirmed the value in maintaining that strategy. “It’s a good fit and a productive relationship because we bring one set of skills to the table and CHP has another set,” she said. “Both are necessary to do definitive validated policy research.” Ω

Center for Health Policy | 25

DC375.10 CEC508 Clinical Support & Education (CS&E) Building Columbia, MO 65212 T: (573) 882-1491 F: (573) 882-9000

Copyright Š 2013 — Curators of the University of Missouri. All rights reserved. DMCA and other copyright information. An equal opportunity/affirmative action institution.

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