1. SHC Capabilities

2. The National Minority Quality Forum and the
Data Warehouse
• Founded in 1998, NMQF is a non-profit
Washington-based, health care research and
education organization.
• Seeks to eliminate the disproportionate burden
of premature death and preventable illness in
racial and ethnic minorities and other special
populations through data-driven initiatives.
• Has developed a comprehensive database with over 2 billion patient
records used to define disease prevalence, costs, and outcomes for
demographic subpopulations at the zip code level.

3. Sustainable Healthy Communities, LLC
•For-profit extending NMQF outreach
•Exclusive publishing rights for NMQF databases, including 15
years+ of analyzed Medicare and Medicaid studies
•Mission is to translate data into tools for patients,
community leaders, policy-makers, clinicians, researchers,
and innovators to achieve health equity and the triple aim—
better care, outcomes, and value.

4. Health Indices: Map disease by prevalence, cost, outcomes, co-morbidities,
socioeconomic status, Rx drug use, payer, environmental/social factors
Advisory Groups: Gain input of leading experts,
policy-makers, innovators, and community
representatives on data use
Research Support: Examine trends, correlates,
and test hypotheses using health index data
Education: Help clinicians, community groups, and
patients put health index data into use for better
outcomes – minority-serving clinician networks
Clinical Trial Support: Join nation’s top campaign
to encourage diversity in clinical trials—I’M IN, plus trial recruitment services
informed by health index data
SHC Products

5. Examples of Health Indices

6. Some of Our Partners

7. Our Leadership Team: Decades of Health Policy,
Research, Education, and Quality Accomplishment
Gary Puckrein,
PhD, SHC
founder and CEO
May-Lynn
Andresen, BSN-
RN, SHC VP for
Patient
Engagement
Bernard M. Rosof,
MD, MACP, SHC
President
Laura Lee Hall,
PhD, SHC COO

8. What Have We Learned? Health Care Market Has
Predictable Structure to Guide Resource Management
• Geography Matters: Stable health care consumption
patterns exist in specific geographic locales over time
• Predictable Forces Shape the Market: Consumption
patterns reflect disease prevalence, patient response to
those diseases, practice variation, and health care
system structure and function
• Critical Intelligence: This knowledge is stable and
predictable, and algorithms can be built that can
anticipate consumption patterns.
• The Value Proposition: An understanding of these
consumption patterns can improve management of
health care resources.

9. Big Data: Challenges and Solutions
• Volume • Rapidly
changing
• Complex
technology
platforms
• Different
data sets
• Expert
analysis
required
• Outputs
not always
actionable,
understandable
CHALLENGES
A SOLUTION
• MAKE IT VISUAL

10. • Maps provide demographic intelligence about
acute and chronic disorders at the zip code level
– segmented by age, gender, race/ethnicity – to:
• Map any index disease by prevalence, cost,
outcomes, comorbidities, socioeconomic status or
other data type for any state, MSA, congressional
and state legislative districts
• Define where the unmet needs exist
• Forecast trends using predictive analytics
• Produce customized reports to support
educational, advocacy and policy efforts
GIS-based Data Visualization
Confidential: ForAdvisory BoardUseOnly

11. Health Index Data in Action:
Real-world Examples

12. Americans Live in 38,000 Zip Codes
Most Minorities Live in 7,500
50%of Asian Live in 1,500 Zip Codes 70%of Hispanics Live in 2,500 Zip Codes
70%of Blacks Live in 2,500 Zip Codes 70%of Other Minorities Live in 1,000 Zip Codes

13. Adult Immunization Index

14. U.S. Diabetes Index

15. Zip code Level Identification of Patients
Investigators, Points of Care, and Trial Sites
Targeting is key

16. Which Doctors Serve Patients with Diabetes? A
Health Index-ACP Member Map

17. Understand Specific Physicians’ Patient Profile
2013
229 Multiple Sclerosis Patients
Ruth Kellum Fredericks, M.D.
Neurology
971 Lakeland Dr.
Suite 657
Jackson, Mississippi 39216-4643
Telephone 601-200-2780
Fax Number 601-200-5929
BENE_RACE # BENE % Bene All Cause Cost % All Cause Cost
All Cause Bene Out of
Pocket
% All Cause Bene Out
of Pocket
Average Bene Out of
Pocket
White 146 64% $1,559,361 64% $494,570 69% $3,387.47
Black 81 35% $859,276 35% $220,891 31% $2,727.05
Asian 2 1% $17,924 1% $4,122 1% $2,061.14
229 $2,436,562 $719,584
BENE_RACE # Bene
Medicare Part B
Payments
% Medicare Part B
Payments
Beneficiary Part B Out of
Pocket
% Beneficiary Part B Out
of Pocket
Average Beneficiary Out of
Pocket
White 146 $166,947 61% $41,985 60% $1,143.48
Black 81 $108,956 39% $27,645 40% $1,345.13
Asian 2 $37 0% $10 0% $18.71
229 $275,941 $69,640 $1,204.98
BENE_RACE
Tysabri
intraveno
us
Pro-C-
Dure 5
injection
Solu-
Medrol
(PF)
injection
dexamethaso
ne sodium
phosphate
injection
Celestone
Soluspan
injection
Depo-
Medrol
injection
triamcinolone
acetonide
injection
80 mg
IM
Methylprednis
olone acetate
20 mg
# of Part
B
Medicati
ons
# Bene
% of Part B
Medications
White 51 39 35 24 21 18 10 8 1 207 146 73%
Black 36 1 15 5 3 1 11 72 81 26%
Asian 3 3 2 1%
Total 282 229

18. Part D Beneficiaries # %
Blacks with CHF On Insulin SMBG 50,902 67%
Blacks with CHF On Insulin No SMBG* 25,326 33%
Total Blacks with CHF On Insulin 76,228
* DME Reimbursements Under $200 per Year
The Power of Data, Research, and Advocacy:
Are African Americans with Diabetes and HF Accessing
Needed Care with Policy Change?

19. Beyond Claims Data: National Surveys

20. Environmental Factors

21. Advocacy and Resource Distribution

22. Narrow Your Focus… by the Individual
Patient Characteristics
• Age
• Gender
• Race/ethnicity
• Diagnosis
• Comorbidity
• Health insurance
Provider Characteristics
• Demographics
• Billing zip code
• Patient profile
• Rx
• Reimbursement profile

23. Narrow Your Focus… Geographically
• National
• State/county
• MSA
• Zip code
• Legislative or school
districts
• Individual
clinic/provider

24. Narrow Your Focus… By Social Demographic Clusters

25. Narrow Your Focus… Key Statistics
•Incidence
•Prevalence
•Quality of care
•Cost
•Outcomes

26. Thank you.
For more information, contact Laura Lee Hall at
lhall@shcllc.info