Summary - Citizens’ Health Care Working Group Public Hearing
Wednesday, June 8, 2005
Randy Johnson, Chair
Catherine McLaughlin, Vice Chair
George Grob, Executive Director
Dan Jones, Dean and Vice Chancellor of the University of Mississippi
Medical Center (UMMC)
Roy Mitchell, Mississippi Health Advocate Program
Dr. Hermann Taylor, Mississippi Medical Center
Bill Croswell, Chamber of Commerce
Dr. Janice Bacon, G.A. Carmichael Community Health Center
Primus Wheeler, Jackson Medical Mall
Randy Johnson, the Chair, opened the public hearing at 8 a.m.. Members of the public were present. The Members of the Citizens Health Care Working Group (CHCWG) introduced themselves.
Hearing Participants and their Topics are provided below.
Access, Safety Net, Health Disparities
Dr. Dan Jones, Dean and Vice Chancellor of the University of Mississippi Medical Center (UMMC)
Health disparities comprise the largest health problem in the United States. The more rural and poorer a State, the greater is the problem of assuring health care. The UMMC is the only academic medical center in Mississippi. It is the tertiary care safety net hospital for the state. Access to care is a major part of the health disparities problem. We literally have no plan for assuring access to care. Using the analogy of providing enough food; we have food stamps, but we don’t expect grocery stores to provide free food. But we do expect health care providers to provide unreimbursed care for the uninsured. Last year, uninsured care cost the UMMC $73 million out of a total budget of $450 million. This represents an almost geometric series of increases in the cost of uninsured care. The organization will have a loss of about $30 million this year (2005) due to expenditures for uninsured care. UMMC is establishing policies to enable it to continue providing care for the uninsured; these include co-payment for non-emergency care, no free non-emergency care, and no longer accepting transfers from other facilities for non-emergency care. This is not hard-hearted but rather essential financial policy-setting in order to be able to sustain operations. The financial crisis is real and is present today. We will be out of business unless we deny care to patients. It is time for a national solution to address this problem.
Roy Mitchell, Mississippi Health Advocate Program
The Health Advocate Program (HAP) is a nonprofit advocate program sponsored by the Sisters of Mercy. HAP advocates improved health and welfare policies. There remain serious health care shortages in Mississippi. There are 94,000 individuals with no health insurance. The state has 750,000 Medicaid eligible, and there are many underserved counties. Access and reimbursement must be looked at as a whole. The uninsured care system is fragmented. Safety net providers include federal, county, and local organizations. The state has a significant number of Health Professional Shortage areas and a disproportionate number of Community Health Centers compared to other states (22 centers with 83 primary care delivery facilities providing 821,000 medical visits per year in 2003). Mississippi hospitals spent $706 million in 2003 for uncompensated care. Medicaid is the primary source for financing care for uninsured patients. Mississippi relies heavily on Medicaid and has the highest Federal Medicaid Assistance Percentage (FMAP) rate available: 77.23%, and a matching rate of 83.6% for the State Children’s Health Insurance Program (SCHIP). Because it relies so heavily of these sources of funding, any changes in Medicaid funding have a big impact on the state’s budget. Mississippi providers cannot sustain cuts in Medicaid reimbursement.
There are many holes in the health care safety net due to: the significant number of rural counties, inadequate coverage, lack of providers in many areas, a rapidly growing immigrant population (the Hispanic population, which has quadrupled in past decade, has the highest rate of uninsurance of all groups in the state), and a population with significant chronic illness and disabilities with needs beyond those of most states. The patchwork system is full of holes. HAP recommends: that Mississippi: take full advantage of Federal funds, avoid duplication of services, enhance service delivery, share information systems, expand eligibility of SCHIP coverage to parents of low income kids, expand community health centers in underserved areas, enable private nonprofit organizations to qualify both as Federally qualified health centers and for grant funds, expand the capacity of existing centers, and assure access to cost effective care.
Dr. Hermann Taylor, Mississippi Medical Center
When the American economy sneezes, the underserved catch pneumonia. Cardiovascular disease is in its golden age; there have been many outstanding accomplishments in the field that have led to a dramatic decline in mortality from these causes. However, there are widely divergent trends if analyzed by race and ethnicity. Cardiovascular disease from 1969 through 2000 has been declining for the American population over all. However, African Americans have not shared in these advances and continue to fall behind in cardiovascular disease. This is particularly important for women of color for whom there are clear trends indicating that their mortality rate for cardiovascular disease could soon overtake that for white men. Instead of a system in which everyone can take advantage of the fruits of health care technology. In some instances, we have health disparities of upwards of 14 to 1. African Americans receive fewer health preventive screenings and make less use of known treatments; Latinos receive fewer screenings and have worse pain management; Asians receive fewer vaccinations and pap smears. Race and ethnicity matter. There are differences in health and health care and consequently in health outcomes. In this golden age – that doesn’t glitter for everyone – there are still opportunities for improvement. This is a multilayered problem. We need a health literacy and health education focus. We need to focus on individual providers – how they approach their patients and how they can establish trust. Issues of communication are subtle – cultural competency and cultural literacy need attention.
A large part of the disparity will be found to be system-based and the solutions will lie in examining and addressing these system-wide issues.
Randy Johnson: There’s no silver bullet to solving the problems you have identified, but what is the best investment of dollars to address disparities of coverage and health?
Taylor: Whatever broadens coverage; whatever broadens the ability of people to pay for health care from the health care system. The 45 million uninsured is a national shame; we need to cover those individuals. Preventive care should be a major emphasis: addressing problems “upstream” (prior to illness).
Mitchell: Use the existing infrastructure of the state; improve coordination; use IT, including making non-profits qualify as community health centers and allow them to participate.
Jones: Provide universal coverage for a core set of preventive and treatment services. We need to couple rational universal health care coverage and availability of services with a financial plan.
Catherine McLaughlin: What do you think about Sherman James’ studies (of the effect of stress on health) and his use of John Henry (the railroad steel driver won the race against the nail machine but then died from the exertion) as a metaphor to describe this effect?
Taylor: This is an important subject. To attack those values, we need a fundamental change in the way we relate to each other and throwing off the bad ways from the past that still survive. We need to look to the future when race becomes irrelevant and we have a level playing field. Meantime we need to address stresses that make health care outcomes worse for minorities. A long term effort is needed to address this. There is an epidemic of depression.
Jones: Dr. Taylor’s wife, Jasmine Tayor, is a psychiatrist; she’d appreciate the question.
Taylor: I wish she was here right now.
Montye Conlan: Can you address the role of patients taking charge of their own care, empowerment and education?
Taylor: These things are critical. Community Health Advisors Network, a train-the-trainer model, takes natural leaders in the community and trains them to advise their community members about good habits and health practices. The idea is that each of these individuals that we train then hold their own meetings in their community and promote better health care and personal habits. The purpose is to translate discoveries by health research centers into information everyone can use so it doesn’t gather dust. NIH needs to focus more on this type of translation. While low literacy materials are good, they need to be supplemented by person-to-person interaction.
Mitchell: HAP is interested in making information, particularly on the rights and responsibilities of Medicaid patients more available and strengthening the role of non-profit organizations.
Mitchell: These kinds of programs are operated by various nationally recognized and well funded organizations. With a low-budget and with 42% of our patient population covered by Medicaid, UMMC doesn’t have much money to extend its educational efforts, even though the needs are great because of poverty and lower literacy.
Therese Hughes: Can you address the issue of patient compliance which would reduce costs? Also, what about the effect of the ethnic balance and achieving an appropriate balance? Third, what about DSH (Disproportionate Share Hospital) dollar losses; what did the Mississippi Medicaid redesign involve? In California, DSH redesign and changes in intergovernmental transfers can destroy funding support.
Mitchell: DSH dollars were not great but are decreasing and are part of the current challenge. We still have intergovernmental transfers. “Disingenuous schemes” is the phrase the Centers for Medicare and Medicaid Services (CMS) is now using to describe intergovernmental transfers and they are gradually doing away with our ability to pursue these. This will be bad for our programs and for the state; we received back $18 million less than we gave to Medicaid (in the most recent year for which data is available). Funds for Medicaid patients are decreasing. It represents an aggregate $750 million loss in the health care economy in the state. It will mean sicker patients (and perhaps higher mortality). and will disproportionately affect safety net providers and the underserved Regarding the number of providers, Mississippi has fewer per capita than any other state; we train more than the national average and retain more but have fewer that come from elsewhere and migrate in. In general, fewer people move to Mississippi than elsewhere. We have a burden of history. But we train and retain more: we graduate 100 trained physicians per year; the program is robust; in addition, the dental school has been moving toward greater diversity although there is still a distance to go.
Catherine McLaughlin: We have to be careful how diversity is handled at professional schools; for instance, in Michigan the Law School was sued regarding its diversity policies.
Mitchell: Nothing I’d like better than for Mississippi to be sued for being too aggressive regarding efforts to assure diversity. Regarding the congruence between provider and patients, African American providers tend more than others to practice in communities of the same race/ethnicity. Mississippi is 40% black. Until there is greater racial parity between physicians and their communities, we need to have a focus on trans-cultural interactions: at the bed side and all along the way. We need to have a sense of urgency about this, especially regarding diversity because “the body count is rising.” Dr. Satcher (the former United States Surgeon General) has indicated that 83,000 deaths could be attributed directly to health disparities, just in the last year. These are unnecessary deaths and represent personal tragedy. I hope we can get beyond these circumstances.
Frank Baumeister: This is our personal shame; however, there isn’t money forthcoming for the disadvantaged poor. At one end of spectrum you have starvation and at the other end incredible wealth. There is Medicaid “starvation” and, in some parts of Medicare, exploitative spending. The way the system is designed now, for public moneys, a disproportionate amount goes to the Medicare population. In Oregon, we toyed with lumping all public moneys together. We looked at providing universal care across entire population by combining funds. Senator Wyden has said there is a lot of money in the coronary pot, for instance. If you were king, how would you use those monies?
Jones: I agree there’s enough money; it’s a question of how we use those funds. However, we all recognize we can’t provide everything to everyone. Seeking to define health rights in Oregon was a bold move. Eventually, the country must arrive at identifying a defined set of health care rights: a national approach, taking the dollars and rationally redistributing them is the right idea. This country may decide we want a higher level of health care than other countries but could do it across the board. Because the current rate of increase in Medicaid expenditures—largely driven by pharmaceuticals—is unsustainable, there will be increasingly pressure to reduce funding.
Mitchell: A single payer system is probably where this country will go. Mississippi Medicaid recipients are very apprehensive regarding threatened cuts but do wield considerable political clout and were able to get State reductions rescinded by putting a human “face” on Medicaid. We need to look at the reimbursement of pharmaceutical companies rather than first cutting coverage of drugs for patients.
Jones: Universal coverage of a basic set of treatment and prevention services is needed; We may have to come back to addressing the issue of rationing care. To control costs, yet still provide care for, for instance, type II diabetes, we’ve reduced from seven to five, the number of prescriptions that will be provided under Medicaid per month; reduced down to two, number of non-generic drugs covered, thus possibly reducing ideal care.
The Reality of Being Uninsured
(Additional research information regarding the uninsured may be found at: www.umich.edu/eriu.)
I suffered from a herniated lumbar disk and visited a doctor—a neurosurgeon. Subsequently, I found out my employer had cancelled my insurance coverage. I was told that they were well within rights to cancel the policy and that they had up to 30 days during which to notify me. I was accepted for rehabilitation services and the surgery was scheduled. My disks are still bulging. Not having insurance, when certain conditions occur, other systems in the body go “AWOL.” I go to a free clinic. My blood sugar went sky high. There is a myth that the uninsured are poor and uneducated. Where do you go when you are dropped from insurance and your pharmacy card no longer works?
I never thought this would happen to me. I had a good job and a home. My co-occurring illnesses led to my becoming homeless. Once my COBRA (Consolidated Omnibus Reconciliation Act of 1986, a law that required employers to continue to permit departing employees to be able to continue to be eligible for coverage under the company plan for at least 18 months post employment) ran out, I couldn’t get medical care. I never thought I’d be in this position. I sought care in free clinics but the time element became and issue. The pharmaceuticals I was prescribed caused memory loss and made me unemployable. I relied on the safety net of my family for expenses. Now, I’m much better and back in the workforce. However, it is still necessary to wait 90 days before becoming eligible again for insurance. In addition, preexisting conditions may prevent one from being insured; high costs means insurance may be prohibitively expensive. The disease I suffer from doesn’t stop just because health care coverage stops. There are some limits in the system that need to be addressed.
Randy Johnson: What would your one most important recommendation be?
Dye: Increase patient assistance programs; they are fading away. Eliminate limits on individuals obtaining insurance.
Rucker: We’re told that if you get a good education and a job, certain bad things won’t happen; however employers may not fully inform employees of their benefit coverage. There needs to be TV documentaries about what to do if you are without insurance and in desperate need of medical care, where do you go to get the ball rolling? Even take this to churches and ministries; let this be one of the platforms they can sponsor. Even though I have two sisters who work in health care, I didn’t know about the potential limits of my coverage.
Catherine McLaughlin: It sounds like you are bringing up the need for new forms of education: to educate individuals when they get sick about where they can go for care or services and to educate the public that this can happen to them and they need to be aware of this risk.
Montye Conlan: Thank you both for coming; I feel you are both my peers. I hope that everyone will hear that this too can happen to any of us and also that these events require personal courage to meet the challenges. Do you seek to help others from what you have learned? Also, how do you feel when it is suggested that patients should simply use generic drugs?
Dye: I’m active in a health ministry with a local church and community outreach efforts and I’ve returned to school to be trained as a drug and alcohol counselor. It seems like the less expensive generic drugs may be used exclusively and possibly inappropriately; the danger is that providers may prescribe a generic when a proprietary drug would be more effective.
Rucker: I currently get no income or assistance and am dependent on my family; I had to move back in with my mother. My church is providing me some support. Earnings limits in health coverage programs may cut people off who still need coverage—being well paid for six months and then becoming unemployed may result in being uninsured for a period of time if over all earnings were too much, even though the money is gone.
Deborah Stehr: I’ve previously heard about people expecting that education and employment should be sufficient to prevent individuals from becoming uninsured.
Dorothy Bazos: How would your lives have been different if we had a system of universal health care coverage?
Rucker: I would have been well now instead of still being ill. However, even with insurance, health care may be late or inadequate. Heath care needs also to be timely; otherwise, one may get more seriously ill while waiting for care. The delay that leaves some people between Medicaid and Medicare for a six month waiting period means that individuals needing care don’t receive it. Not only having care but having good care is important, including mental health care.
Dye: In general, universal health care coverage would mean that individuals could get care they need. However, universal health care also implies socialized medicine to me and that scares me. There was a safety net out there that saved me; of course, it could always be better. Health care costs so much; there needs to be reform of the health insurance companies themselves since providing coverage has been lucrative for them.
Randy Johnson: What recommendations do you have about how the Citizens’ Health Care Working Group should communicate with citizens nationally?
Rucker: Town meetings are wonderful; give them a catchy title. When we all go to read an article, an interesting title will draw us in; don’t use one that will put us to sleep. Work through faith based initiatives and churches. Have a day long or week long summit and announce it well in advance so people have time to plan. Make it eligible to count toward required professional continued education units so employers could pay for it and so that there is credit available for it. Encourage Human Resources offices to provide better information to employees.
Dye: Form a referential network with places where this information can be distributed; provide numbers to call about where resources for health care can be obtained. Go through health associations and form a network that is easily accessible.
Local Access Initiatives
Bill Croswell, Chamber of Commerce (Chamber Plus Insurance Product)
Chamber Plus is subsidiary of the Chamber of Commerce; it was formed in response to the perceived need for health insurance coverage for employees of small businesses in 1996. It was designed in order to secure group health insurance coverage for small employers. A request for proposal was developed and a contract with Blue Cross/Blue Shield established that was then broadly marketed, in order to obtain a discounted rate. Chamber Plus now has 1,400 businesses participating and covers 20,000 lives; 60% of these are people who did not have any prior coverage and now have coverage. In 1998, seeing our success, several other Chambers of Commerce throughout the state solicited information. There are now 54 Chambers of Commerce offering health care to their members. The program has been modified over time to keep it competitive. Organizations eligible are those insuring from one life up to 50; the plan is not offered to businesses with over 50 employees.
Dr. Janice Bacon, G.A. Carmichael Community Health Center
(See Comments accompanying Dr. Bacon’s Power Point slides [4.8 MB] for her presentation to the Citizens’ Health Care Working Group.) [PDF version of slides without comments, 0.8 MB]
Primus Wheeler, Jackson Medical Mall
(See Comments accompanying Primus Wheeler’s Power Point slides [5.8 MB] for his presentation to the Citizens’ Health Care Working Group.) [PDF version of slides without comments, 2.1 MB]
Randy Johnson: I wish to thank you and commend you on all that you have achieved. What has made your success possible?
Bacon: We realized we couldn’t do it alone; it needed community focus; and we needed to look at all levels of the organization. If something wasn’t working, we’d look at the entire system. Also, we do get staff longevity so seeing how to help them to achieve their most is a priority. Also, we’ll approach/ask anyone for help and money; we observe no restrictions.
Wheeler: We’ve found that one plus one can equal three; collaboration and partnering with any and all is central to what we’ve done. A lot has been achieved as a result of this collaboration and working together.
Croswell: The whole is definitely greater than the sum of the separate parts. We work with groups to achieve shared goals.
Deborah Stehr: What does your insurance cost? I wonder how other states have succeeded in providing health insurance.
Croswell: About $250 per month per insured individual, including a $500 deductible; the coverage includes $2 million in major medical coverage. The other Chambers of Commerce vary in size as well so their plans will vary also. This approach has provided a market for sellers of insurance. The COSI program in Cleveland is a model we looked at so as not to reinvent the wheel.
Catherine McLaughlin: What percent of your members end up not being eligible; the COSI program had a major underwriting problem.
Croswell: This has not been a problem here: there are 1,400 groups.. It has not been as high as 30%.
Montye Conlan: How do you disseminate information?
Bacon: We give it to teachers for kids, put it in their book bags. We also do a newsletter for each school that comes out three times each year. We teach various health classes in the schools (such as a Healthy Living Class, to address obesity). The asthma component is significant because it is the biggest cause of student absenteeism. As a result of this focus, attendance in school has improved.
Catherine McLaughlin: How important is the “great man” theory in how one energizes people to successfully pursue an initiative? While the delivery of health care is local, the financing is not. Can you discuss this tension between local initiatives and broader funding and the difficulties that some communities will face that will not be able to address the balance.
Wheeler: Initiatives cannot be replicated in every state. Creative funding from other sources is needed. As local communities form partnerships and work collaboratively, they can more effectively and better obtain and utilize the resources that are available. We also need to move from catastrophic to preventive care and provide better chronic care and education. As more resources are needed, they will need to come from other sources. An effective funding mechanism and collaboration is essential to building something like the Medical Mall.
Frank Baumeister: In numbers, there is strength: by coming together, activities like the Chambers of Commerce or small businesses can come together to address the power of insurance companies.
Croswell: You have to decide that “no” is not an acceptable answer. Also look for a good plan rather than looking for a great plan; start with a good plan and tweak it, to make it what is needed; then make modifications and adjustments marginally and incrementally over time to improve it for the benefit of the members. I’m a “can do” guy and worked to make it work for our needs. Make your plans flexible and stick to your goals.
Wheeler: Success breeds success. Don’t try to clone the success or believe that it is as simple as looking for a boilerplate model a la franchises; each circumstance is different and requires differential responses apropos of the specific circumstances. You have to have great vision, great leadership; keep executing the plan, be creative about how to overcome obstacles.
Bacon: It is critical to empower patients; empowered patients will seek their own good. Establish a patient-centered system. We treat the patient as special: whether giving them T-shirts, putting their pictures on a wall for diabetes. We seek to avoid blaming the patient or labeling them as “non-compliant.” We try to get them truly involved and to recognize and hold them in high regard for what they do.
Therese Hughes: Please provide your advice and stories of your success when we are ready for feed back.
The Chair adjourned the public hearing at 2:00 p.m.
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