What A Physician Sees What A Physician Sees in Health Reformin Health ReformGerard Clancy, M.DPresidentUniversity of Oklahoma, Tulsa

Overview of SessionsOverview of Sessions

1. “Undeniable” Driving Factors for Health Reform.

2. At least 5 Federal Initiatives in play regarding health reform.

3. What next regarding legislative process.4. Impact for Oklahoma.

Driving Factors 1 and 2..Driving Factors 1 and 2..

Cost and Quality of Health Care in the US

Drive to Bend the Health Care Cost Curve

Health Spending in the US is quite variable.Health Spending in the US is quite variable.

Dartmouth Health Atlas 2009Dartmouth Health Atlas 2009

Not OK!!Not OK!!

Oklahoma’s extra Oklahoma’s extra burden on health burden on health leaders-leaders-Reduce costs in a Reduce costs in a State with terrible State with terrible health statushealth status

Driving Factor 3…Driving Factor 3…Moral Obligation – those without

health care coverage are suffering

Probability of late vs. early diagnosis of cancer, uninsured compared to those with

commercial insurance, 1994

1.7

2.6

1.4

1.5

0.0 1.0 2.0 3.0

Colorectalcancer

Melanoma

Breast cancer

Prostatecancer

Source: Roetzheim, et. al., 1999; KFF Chartbook

47 million uninsured in the US - Individuals without insurance are 1.4 to 2.6 times more likely than the insured to be diagnosed with last versus early stage cancer.

Bedlam Evening Dermatology Clinic

Bedlam Evening Bedlam Evening Dermatology ClinicDermatology Clinic

Bedlam Evening Dermatology Clinic

Driving Factor 4…Driving Factor 4…

Physician distribution by specialty and geography

US short by 250,000 US short by 250,000 physicians in next 10 years physicians in next 10 years AAMCAAMC

• Increase in US population• Increase in life expectancy• Baby boomer demand• Declines in medical school class sizes.

TOTAL PHYSICIANS IN 2005PER 100K POPULATION IN THE UNITED STATES

0

50

100

150

200

250

300

350

400

450

500

AK AL

AR

AZ

CA

CN

CO DE

FL

GA H

IIA ID IL IN KS

KY LA MA

MD

ME MI

MN

MO

MS

MT

NC

ND

NE

NH NJ

NM

NV

NY

OH

OK

OR

PA R

IS

CS

D TN

TX

UT

VA VT

WA WI

WV

WY

Created by Michael Lapolla, OU College of Public Health, December 2007

23

204 228302

350

194

1,616

1665

11866 63 28

755

2,921

352

0

500

1,000

1,500

2,000

2,500

3,000

Most Rural 7 6 5 4 3 2 Most Urban

MD PHYSICIANS

DO PHYSICIANS

PHYSICIANS IN OKLAHOMABY TYPE OF COUNTY

Counties aggregated using the 2003 Rural/Urban Continuum Codes, Economic Research Service, Department of Agriculture. Physicians are the Total Active Non-Federal Physicians (both MD and DO) per the American Medical Association Physician Masterfile as of December 31, 2005. Source: Area Resource File, June 2007, DHHS,HRSA, BHPr Evaluation and Analysis Branch

Created by Michael Lapolla, OU College of Public Health, December 2007

MDs and DOs practice MDs and DOs practice in Urban Oklahomain Urban Oklahoma

Age-Adjusted Death Rate in Tulsa Physician Density in Tulsa

Oklahoma among the last in the US in Physicians per Capita

Part 2 – Health Reform

5 Federal Responses 5 Federal Responses in 2009in 2009

1. American Recovery and Reconstruction Act - Stimulus2. Public Health Services Act3. America’s Health Future Act – Senate Finance Bill4. America’s Affordable Health Choices Act – House Bill5. Republican Option

ARRA – “Stimulus”ARRA – “Stimulus”

Health Arena:• Propped up Medicaid – kept Medicaid from decreasing

rates, eligibility and benefits. • Health facility construction – mostly research• NIH Challenge Grants - • Federally Qualified Health Center expansions – clinic

capacity and facilities. • Health Information Technologies:

– Electronic Medical Records– Health Information Exchange

Public Health Services ActPublic Health Services ActAmerica’s Affordable Health Choices ActAmerica’s Affordable Health Choices ActAmerica’s Health Future ActAmerica’s Health Future Act

2009 Health Reform Initiatives

• Health Insurance ReformHealth Insurance Reform• Expanded health care coverage – with or Expanded health care coverage – with or

without “public option.”without “public option.”

• CLASS – Community Living Assistance Support Services

• Community Health Teams – Medical Home Model, school-based clinics

• Underserved populations health outcomes research.

• Regionalized emergency response systems. • Regional Health Information Exchange

Consortia• Interdisciplinary work – MDs, SW, PharmD,

RNs for underserved populations. • Health Workforce – primary care, mental

health, PAs, NPs for underserved populations.

• Redistribution – physician geography and specialties to serve underserved populations.

1. Insurance Reform – 15% of Bills

• Limit lifetime limits• Prohibit denial of coverage because of

pre-existing illness• Portability across employers• Health benefit plan exchanges• Risk pooling for individuals.• Increasing competition – across State

lines.

2.2. Health Care Coverage Expansion – Health Care Coverage Expansion – 15% of Bills15% of Bills

• Federal Assistance Percentage (FMAP) increased and extended – pertinent to Medicaid and GME.

• Expanded Medicaid and SCHIP- 150% of poverty.• American Health Benefit “Gateways” – affordable

insurance options with mandated basic package.• “Navigators” – educate and facilitate the public to be

insured.• Mandates on who must be insured.• Public option – government sponsored health coverage.

– Senate – No– House - Yes

3.3. Modification of Health Care Modification of Health Care DeliveryDelivery

• CLASS – Community Living Assistance Support Services

• Community Health Teams – Patient Centered Medical Home Model

• Regionalized Systems for Emergency Care Responsiveness

• Trauma Care Systems

• Preventive Care• Care Coordination• Nurse Managed Health

Clinics (NMHCs)• School Based Health

Clinics (SBHCs)• Dental Care Outreach• Community

Transformation Grants

4. 4. Quality, Transparency and Quality, Transparency and EffectivenessEffectiveness

• Comparative Effectiveness Research• Demonstration programs to integrate quality

improvement and patient safety training into clinical education in the health care professions:– MD– RN– PharmD– SW

• Center for Quality Improvement.• Web Hubs to compare health system and

physician quality performance.

5. 5. Health Information TechnologyHealth Information Technology

• Promotion of use of EMR initially through incentive payments. Later – lack of use of EMR results in decreased payment.

• Health Information Exchange – at the regional, multi-institution level (not closed integrated delivery systems).

• Health Information Coordination of Care.• Regional Centers of Excellence.• Regional Health Information Technology Health

Workforce Training Centers.

6.6. Health Care WorkforceHealth Care Workforce

• Focus on mal-distribution at the specialty and geographic levels.

• Moving new health care workforce into serving underserved populations.

• State and Regional collaboratives of planning and implementation grants to expand health care workforce.

• Loan Assistance programs to promote care of underserved – health “peace corps”.

• Nurse faculty loan programs.

• Promotion of increased health workforce diversity.

• Expand training of:– IM, FM, Geriatrics,

Pediatrics, Pediatric subspecialties, Psychiatry, Child Psychiatry, Nursing, Dentistry, Public Health, PA, NP, Allied Health.

– General Surgery – Community Based

Residency Programs– Those over the CAP– Regional population growth

Common Themes Across BillsCommon Themes Across Bills

• Insurance Reform• Expanded Health Insurance

Coverage• Care of the Underserved• Cross Institution Collaboration

– Medical education– ER systems– Trauma systems– HIT

• Community Based Care– CLASS– SBHC

• Team Care– Patient Centered Medical

Home– Interdisciplinary – MD, PA /

NP, RN, SW, PharmD• Medical Education swings

away from many subspecialty training programs: – Primary Care– Peds Subspecialties,

Psychiatry– Geriatrics– Nursing– PA and NPs– Public Health

Republican Plan – November 2009Republican Plan – November 2009

• Greater focus on health care cost reduction.• Less focus on insurance coverage expansion for uninsured.• No subsidies for uninsured to buy health care coverage.• Lower premiums for non-employer based coverage by 7% by 2016.

1. Expand "high-risk pools" to extend coverage to people with preexisting conditions.2. Limit noneconomic damages in malpractice lawsuits to $250,000.3. Help small businesses band together to buy insurance by reducing regulations.4. Give incentives to states to reduce the number of uninsured and cut premium costs.5. Allow insurers to sell their products across state lines. Insurers would have to follow

the laws in their home state but not the consumer- protection laws in all states where they sell policies.

6. Give employers more flexibility to offer discounts to workers who meet standards for a healthy lifestyle.

7. Allow young adults to stay on parents' policies through age 25. 8. Allow people to choose whether to buy insurance, and let employers choose whether

to offer it.

Paying for health reform?Paying for health reform?Taxation

– House Bill - $ 500,000 million annually.

– Surtax on household income above $ 350,000 in House Plan

– New Medical Device Taxes

Shifts in Reimbursement– Reduced hospital payment for

readmissions.– Medicare, Medicaid, DSH,

GME, IME?– Commercial insurance

reimbursement rates will follow Medicare rates.

Cost Reduction Strategies:– Medicare - $ 400,000 million

annually – House Bill– Preventive care– Primary Care, Physician

Extenders– Reduced Hospitalizations– Reduced errors– HIT– Fraud and Abuse– Law Suit Reform– Reduced hospitalization

rates / beds.

Cost Estimates:– House - $ 1 trillion over 10

years– Senate ?– Republican – $ 61billion over

10 years.

Covering the UninsuredCovering the Uninsured

Currently 47,000,000 Uninsured.By 2019, CBO estimates: • House Plan

– 18,000,000 uninsured

• Senate Plan– 25,000,000 uninsured

• Republican Plan– 52,000,000

Positioning Tulsa for Major ReformsPositioning Tulsa for Major Reforms

• Gateways Insure Oklahoma• Navigator Kim Holland’s

Insurance HUB proposal• Regional HIT Greater Tulsa

Health Access Network (Greater THAN)

• CLASS Community Based – Bedlam Network, SBHC, 3 IMPACT teams, Mobile Geriatrics

• Team Care Patient Centered Medical Home for uninsured and Medicaid populations, 3 IMPACT – mobile psychiatry teams.

• Emergency Responsiveness Oklahoma Institute for Disaster and Emergency Medicine, MERC, EMSA

• Quality and Comparative Effectiveness Oklahoma Institute for Quality, Center for Community Engagement, Community Health Outcomes In Research (CHOIR).

• Resident and medical student education expansion ?

• OU-Tulsa Health Science Center education programs - peds, psychiatry, IM, FM, geriatrics, g surgery, nursing, allied health, public health, PAs, NPs.

Oklahoma:– Poor health – United, Commonwealth

Fund– One of the lowest in number of

physicians per capita already. – Biggest Vulnerability = physician

shortages and push for health system integration (closed system) paired with low reimbursement rates in Medicaid and Public Option will leave the poor looking in from the outside…unless we expand medical school education programs and medical school clinical and community health center services.

Massachusetts:– One of the healthiest

States in the US– Highest number of

physicians per capita in the US.

– Already with mandatory health care coverage.

– Not enough doctors to see the patients.

Legislative Process ?Legislative Process ?

Senate Finance Committee Senate Floor

ARRA – Passed Into Law

Republican Proposals

House Bill Vote passed

Public Health Services Act

Agency Policies, Procedures and Rules• Health and Human Services• Centers for Medicare and Medicaid• Agency for Health Research and Quality• Centers for Disease Control

House, Senate andWhite House Negotiations

Passed Into Law ?