Summer 2012 Quarterly Newsletter
CONTENTS:
Director's
Column
Partner
Focus
Special
Feature
RHAC
Profile
SUMMER
2012
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Dungan-Seaver at
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DIRECTOR'S COLUMN
COVERAGE CHANGES AND THE SAFETY NET
Who will remain uninsured, and who will gain coverage in the next few years?
The characteristics of both groups have implications for Minnesota’s rural and
urban health care safety net.
Mark Schoenbaum
Two recent reports estimate coverage and uninsurance in Minnesota as health
reform changes roll out. A study for the Minnesota Department of Commerce
estimates that the number of uninsured in Minnesota will drop by 290,000,
leaving 210,000 uninsured ("The Impact of the ACA and Exchange on
Minnesota," Minnesota Department of Commerce, April 2012). A similar estimate
by the Urban Institute estimated that 230,000 would have remained uninsured if
the Affordable Care Act had been in place in 2011 ("Who Will Be Uninsured After
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Health Insurance Reform?" Urban Institute, March 2011) .
Over half of the newly covered - about 165,000 people - will have incomes below
200 percent of the federal poverty level (FPL), according to the Commerce
Department report. Two of the groups that will grow are those publicly insured
and those securing private policies through the developing health insurance
exchange, which expects enrollment from employees in small firms and those in
the individual market. Public programs will also expand by over 100,000
enrollees. Of the newly insured, 29 percent will be non-white or Hispanic.
Who will remain uninsured? About half, or 105,000 to 111,000, will have
incomes under 138 percent of poverty. Most of these will be eligible but not
enrolled in public programs or the exchange, and a share will be young and
single. Over one third (36 percent) will be exempt from the mandate, some
because they do not have an affordable insurance option. Another third (34
percent) will be non-white or Hispanic, 12 percent will be undocumented
immigrants and 43 percent will be subject to the mandate but not insured.
In addition, many Minnesotans of course will continue to be covered by
Medicare. In rural areas, the already high proportion of the population covered by
Medicare will continue to grow.
What are the implications of these changes for Minnesota’s safety net of rural
health providers and inner-city community clinics?
In rural areas, where many are employed part time, by small business or self
employed, many of those now insured will likely receive better coverage through
the plans and subsidies available in the health insurance exchange. Others in
these groups will be able to buy insurance for the first time. All can be expected
to seek care more regularly. In addition, undocumented immigrants will continue
to be uninsured and some who are marginally employed may still lack affordable
options.
Overall, demand for services in rural Minnesota will rise from the newly covered
and the growing Medicare population, and the uninsured will be a smaller but still
noticeable component of the community. More will likely seek mental health
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services, exacerbating the demand on already thin mental health resources and
bringing even more mental health conditions into primary care offices. The
demand for dental services will also rise as more people gain public coverage.
In the Twin Cities, a significant portion of the newly insured will be the current
clientele of Federally Qualified Health Centers and other community clinics.
Many of these patients will now arrive with a payment source. In addition to more
insured and public programs patients, undocumented immigrants and other
uninsured will remain. As the Urban Institute put it, “Safety net providers and
programs will still face the challenge of substantial numbers of uninsured who
cannot afford a full range of needed services.”
One place to look for an example of health reform’s effect on community health
centers (CHCs) is Massachusetts. Massachusetts’ CHCs, which treated many
uninsured patients before that state’s 2006 reform law, expected to lose them
when they became insured. Instead, health centers gained 100,000 patients, a
31 percent increase in volume, though costs rose slightly more than revenues
from these patients. Massachusetts patients report that they go to CHCs
because they are convenient, affordable and provide additional services. ("Safety
Net Providers After Health Reform: Lessons from Massachusetts," Leighton Ku
et al. Archives of Internal Medicine 171[15]: 1379-84, Aug. 8, 2011).
For all these rural and urban safety net providers, demand for both more primary
care providers, specialists and staff at all levels will grow. Facilities may need to
be expanded. Health information technology systems must be in place, hours will
need to be extended and more.
How can providers and policymakers prepare for these changes? In addition to
continuing efforts to grow the health care workforce, resources will need to be
stretched through team-based care to meet new demand and the expectations
for coordination and outcomes under reform. There will also be opportunities for
health promotion and prevention. In rural Minnesota, the case for Federally
Qualified Health Centers in communities like Bemidji, Princeton and Tower will
be even stronger, and opportunities to establish FQHCs in southwest Minnesota
and other areas should also be explored.
This is also the time to make tangible the contribution telehealth can make,
especially in mental health. And there will clearly be a role for safety net
providers in connecting patients to options available in the health insurance
exchange, and perhaps an ongoing role for community coverage approaches
such as those developed by Portico in the Twin Cities and PrimeWest in rural
Minnesota. State and federal financial support for safety net providers will remain
important.
As always, the Office of Rural Health and Primary Care is here to provide
support in these changing times. Please let us know how we can help as you
plan for reform.
Mark Schoenbaum is director of the Office of Rural Health and Primary Care and
can be reached at [email protected] or 651-201-3859.
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Summer 2012 Quarterly Newsletter
PARTNER FOCUS
INTEGRATING PRIMARY AND BEHAVIORAL HEALTH CARE: A
COMMUNITY HEALTH CENTER'S EXPERIENCE
The case for integrating primary and mental health care services seems to
grow stronger every day. More primary care providers are seeing patients with
untreated mental health problems. Many individuals with mental health
disorders go without needed medical care. Failure to treat co-occurring
physical and mental health conditions – especially common among those with
chronic conditions such as diabetes, asthma and heart disease – leads to
poorer health outcomes and higher costs.
Even so, true integration of care remains rare and difficult. Community-University Health Care
Center
The experience of Community-University Health Care Center (CUHCC) in
south Minneapolis, long a leader in community-based mental health and
primary care, shows both the promise and the challenge of fully integrating
such services. As a Federally Qualified Health Center, CUHCC is unique in
Minnesota in the range of mental health services offered – including therapy,
psychiatry, case management for adults with serious and persistent mental
illness (SPMI), and adult rehabilitative mental health services (ARMHS). It is
also unusual in the number of patients receiving services in multiple, often
integrated areas of care: Of 1,661 behavioral health patients, 67 percent also
receive medical services at CUHCC and 31 percent receive mental health,
medical and dental services. A gradual progression toward integration
The health center’s approach to integration reflects its history and a gradual
evolution. First established as a pediatric clinic in 1966, CUHCC offered a fullfledged mental health program and dental services before it added adult
medical care in 1975. A first step in integrating those services was to create an
overall Clinical Director, who oversees most of CUHCC’s clinical services
(across medical, behavioral and dental). With the support of a Healthier
Minnesota Community Clinic Fund grant, it then added medical assistant staff
dedicated to supporting behavioral health patients. Today, over 90 percent of
those patients are now screened regularly for blood pressure, weight and
tobacco use, with medical care follow up as necessary, supported by an
Electronic Health Record (EHR) for each patient shared by all their providers. Care for patients initially seen on the medical side but identified as having
mental health needs is not as immediately integrated – that is, same-day dual
care is not generally possible, in part because of the diagnostic assessment
required to establish medical necessity for mental health services. However,
such patients are flagged in the shared Electronic Health Record (EHR)
system and nurses work to coordinate their follow-up care. Medical and
mental health providers often consult on such cases as well. Integration with
dental care is still more difficult, but the shared EHR helps here too, and
occurs increasingly with CUHCC’s pediatric patients in particular. CUHCC’s next phase is to develop integrated care teams around major
patient populations, including teams for women’s health, pediatric preventive
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care, adult preventive care, OB services, diabetes and depression. Their hope
is to have “care managers” who can work with a panel of 60-70 patients each
and serve as a bridge across the various providers and services needed by a
given patient.
The challenge of different training, different funding
Attaining integration hasn’t been easy for CUHCC, nor is it complete.
“Integration is really a work in progress,” says Colleen McDonald Diouf,
CUHCC’s Associate Director. “You don’t just achieve it, especially since
medical and mental health training and funding sources continue to be so
different from each other. It’s an ongoing journey across those differences.”
And those differences are significant. Primary care and behavioral health
providers come to patient care with dramatically dissimilar cultures, languages
and processes. This has been the toughest part of integration, according to
McDonald Diouf. “Bringing the two disciplines' perspectives together, so one
doesn’t feel dominated by the other, is an ongoing issue,” she says. A second major challenge is financial. As a Rule 29 provider through the
Department of Human Services, CUHCC is reimbursed for mental health
services provided under that program. A mental health provider must first
complete a full diagnostic assessment, however, a process that can take 1-2
visits. This complicates and slows integration with medical care.
Other challenges have included the physical layout of the clinic – how to
provide an environment that supports the distinct needs of medical services
and behavioral health care, but also integrates those services – and finding
support staff, such as the medical assistants who have played such a crucial
integrative role at CUHCC, who understand how the two disciplines work and
are willing to work with a patient population experiencing serious mental
illness.
Words of wisdom
Despite these challenges, CUHCC has found integration to be a powerful and
worthwhile strategy, and one it continues to pursue. McDonald Diouf offers
these lessons learned for other organizations looking to integrate their
services:
Most importantly, build teams. When providers are able to work across
disciplines to serve a complex patient, they feel a tremendous amount of
satisfaction in the quality of care they are able to provide.
Be aware of -- and work through -- differences in how the disciplines are
trained and their clinical approaches.
Make provider roles clear, particularly around diagnosis issues, work
flow and approach.
Be ready to work through differences in how medical and mental health
services can be billed.
Enlist clinical champions on both sides.
Know it will take a lot of time and dedicated resources to make it
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happen.
Use “bridge” positions such as care managers, nurses and others to
help integrate services, but know they must build trust with all disciplines
for integration to be effective.
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SPECIAL FEATURE
RURAL HOSPITAL CEOs TALK HEALTH REFORM AND MORE
This year’s Minnesota Rural Health Conference, held in Duluth in late June,
included a roundtable discussion among the Chief Executive Officers of three
rural hospitals. The following are some of the major themes that emerged
there and echoed throughout the conference.
Major change is coming – and in key ways rural Minnesota is well
positioned for it. This year’s conference resonated with questions and
predictions about how health reform will play out in rural settings. The three
CEOs agreed it will cause significant shifts, but also spoke to ways their
hospitals have already begun making changes that position them well for
reform -- including quality initiatives such as the RARE campaign (Reducing
Avoidable Readmissions Effectively), which appears to be successfully
improving a measure that will affect hospitals’ reimbursement from Medicare.
Others have begun integrating services and exploring relationships with other
systems and public health – what Riverwood Healthcare Center CEO Michael
Hagen called “value contracting.” Riverwood, located in Aitkin, has also
changed how it pays providers, now basing it partly on risk and quality rather
than simply productivity. Other conference presentations also highlighted ways rural Minnesota may be
well suited to the impending change. Many rural areas are already very
focused on primary care as the foundation of the local health system, and
integrate those services with both the community and the hospital. They also
have strong histories of partnering to provide services. In the conference’s
policy forum, Commissioner of Human Services Lucinda E. Jesson noted this
positions them well for collaboration on key issues like readmissions and care
transitions. Many hospitals in rural Minnesota also appear to be on a strong financial
footing for reform, at least for now. A presentation at the roundtable of hospital
CFOs showed that as of 2010, most Critical Access Hospitals (CAHs) in
Minnesota were at low risk for financial distress and none were at high risk.
Most were also performing well in key financial benchmarks, including cash
flow margins.
Still, challenges lurk. The CEOs touched on two of the biggest issues about
health reform raised at the conference: access and new payment
methodologies. The opening keynote called access the most important issue of
all. “My fear is that in building a more efficient system, we’ll lose access,
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especially for rural populations,” said Bill Finerfrock, Vice President of Health
Policy at Capitol Associates in Washington DC. “We need to make sure this is
re-inserted into the policy discussion.” The CEOs at the roundtable agreed it
will be key, particularly across the various levels of care.
Riverwood CEO Michael Hagen of Aitkin called the prospect of bundled
payments a “looming issue” and potentially a big problem for CAHs. As a CAH,
his hospital is now reimbursed for its costs under Medicare, but faces financial
challenges serving other patients. At the policy forum later in the conference,
Stratis Health CEO Jennifer Lundblad went further, saying that rural health
advocates are “kidding ourselves if we think the CAH cost-plus reimbursement
system can be sustained.” Or as Lawrence Massa, president of the Minnesota
Hospital Association, put it: “Rural people can be leaders on the delivery side,
but I worry about the financial side.”
Either way, the new era will require more partnerships and different
structures. The CEOs agreed the future will require even higher degrees of
collaboration and different ways of delivering services. This echoed the
conference’s keynote speech, in which Bill Finerfrock predicted that hospitals
will no longer be able to operate as “islands,” but instead will need to integrate
and coordinate with other providers, particularly with primary care as the portal
into larger systems. This won’t necessarily take the form of Accountable Care Organizations
(ACOs), however, which Finerfrock doesn’t believe will work in rural
settings. None of the three CEOs at the roundtable see themselves playing a
leading role in ACO, either. River’s Edge Hospital and Clinic in St. Peter is
exploring a virtual ACO with other independents, said CEO Colleen Spike,
though even then rural communities' small size may be an issue.
Focusing on community need will be key. Numerous conference
participants, including these CEOs, emphasized basing decisions above all on
a given community’s unique characteristics. “Today there is more talk about
growth to fully meet community need,” said Spike of River’s Edge. This local
focus can also help decisionmakers navigate and evaluate the many options
emerging, according to Stratis’ Lundblad: “Stay focused on what your
community needs rather than latching on to all the new ideas or chasing
models designed for urban areas.” It may also help with difficult decisions
about which service lines a hospital may need to drop or provide indirectly. “It
gets to the heart of the community,” said David Nelson, of St. Francis
Healthcare Campus in Breckinridge, but is increasingly necessary.
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RHAC MEMBER PROFILE
ORHPC TALKS WITH RURAL HEALTH ADVISORY COMMITTEE (RHAC)
MEMBER RAY CHRISTENSEN
Please explain your professional work to us . . .
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Ray Christensen, M.D.
I’m a family physician and I’ve practiced family medicine in Moose Lake for 40
years. I’m also currently assistant dean for rural health for the University of
Minnesota. I also serve as Medical Director for Mercy Hospital and Augustana
Mercy Health Care Center in Moose Lake, and I’m treasurer of the Minnesota
Academy of Family Physicians.
At the national level, I am currently involved with the National Rural Health
Association (NRHA). I’m on the NRHA Board and chair the Clinical Services
Constituency Group, which I’ve done for some time. I also serve on its
Government Affairs Committee and the Rural Congress, the policymaking body
of the NRHA. I’m also a Minnesota Medical Association delegate to the
American Medical Association (AMA).
And your life away from work?
There isn’t any! No, away from work I enjoy family and walking. I live on the
North Shore and walk every day on Old 61. I also really enjoy the night sky –
the Northern Lights, the planets and stars. I’m also involved in the Masons and
currently serve on the Minnesota Masonic Charities Board, which grants
scholarships and supports other important causes.
What do you think are the most important issues facing rural health?
My mission is to provide access to high-quality health care to rural citizens and
their visitors, and I try to make my decisions based on that. Right now, the big
issue is how to maintain access and how that might be affected by the
Affordable Care Act.
I think it’s important that we try to bring the strength and resiliency of rural
communities to health care policy. I think all of health care policy would benefit
from looking more closely at what we do in rural, particularly how we bring
community into health care.
Finally, the struggle for a health care workforce continues. My work at the
university is to make sure we train rural family physicians, including physicians
for Native American communities. One of the most difficult problems right now
is finding rural training sites and preceptors for medical students. We need
preceptors in rural communities.
What do you think would make the most difference for rural health?
The thing that’s going to make the most difference for health care – health
care period, not just rural health care – is the large untapped resource we
have in the patient. That is, the patient taking responsibility for their own health
and health care. It has to do with prevention and it has to do with all the
related pieces – including that I as a physician explain and teach in a way
that’s assisting patients with their care and not preaching. We need our rural
citizens to take ownership of their health. If we could make that happen, it
could save a lot of money. Some say that’s the largest untapped resource we
have available right now for better health care and better health care
outcomes.
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I also hope we can continue finding rural young people who are willing to go
back and serve their community in the health care workforce. In my case, it’s
finding doctors, but it’s not only physicians we need.
The Rural Health Advisory Committee advises the commissioner of the Minnesota
Department of Health and other state agencies on rural issues; provides a systematic and
cohesive approach toward rural health issues; and encourages cooperation among rural
communities and providers. Meeting information is online.
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VIEW ONLINE ALL PREVIOUS ISSUES OF THE OFFICE OF RURAL HEALTH AND PRIMARY CARE PUBLICATIONS.
Minnesota Office of Rural Health and Primary Care
P. O. Box 64882
St. Paul, Minnesota 55164-0882
Phone 651-201-3838
Toll free in Minnesota 800-366-5424
Fax: 651-201-3830
TDD: 651-201-5797
www.health.state.mn.us/divs/orhpc
MISSION: To promote access to quality health care for rural and underserved urban
Minnesotans. From our unique position within state government, we work as partners with
communities, providers, policymakers and other organizations. Together, we develop
innovative approaches and tailor our tools and resources to the diverse populations we serve
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