One of the most comprehensive health surveys in the history of Tulsa County wasn't spawned to help provide care for the basic necessities of the most needy, but to satisfy new regulations from the IRS.
As part of new tax code changes related to the Affordable Care Act, nonprofit hospitals must now come up with a health-related community needs assessment. When the Tulsa Health Department a couple of years ago became interested in developing a new survey to drill deep into the health concerns of county residents, it could count on support from St. John and Saint Francis.
The two hospitals, along with the George Kaiser Family Foundation, paid for the $75,000 survey.
"The real catalyst was definitely the IRS requirements, as well as the health department was undergoing a national accreditation process and had to complete a needs assessment," said Lynnsey Childress, a community relations specialist with the health department.
Childress sat in on three or four meetings held to develop the survey. Several other groups had a place at the table, including Hillcrest, OU-Tulsa, the nonprofit Community Service Council, and a few others.
"We really pooled our resources," Childress said. Eventually, a contract to conduct the survey was awarded to the University of Nebraska Public Policy Center, an organization very experienced with conducting such surveys, Childress said.
Along with questions about specific health areas, the approximately 70-question phone survey also asked about access to health care.
"Obviously, the hospitals were interested in that," Childress said, describing how the questions were put together. "Especially questions that were related to what time of day people access healthcare, things related to prescription costs, co-pay costs." Along with the large hospitals, other health care providers like Morton also helped craft those questions, Childress said.
One big question centered around health insurance. Survey results measuring the uninsured population were "extremely close" to estimates published by the U.S. Census Bureau, Childress said. According to the survey, just over one in four Tulsa County adults stated they had no insurance. Almost one out of every two people reported having employer-provided or private insurance.
The survey, done in the early months of last year, found that 6.2 percent of people had Medicaid, the nation's safety-net insurance, known in Oklahoma as SoonerCare. Another 4.7 percent reported having self-purchased health insurance.
Health care reform might change those numbers, perhaps even dramatically.
And so, beginning Tuesday, Oct. 1, health consumers will be able to test drive a new federal system designed to make it easier for individuals to purchase insurance on their own.
These exchanges, being made available, in one form or another, in every state, allow everyone -- not just the working poor -- to scout new insurance options. But special subsidies in the form of tax credits are in place to make insurance more affordable for those with an income ranging from 100 to 400 percent of the federal poverty level.
For those below that scale, the options aren't the same.
"What's going to happen is, you're going to have two families that live next door to each other. Both, maybe a family of three, with one working adult. One family earns $25,000, so they'll be eligible for coverage through the exchange, with a generous subsidy to help cover the cost, and the family next door with less income, that makes only $15,000 a year, will be ineligible because they fall into this coverage crater," said David Blatt, director of the Oklahoma Policy Institute.
As reported in previous "Medicaid Madness" stories in Urban Tulsa Weekly, architects of the Affordable Care Act envisioned an expansion of Medicaid to take care of the health care coverage needs of this population. But attempts to peel back the act through a legal challenge brought the matter to the U.S. Supreme Court. The much-anticipated ruling generally upheld the insurance mandate, which will require many Americans to purchase health insurance or pay what the court ruled amounts to a tax should they choose to remain uninsured.
But the court ruling also effectively made Medicaid expansion optional for states. Further emphasizing the partisan-divide when it comes to "ObamaCare," many Republican governors have stiff-armed the expansion, including Oklahoma Gov. Mary Fallin. Instead, she has called for development of an "Oklahoma plan" to address the health insurance needs of low-income adults.
Hospitals have been loudly advocating for Oklahoma to at least accept federal money earmarked for Medicaid expansion, a notion also recommended by a consultant group that put together recommendations for a plan to provide heath care coverage help to low-income residents.
"Our state is eligible to receive $8.6 billion over 10 years to help citizens get the health care they need. Some say we can't afford to take this money, but the truth is, we can't afford not to," states the message on the slick website, APlanForOklahoma.com, that's backed by the Oklahoma Hospital Association.
The website goes on to make the argument that the financial pain of uncompensated health care actually goes to all Oklahomans in the form of "higher insurance premiums and increased costs."
Blatt, an advocate for Medicaid expansion, sees the coming months as doing nothing but adding pressure on state lawmakers to come up with some sort of state-backed solution to help this group of low-income Oklahomans.
In Blatt's view, there will be a strong reaction to seeing some people helped by the health insurance exchange and others left out.
"As awareness of situations like that develop, there will be growing pressure to say, 'Hey, we've got to fix this,'" Blatt said. He added: "Whether we do it through a Medicaid expansion, or do it through premium assistance, to have that population go onto the exchange, I think there's a lot of details to be figured out. But there are options and there will be, I think, some pressure."
How many others will see the situation the way Blatt does? The health department survey asked participants to describe their top health concerns.
"It was a completely open-ended question," Childress said. Factoring answers to another question relating to concerns, poor diet and inactivity topped the list. Next, worries about obesity. Third and fourth were drug and alcohol abuse and then chronic disease concerns.
Concerns about access to health care came in at number five.
"I definitely think that there's a hierarchy of needs. I think that there are some areas of Tulsa County where we can definitely see that access is probably a lower concern," Childress said. "Usually, you only think about having to access the doctor when you're sick, but things like poor diet, having access to quality food -- everybody eats every day. We prioritize everyday necessities over access to health care, but I think that's all the more reason for community partners who work with people on access to health care to really reach out to people."
Health Care "Navigators"
Beginning Oct. 1, local residents can call 2-1-1 to get information about the new health insurance exchange, with staffers of the social services hotline still undergoing training in the days leading up to HealthCare.gov opening up for business.
Making that call will be Laura Ross-White.
She's wanted health insurance, but "it was never financially feasible for me as an undergraduate or graduate student to have a plan on my own," said Ross, 30.
She and her husband, Rusty, put their health-care dollars instead on a policy for their five-year-old daughter. They also have two adopted children and care for two foster children in their Tulsa home.
Ross-White, 30, said she has no pre-existing conditions, but still couldn't afford the $150 a month premium for herself. With her husband on the same policy, the monthly expense would have been over $400, she said.
She earned her master's degree in May and found work as a contractor with the non-profit Community Service Council, but, like many such jobs, it doesn't come with insurance benefits.
Having insurance to at least take care of preventive screening and medicine costs is "important to me as someone who has children and wants to be around for a really long time to share their lives," Ross-White said.
The 2-1-1 helpers are only a few of the people in Tulsa County being trained on the new health care options.
At Morton, which is designated as a Federally Qualified Health Center by government authorities, federal grant money -- about $150,000 -- will pay for new positions described as "navigators." These new positions -- Morton might hire between four and eight of them -- are designed mainly to help patients explore the new health insurance exchange.
"We assist them; we educate them on what's available. We educate them on what they might be eligible for. We will educate them on the costs," said Cassie Clayton, Morton's chief nursing officer. "Our navigators are going to training sessions, because it is daunting."
It's hard to guess what effect these positions will have -- despite some highly precise numbers from the federal government.
Statewide, about $1.7 million in federal funds were expected to support 38 positions based at such federally-qualified health centers, according to the U.S. Department of Health and Human Services. In total, the government estimates that these workers will assist 43,908 people "with enrollment into affordable health insurance coverage," the department's website states.
Clayton spoke before going through a scheduled Sept. 11 training for such navigators. But she said she expects there to be demand for the navigators.
"How difficult do I think it's going to be? I think that right off the bat we probably will have quite a few people who are interested in signing up," Clayton said. Slightly more than half of all Morton patients have no insurance.
The plan was for the new outreach workers to be available at the eight Morton locations in northeast Oklahoma and that they attend "any type of event or venue that we can get into, to identify people who might need health insurance and help to enroll them, to educate them."
It's not the only program with a similar purpose, according to Bob Moos, a spokesman for the Centers for Medicare and Medicaid Services, the federal agency that oversees Medicare and Medicaid.
Other groups throughout the state will also receive a total of roughly $1.6 million in grant money to develop patient navigator programs. Another group of workers will not be known as navigators but as "certified application counselors," Moos said.
"They, too, will sit down with folks and help them through the process," Moos said. "Most of these folks are going to be working at, say, hospitals or social service agencies or community health centers."
Clayton emphasized that the Morton positions will be independent of the insurance industry.
"We won't be steering them to a specific vendor," Clayton said.
But the very existence of these new positions has brought forth criticism, in Oklahoma and elsewhere.
Back in 2011, Oklahoma Insurance Commissioner John Doak expressed concern, stating that only licensed insurance agents and brokers should be so hands-on in helping people with the new insurance exchange. In other states, Republican leaders have tried to dictate limits on where such navigators can conduct outreach to potential enrollees.
Moos noted that insurance agents and brokers "can in fact walk people through this process as well, and help make selections on insurance plans." He advised potential enrollees that they "need to be aware there's a business relationship between agent-broker and insurance companies."
The health department followed up its survey with several focus groups conducted by Littlefield branding agency, Childress said.
When it comes to accessing health care, "I definitely think that the focus groups are more telling in that area than the survey itself," Childress said. "I think us being able to follow up on some of those initial questions and really understand where people's concerns lie, that's the better picture for us."
And what did the health department learn from such focus groups (Childress said there were 12, with a total of 91 participants)?
"I definitely think that what we've seen is that the new options can be very confusing," Childress said.
Already, however, there have been "a couple of smaller insurance agencies who are taking on some of the responsibility of getting people signed up under the Affordable Care Act," Childress said.
What resonates for those potential enrollees? Childress said it boils down to having "very simple messages out there that are simple to understand."
BeCoveredOklahoma.org is the effort by Blue Cross and Blue Shield of Oklahoma to do just that, though the insurer's name can only be found on the main page in tiny letters at the bottom.
Another insurer, CommunityCare, is owned by St. John and Saint Francis.
Childress wasn't sure if an insurance company had much direct input into the survey questions, but that doesn't mean local insurers have been taking a passive role amid the changes to the health care system -- instead, they've taken on a big picture view of health care reform.
When it comes down to it, the Affordable Care Act doesn't boil down to simply new options and regulations regarding health insurance.
That's what Dr. Gerard Clancy discovered when he pored over the two thousand or so pages of the legislation.
"Only about 30 percent of the bill dealt with expanded Medicaid coverage, the individual mandate and insurance reforms," said Clancy, president of the University of Oklahoma-Tulsa. "There was another 70 percent of the bill that was trying to modify the health care delivery system to improve access, to be more efficient, be more attentive to quality. And it really was a systems reengineering set of initiatives."
Source: 2012 Tulsa County Community Health Needs Assessment
Clancy and others will say that while Tulsa and Oklahoma have health outcomes among the worst nationally, the community actually has become a hotbed of such health care delivery system reforms.
MyHealth, for example, is a nonprofit coalition with strong business backing. Its goal is to push forward with information technology innovation to create what's known as a "health information exchange", so that doctors can easily access patient records -- even if those records were created in a clinic or at the office of an unaffiliated doctor.
The initiative, headed by Dr. David Kendrick, led to Tulsa being selected as what's known as a "Beacon community", a designation that came with a $12 million grant in 2010.
Many hopes are pinned on another reform as well--the patient-centered medical home concept. Generally speaking, it's a system designed around improving the coordination of care by involving a team of medical professionals who collaborate to form a "home" team for each patient.
The concept, in varying stages, has become popular in Oklahoma. The OU-Tulsa medical school embraced it under former longtime dean, Dr. Dan Duffy, as have the OU medical clinics and other health care providers, like the Community Health Connection.
But a highly concentrated effort -- basically an experiment -- has been going on in Tulsa with support from the federal government. Here, the city is locus to one of only a few sites where the ongoing Comprehensive Primary Care Initiative evolves.
This effort involves commitments from the Centers for Medicare and Medicaid Services and also two major insurers, CommunityCare and Blue Cross and Blue Shield, to provide reimbursement to the roughly 70 primary care providers taking part.
Unlike the standard fee-for-service model, this effort involves "bonus payments" to doctors for better-coordinated care for patients.
Rather than payments made per visit, "we pay a fee to all participating physicians that is non-visit based," said Joseph Cunningham, vice president and chief medical officer for Blue Cross and Blue Shield of Oklahoma. "We just pay you a fee based on who you're taking care of."
Cunningham described how a personal connection led the insurance organization taking part in the project.
The former OU dean Duffy "was a professor of mine when I was a resident," Cunningham said. "I've known him for years. He helped train my two boys in medical school, too."
When Duffy approached Cunningham about Blue Cross and Blue Shield -- the single largest private insurer in the state -- about taking part, "had it been almost anybody else outside of Blue Cross asking me to look at it, I would have respectfully declined," Cunningham said.
To participate with federal backing, the demonstration project needed a mix of "payers" to be at least 60 percent of the total reimbursements received by a physician, Cunningham said.
"Dr. Duffy knew Blue Cross is the market leader in this state," Cunningham said, describing the organization as "the largest third-party payer" in Oklahoma, making up between 30 to 40 percent of a physician's total reimbursements. "When I read it, it seemed like a very good initiative because we'd also been working with MyHealth," Cunningham said, adding that MyHealth's involvement in the medical home project was very important. The message was "don't even consider us if everyone isn't participating with this HIE," Cunningham said, referring to the "health information exchange" that, as of this year, now has almost 100 health care providers and organizations signed up.
"The goals are very simple: better health, better care and lower costs, and I thought those goals, being simple like that, would fit in virtually any business model," Cunningham said. "If we could get better health for our members, better care, being delivered at a lower cost, then we could potentially lower our premiums and cover more people."
Inside the insurance industry, individuals can be given what's known as a "risk score" based on a variety of factors, Cunningham said. Such scores can be grouped according to geography, he said, describing how Blue Cross and Blue Shield might evaluate changes in health.
"Everybody that lives in this zip code, what's their average risk score? If we can change their average risk score to the positive, that shows us we can improve their health," Cunningham said.
Kendrick has said in the past that insurers can be key figures in health care reform by "recognizing and rewarding" physicians who achieve certain quality measures. In the consultants' report delivered to Oklahoma leaders in June, a key recommendation was to focus more on health outcomes when crafting a plan for the low-income, uninsured population.
Cunningham suggested that insurers can play an even more central role in this type of reform. Insurance enrollees can also be assigned an "opportunity score," which he described as measuring "what opportunities are there to improve somebody's health." This can include scrutinizing the quality of treatment a patient receives; a person with cancer, for example, "if they're being treated perfectly, their opportunity score is zero," Cunningham said.
This information isn't just held by the insurance company. "We're trying to show doctors through these analytics and these data changes what opportunities are out there," Cunningham said.
He elaborated on what an insurance company sees as the best way forward to evaluate the health care system.
"As we look to the future, we have to pay for value, and value is a combination between cost and quality," Cunningham said. "It can't be based just on cost. And, honestly, sometimes you can buy a little more quality that costs you a whole lot of money, but the value isn't there."
Jack Sommers, the senior vice president and chief medical officer for CommunityCare, said "there has to be a balance."
He gave as an example a procedure that's paid for by government insurance despite "two very good randomized, controlled trials" done recently that show the procedure is no more effective than a placebo.
"I think there's a lot of waste in the system that's like that. You're providing something that has no value, the issue is when do you stop and say, 'No, I'm not going to provide this,'" Sommers said. He emphasized the importance of making sure a treatment is proven effective before it's prescribed.
Ultimately, Cunningham said, "we're trying to say we need to pay doctors to keep people healthier, so that's really what we're trying to move to."
It remains to be seen exactly what results from the reimbursement approach taken by the Comprehensive Primary Care Initiative.
Dr. Gerard Clancy
"We're early in this project," Cunningham said. "We don't expect to see significant savings early."
Clancy said that, in general, the cost of doctors accounts for about two out of every 10 dollars spent on health care. The rest of the cost comes from decisions made by doctors -- in other words, the tests and treatment they prescribe.
"That's always been the stretch with the Affordable Care Act ... that transforming the healthcare system, how you actually deliver care, there's a way to reduce costs," Clancy said. But with a concept like the comprehensive medical care home, "it's an experiment that needs to be done," he said.
"I have to focus on the health of all Oklahomans," Cunningham said. He said it another way: "I don't care what card they carry. I care that they're healthy."
Sommers said the demonstration project also has improved the relationship between insurers and medical professionals. He also noted trends in the industry of patients changing policies as another reason to focus on community health.
"We're going to get that patient next year, probably anyway, so let's make it better for everybody," Sommers said.
Blue Cross and Blue Shield has agreed to be part of an application put together by Kendrick seeking what's known as a Health Care Innovation Award that, in some ways at least, would take this Tulsa demonstration project statewide.
By partnering with the Oklahoma Health Care Authority, also a participant in the Tulsa project, the result, in the words of Cunningham, could be "basically a care management system in place so we can have coordinated care across the state."
Cunningham seems sold on the idea. "This is the right thing to do, whether we get the grant money or not," he said, emphasizing that Blue Cross and Blue Shield received no grant money to be involved in the Tulsa-based Comprehensive Primary Care Initiative.
It will be a few months before the grant application is reviewed by federal authorities.
Meanwhile, state officials hailed as a victory the extension of Insure Oklahoma, a program developed to offer low-income workers partially-subsidized health insurance. The program had been set to lose its federal funding at the end of this year, but the state and federal health care authorities negotiated a one-year extension.
"I think there was some give and take on both sides," Blatt said. "I think for the state, the give was to reduce the co-pay levels for those who would remain in Insure Oklahoma to be much more in line with traditional Medicaid co-payment levels. So (for) that population that will be in the individual plan of Insure Oklahoma; it's going to look a lot like Medicaid, which is what the Affordable Care Act has intended for those with incomes below 100 percent."
It's estimated that 8,000 adults will no longer qualify for the program, more than a quarter of all enrollees.
Blatt said the extension buys time.
There remains a strange bedfellows grassroots/business citizens group advocating for acceptance of Medicaid and the opposite, including the conservative think tank Oklahoma Council of Public Affairs, who are vocally opposed to accepting federal dollars for health care reform.
"I think it's unlikely there's going to be much movement before the start of the new year," Blatt said.
As far as expanding the concepts included in the patient-centered medical home model, Clancy said the challenge is about "aligning those that need it, with it."
Future stories in Urban Tulsa Weekly's "Medicaid Madness" series will highlight a system undergoing major reform.
The changes might be a bit of a bumpy ride for patients.
"A good analogy is the aviation industry," Clancy said. "Thirty years ago, the aviation industry had a safety record that was very concerning."
This led to a massive revamp of safety procedures.
"What you've seen is a much safer aviation industry as far as a safety record, but it's not very consumer friendly," Clancy said. "We may see the same thing in health care. A much more efficient health care system that may be more cost effective, but it may be harder to be a patient in it, compared to where we were before."
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