Health Policy and Family Medicine Advocacy Education Workforce

Health Policy and Family Medicine: Advocacy, Education, Workforce, and Research 41 st STFM Annual Spring Conference May 2, 2008 Theme Day Session T 1

Presenters • • Eric Henley, MD, MPH Margaret Kirkegaard, MD, MPH Bruce Goldberg, MD Russ Robertson, MD Ron Labuguen, MD Valerie Reese, MD Patricia Gotsch, MD

Format of Today’s Session • Seminar (90 minutes) – State health policy – Medical home model – Family Medicine educators’ roles as advocates and advocacy educators • Lecture-Discussion #1 (45 minutes) – Council on Graduate Medical Education (COGME) – Primary care workforce – Place of the medical home in national discussions • Lecture-Discussion #2 (45 minutes) – How research can best inform health policy development

Format of Today’s Seminar • Health Care Reform Efforts and the Role of Family Medicine in Policy Development (40 minutes) – Texas, California, Illinois, Pennsylvania • Small Group Discussions (25 minutes) – Curriculum development, Faculty development, Public Advocacy • Large Group Discussion (20 minutes) • Conclusions

Objectives • At the end of this seminar, attendees will be able to – Describe health reform policies in four states (Texas, California, Illinois, and Pennsylvania) that address access to care and the role of the medical home – Discuss the role of family medicine educators as advocates and developers of advocacy curricula – Identify common attributes of successful advocacy and policy development by comparing these four states and examples presented by attendees

Texas: A Broken Health System Valerie F. Reese, MD

The Numbers • Texas has the highest percentage of uninsured people in the United States. (25%) • 5. 6 million Texans have no insurance • 5 counties account for close to half of the uninsured in Texas (these counties include Houston, Dallas, Fort Worth, El Paso, and San Antonio)

The Economics • 79% of uninsured Texans are employed either full or part time • Small businesses (<50 employees) constitute 73% of all businesses in Texas. Only 37% of these businesses offer insurance. • 53% of uninsured Texans work in construction, manufacturing, wholesale and retail trade.

Advocacy Efforts • The Primary Care Coalition (TPS, TAFP, TSIM) published 2 reports on the state of the health care system in Texas-“Fractured” and “Fading Away: Access to Primary Care” • Both reports are descriptive and have some recommendations but no concrete action items for members

Fading Away • The one concrete item that came out of the work of the PCC was the enactment of tort reform by the 78 th Texas legislature. • Tort reform has seemed to decrease the stream of providers leaving Texas but has not address the continued lack of access and coverage for Texans

Texas Business • The Texas business community has been very involved in discussions surrounding the problems in the Texas health care system. • In 2006, the Texas Business Association published “Employers and Health Care: Crisis and Solutions”

Code Red Task Force that includes: • large Texas employers • representatives of each of the Texas medical school systems (UT, TX Tech, Texas AM) • county health districts • TX Med Assoc • TX Hospital Assoc • faith-based organizations • other interested individuals and groups

Code Red Initially 10 recommendations including: • suggestions for fees • graduate medical education • increasing community health • strengthening public health systems • changing county health system funding • integrated school health programs • encourage health care delivery system innovation

What Have These Efforts Produced? • HB 109 -restores CHIP funding to 2003 levels • SB 10 -provides for 3 -share/multi-share programs; expands Medicaid’s Health Insurance Premium Program • SB 1254&HB 2548 -expands eligibility for Texas’ Health Insurance Risk Pool • With these laws, over 300, 000 Texans will have access to healthcare coverage

What Next? • Texas has a bi-annual legislative process • 2008 will be a time for groups to get their arguments and data together for the next session in 2009. • There are still 5. 3 million Texans without insurance • Speciality groups and physicians need to get involved

Health Care Reform in California Ronald H. Labuguen, M. D.

Focus on Health Care Reform • October 2006: Governor made health care reform a major focus of 2007 -2008 legislative session • California government factoids: – Biennial legislative sessions – Two-house legislature: Assembly and Senate – Governor can call special legislative sessions – Fiscal Year July 1 - June 30

Proposals – Winter/Spring 2007 • Gov. Arnold Schwarzenegger – Employer “pay-or-play” mandate, state-run insurance pool, universal coverage, higher medical loss ratio • Sen. Don Perata (Senate President pro tem)–SB 48 – Individual and employer mandates • Asm. Fabian Nuñez (Assembly Speaker)–AB 8 – Employer mandate, expand subsidized coverage • Sen. Sheila Kuehl (Chair, Senate Health Comm. )–SB 840 – State-run single payer system – Legislature passed similar proposal in 2006 but Governor vetoed • Republicans – Market incentives

Advantages/Concerns • Advantages: – New attention focused on health care – Increase in Medi-Cal payment rates under some plans • Concerns: – Large number of uninsured (6. 5 million) and Medi. Californians – Capacity of current health care system to absorb newly insured patients • Facilities, workforce pipeline – 2% levy on gross payments to physicians (Governor’s proposal), later dropped – Effect of employer mandates, especially on small businesses

Special Session – Fall 2007 • Republican proposals died in committee • Kuehl’s single payer proposal passed Senate but was later dropped • Perata and Nuñez proposals passed Senate and were later merged • Eventually Governor and Perata/Nuñez proposals merged into single bill: “Health Care Security and Cost Reduction Act” (AB 1 X 1) – Health insurance required for most Californians; health plans required to offer coverage to everyone – State-subsidized insurance with sliding-scale premiums – Expanded Medi-Cal eligibility and increased Medi-Cal payments to physicians and hospitals

Health Care Reform Derailed • December 17, 2007: AB 1 X 1 passed in the Assembly 46 -31 • Bad news: State budget shortfall of $14+ billion – Perata asked for cost estimate from LAO: roughly equal to the estimated cost of implementing AB 1 X 1 – Perata withdrew support--concerned about higherthan-expected premiums vs. deficits • January 28, 2008: AB 1 X 1 died in Senate Committee on Health 7 -1 (Chair = Sen. Kuehl)

What’s Next? • Governor and public still interested in health care reform • Possible ballot initiatives (“Propositions”) – If enough signatures obtained by petition, referendum placed on state ballot to adopt legislation • Medi-Cal rate cuts: 10% starting July 1 • Privatization of health centers – Los Angeles

Healthy San Francisco • Health access program for uninsured residents • Employer mandate – Being challenged in court • Medical home • Cost sharing for patients earning 100%+ of federal poverty line – Copayments, quarterly premiums • Concerns – Facilities, workforce, budget, fairness of cost-sharing

Family Physician Advocacy • California AFP sought involvement early in process – “Primary Care Coalition” “Cognitive Coalition” – Meetings with key players (Governor, legislators), testimony at legislative hearings, grassroots advocacy – “Strong Medicine for California” publication – Congress of Delegates separated from Annual Scientific Assembly, meets in Sacramento • Legislative advocacy and media training, legislative visits

Advocacy in Family Medicine Residency Programs • Voter registration drive • “Advocacy Day” • Advocacy training for residents through California AFP – Media training – Legislative advocacy

Healthcare Reform in Illinois Margaret Kirkegaard, MD, MPH

All Kids • First state to offer insurance to “all kids” without access to affordable insurance • Expansion of SCHIP and Medicaid eligibility • Includes all kids regardless of immigration status, income or medical conditions • Different premium levels and co-pays for various income levels up to $160, 000 per family • Vigorously supported by ICAAP, Endorsed by IAFP

All Kids Continued • Initially projected to cover 235, 000 uninsured children in Illinois • After 6 months of enrollment, 75% of all new applicants were already eligible for Medicaid or SCHIP • Proposed funding ($56 million) through implementation of Primary Care Case Management and Disease Management programs

Proposal for Illinois Covered • 1. 4 million uninsured adults in Illinois • Original proposal called for 3% GRT on all businesses with revenue greater than 2 million • 3% employer assessment for business with more than 10 employees • Vigorously opposed by Illinois State Medical Society • Rejected by the legislature

Illinois Covered continued • Governor used executive authority to cut $500 million out of the state budget for healthcare • Attempted to expand Medicaid to 400% of poverty level through emergency rules procedure • Rejected by Joint Commission on Administrative Rules • Governor proceeded in enrolling new families calling JCAR “advisory” • Prompted ongoing lawsuit

Medical Homes for All • All Kids legislation also introduced Disease Management Program and Primary Care Case Management Program • DM targets 230, 000 pts with chronic diseases, “frequent flyers”, institutionalized, asthma • PCCM: “Illinois Health Connect”, 75% of all clients either choose or assigned to a “medical home” (not currently enforced), includes PMPM

Response of Illinois AFP • Endorsed All Kids • Endorsed Illinois Covered but rejected the GRT proposal • Has worked with DM program to provide CME • Has worked with PCCM program to promote education and awareness

Implications for Teaching • Most Primary Care residencies enrolled as “Medical Homes” • Controversial and contentious reform process makes advocacy difficult

Pennsylvania Valerie Gotsch, MD

Pennsylvania: The Problem • • 8% of Pennsylvanians are uninsured 767, 000 adults; 133, 000 children 71% of these are employed Between 2000 and 2006, premiums have increased 75. 6%; inflation 17%; median wages 13. 3%

Prescription for Pennsylvania is a set of integrated practical strategies for improving the health care of all Pennsylvanians, making the health care system more efficient and containing its cost. Right State | Right Plan | Right Now

Affordability • CAP (Cover All Pennsylvanians): subsidized by the state and offered through private insurers; for eligible small businesses and the uninsured • Not-for-profits must provide “community benefit” • Capital expenditures • Decreasing inappropriate ER use • Requiring health care coverage for students • Fair admission and billing practices

Access • Expanding practice • Increasing access on capabilities for weekends and in the midlevel practitioners evening • Increasing access in • Increasing diversity of primary care shortage the provider workforce areas by providing startup funding for FQHCs; workforce development; financial incentives for underserved areas

Quality • Decreasing hospital acquired infections, medical errors, and unnecessary care • Pay for performance systems • Improve care of chronic disease esp. asthma, diabetes, heart disease, lung disease • • Co-occurring disorders Palliative care Pain management Improving long term living options; providing more home/community options • Long term insurance • Wellness promotion

Examples: Bills in Process • House Bill 1093: Medical school loan forgiveness bill • House Bill 2098: Preventable Serious Adverse Events Act • Senate Bill 246: Smoking Ban

Example: Executive Order • May 2007: Executive Order established the Chronic Care Management, Reimbursement, and Cost Containment Commission • Strategic Plan issued February 2008 • Adopting a “chronic care model” patterned after programs in place at the VA, and in Vermont and Washington • Initially will target diabetes and asthma

Advocacy in Pennsylvania • PAFP: PAC – formed in 2003 • Pennsylvania Medical Society: PAMPACPA Medical Political Action Committee • PA Medical Society – April 8: Advocacy Day • Website/links

PAFP • Medical Home Project – aimed at transitioning young adults with special healthcare needs into Family Medicine medical homes • 17 practices statewide are involved in this demonstration project

Thank You!

Small Group Discussions • Divide into three small groups to discuss the following (25 minutes) – Group A: Curriculum Development – Group B: Faculty Development – Group C: Public Advocacy • Each group selects a reporter to report back to the large group (20 minutes)

Group A: Curriculum Development • What curriculum objectives are appropriate to prepare residents for an active role in the development of state health policy? • What methods can be used to teach residents the skills, knowledge and attitudes to become effective advocates?

Group A: Curriculum Development Small Group notes: • Advocacy Day • How? – – Share stories (“case”) of patients’ needs Health Policy e-mail group Make part of “SBP&I” curriculum Lecture? on history of health care coverage & emergence of current mess – Bring in advocate – Weave into “pipeline” lecture/curriculum • • • Role of medical societies in advocacy “Structured debate” Community medicine rotation Ask State Academy to come to teach Write “letter to editor”

Group B: Faculty Development • How well prepared are Family Medicine educators to teach about health advocacy and policy development? • What strategies can be employed to prepare Family Medicine educators for this role? • What resources are available to assist faculty with this challenge?

Group B: Faculty Development Small Group notes: • Texas: Leadership Development conferences – Legislative update – Legislative Liaison • AAFP/STFM Legislative Conference in DC ~May -June • WWAMI Legislative Network • University (Public Health/Public Policy Schools faculty) • State FP academies • Other coalitions that are successfully advocating

Group C: Public Advocacy • Do family physicians have a role in educating patients (potential voters) about state health policy proposals? • How can the public be educated about the value of primary care and a medical home? • What skills are necessary to be an effective community advocate? • What community partnerships should be pursued to effect health policy change?

Group C: Public Advocacy Small Group notes: • Guiding principles shared by FP’s w/ different payor mixes/patient populations served • Interests of FP’s = Health of the Public? • Decreased (Credibility) – – • As a group Personal interests When to act: – Timing • – • Letters to the Editor etc. Sharing stories Patients (voters) – inform key movers Be an “expert” Media increase publicity –share stories – • • “Sharing the costs” of reform Influence of media – – • • • Conducive environment Know key writers/reporters, letters to the editor Legislators/Administrators Partner with organizations –shared vision – Students

Group A: Curriculum Development • What curriculum objectives are appropriate to prepare residents for an active role in the development of state health policy? • What methods can be used to teach residents the skills, knowledge and attitudes to become effective advocates? Group B: Faculty Development • How well prepared are Family Medicine educators to teach about health advocacy and policy development? • What strategies can be employed to prepare Family Medicine educators for this role? • What resources are available to assist faculty with this challenge? Group C: Public Advocacy • Do family physicians have a role in educating patients (potential voters) about state health policy proposals? • How can the public be educated about the value of primary care and a medical home? • What skills are necessary to be an effective community advocate? • What community partnerships should be pursued to effect health policy change?

Large Group Discussion Group A: Curriculum Development Group B: Faculty Development Group C: Public Advocacy

Resources (see handout)