Pushing the Boulder Uphill Educating the AHC and

Pushing the Boulder Uphill: Educating the AHC and Local Medical Community on the Affordable Care Act Allen Perkins, MD, MPH University of South Alabama

As punishment for tricking the gods, Sisyphus was placed on a hillside in the underworld with a heavy boulder above him. To escape being crushed, he had to push the boulder uphill. The gods told him that if he rolled the stone to the other side they would release him. Each time he reached the top, though, the boulder rolled back down to the bottom, forcing Sisyphus to start over. The phrase "labor of Sisyphus" refers to any hopeless task that must be repeated endlessly.

Mobile Alabama � Population 200, 000 city, 500, 000 metro ◦ 34% African American ◦ Median household income $40, 000 ◦ 19% below FPL � 4 �And then there was Hurricane Katrina and the Oil incident hospitals, none dominant ◦ BCBS of Alabama covers 96% of insured lives � 3 FQHCs in county ◦ None with strong connections with the AHC

University of South Alabama � University of South Alabama Hospitals and Clinics ◦ Children’s and Women’s Hospital (240 beds) � 50% of deliveries in town, 90% + of children's admissions � 6% of children under 18 uninsured ◦ USA Medical Center (120 beds) �Level 1 Trauma Center � 40% all comers uninsured � 33% of admissions for ambulatory sensitive conditions ◦ Practice plan � 200, 000 visits � 24, 000 FM residency, 20, 000 all other adult PC, 50, 000 all Peds, 32, 000 OB, 17, 000 all IM �Dominant payers Medicaid, Tricare �No formal relationship with FQHCs �Provide tertiary care for the FQHCs

Where to get information � Description of law and implementation ◦ White House Health Reform �http: //www. whitehouse. gov/healthreform ◦ Kaiser Family Foundation �http: //healthreform. kff. org/ � Implications of law ◦ New England Journal of Medicine �http: //healthpolicyandreform. nejm. org/ ◦ PCPCC �http: //www. pcpcc. net/ ◦ ADFM list serve � Planning for political realities ◦ The New Republic �http: //www. tnr. com/

Deciding what to focus on � Medicaid expansion ◦ Concern regarding patient loyalty ◦ Important component of the law � Accountable Care Organizations ◦ Based on conversation with Paul Grundy ◦ Written into law � Teaching Health Center ◦ Practice demographics similar to FQHC ◦ Limited expansion written into law ◦ Institutional fear of obligating funds � Healthcare Zones Innovation ◦ Appeal to senior administration ◦ Supported by AAMC ◦ Would allow AHC to take lead ◦ Not funded

Who to educate � Within the University ◦ Senior administration “We don’t know what form health reform will take” August 2010 ◦ Clinical chairs “We tried this in the 1990 s with HMO’s” February 2011 ◦ Medical School Executive Committee “Dr Perkins, can you tell us what you effect the ruling in Florida will have on reform” February 1, 2011

Who to educate � Outside ◦ ◦ ◦ the university Alabama MGMA Academy of Family Physicians Academic Family Medicine Council Rural Health Association Medicaid

How to educate

Showing up to meetings and answering questions

Presentations to Clinical Chairs

Blogging

Targeted e-mail

Blast e-mail

Looking for models that are comparable � North Carolina Cares ◦ Alabama Medicaid � Denver Health ◦ Identify why they are successful with same payer mix � Single Payer Pilots ◦ Medicaid, BC/BS of Alabama, and Medicare cover 90% of Alabamians

Lessons learned � The payment system defines how care is delivered � Community physicians are operating on a very thin margin in Alabama � Academics are scared to death and should be � Even Chairs can be educated � Paul Grundy is an optimist