HEALTH CARE REFORM: The Impact on Minority Populations in Tennessee. by Steven L. Coulter, Tionna L. Jenkins, Stephen G. Jones, and J.

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1 HEALTH CARE REFORM: The Impact on Minority Populations in Tennessee by Steven L. Coulter, Tionna L. Jenkins, Stephen G. Jones, and J. Payne Carden

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3 TABLE OF CONTENTS I. Introduction... 2 II. The Problem of Minority Access to Health Care - What is Known in Tennessee...3 Racial breakdown of the uninsured... 3 Coverage vs. access... 5 III. Diversity Among Medical Professionals and Institutions that Serve Minorities... 6 Current state efforts to address diversity in the physician workforce... 9 AAMC Recommendations on integrating measures to imporve the quality of care What effect will PPACA have on the institutions that have traditionally cared for the uninsured? IV. Health Care Access Index V. An Invitation to Dialogue VI. Conclusions Recommendations Appendices...17 ABOUT THE BLUECROSS BLUESHIELD OF TENNESSEE HEALTH INSTITUTE The BlueCross BlueShield of Tennessee Health Institute was established with the goal of becoming the premier source of information about health care for Tennessee decision makers. It is committed to providing a fact-based intellectual framework that will contribute to the public discussion on health care and policy development. When possible, the Health Institute will articulate with data the likely implications of health care policy changes on the local market in Tennessee. The mission is to inform interested parties about emerging trends through extensive research and analysis and to become a trusted source for reliable insights. BlueCross BlueShield of Tennessee Health Institute is a division of BlueCross BlueShield of Tennessee, an Independent Licensee of the BlueCross BlueShield Association. 1

4 I. INTRODUCTION Minority individuals in the United States have less access to health care and generally poorer health outcomes than do whites. This relationship has been extensively studied, and some of the reasons have been demonstrated. One of those barriers to access for minorities nationally (which for the purposes of this paper will include blacks and Hispanics as defined by the 2009 American Community Survey conducted by the US Census Bureau) has historically been a lower rate of insurance coverage. Blacks and Hispanics in Tennessee share these circumstances. The Patient Protection and Affordable Care Act (PPACA), the formal name for the health care reform law, has as one of its stated purposes reducing or eliminating the disparity in insurance coverage by race. The review of quantitative data, other research and interviews with experts demonstrate that the causes of the problem go far beyond insurance coverage. Other barriers include such things as lack of transportation and lack of service capacity (it really doesn t matter if you live next door to a doctor and have good insurance; if her schedule is full, she can t see you). In Tennessee, for example, minorities are highly concentrated in areas of the state where doctors practices are full, and there is simply no excess capacity to absorb newly covered individuals. What s more, it has been shown that many minority patients prefer to see a medical provider of their own race. A relative shortage of minority providers as appears to exist around the nation and in Tennessee can act as another type of barrier to access. This paper suggests that although PPACA will most decidedly have a favorable impact on access to insurance coverage, it is unlikely to fully address racial disparities in care. As it would be stated in a freshman logic class, coverage is necessary, but not sufficient to effect change. Some solutions have been put forth to address the various causes involved. But the multi-faceted nature of the issue has created another difficulty the problem is difficult to measure. And without a yardstick it is difficult to know how much progress, if any, is being made in addressing the various causes. To facilitate progress, the authors have developed a draft of a Health Care Access Index which helps factor in a variety of causes for lack of access. This is a new concept, and we advance the notion primarily to generate discussion, not to prove that it is accurate. The Health Care Access does not, for example, weight the various factors that the formula considers. Surely some are more important than others, but lacking any real basis for weighting, the authors chose to advance the concept rather than introduce more potential sources of error into the equations. The BlueCross BlueShield of Tennessee Health Institute invites your feedback on both the subject of disparities and upon our first attempt at the Health Care Access Index. In the conclusion of this paper, we will advise how to contribute to the discussion. For now, the Health Institute s goal is to provoke thought and discussion of this important subject, and we hope you find the following stimulating in that regard. The authors gratefully acknowledge TennCare Director Darin Gordon for reviewing and commenting on this manuscript. Any errors and all opinions are, of course, the responsibility of the authors. 2 HEALTH CARE REFORM: The Impact on Minority Populations in Tennessee

5 II. THE PROBLEM OF MINORITY ACCESS TO HEALTH CARE WHAT IS KNOWN IN TENNESSEE The current state of the uninsured in Tennessee In a previous study conducted by the BlueCross BlueShield of Tennessee Health Institute, it was estimated there were 963,000 currently uninsured Tennesseans. 1 Other studies have arrived at somewhat different estimates. One conducted by the University of Memphis estimated 910,000 2, the 2009 American Community Survey estimated 883,000 3, and the University of Wisconsin Population Health Institute estimated that about 1.1 million 4 uninsured people live in Tennessee. Obviously, calculating the number of current uninsured residents is not an exact science as evidenced by the range of about 200,000 people in the four estimates. It is further complicated by the fact that this population demographic is not stable; there are people constantly dropping in and out of periods of being insured. The passage of PPACA has given most of the uninsured population a chance to gain government health insurance or receive subsidies to pay for individual policies. It also mandates employers to offer health insurance. However, there are many issues which PPACA does not address. The Health Institute estimates there will still be between 200,000 and 300,000 uninsured people in Tennessee after the Act is implemented. 5 Additionally, if newly insured patients have poor or no access to primary care physicians, what does their newly acquired insurance actually do for them? Racial breakdown of the uninsured As seen in Figure 1 below, African-Americans and Hispanics make up a disproportionate share of the state s uninsured population. According to the 2010 Census, the population of Tennessee is about 16% African-American and 4% Hispanic, however they account for almost 20% and 12% of Tennessee s uninsured population respectively. These figures mean that about 22% of African-Americans and 54% of Hispanics in the state are uninsured compared to 18% of non-hispanic whites. The authors would like to note that these disproportionate levels of coverage are just one part of a larger problem. Nationally, there continues to be an increase in chronic disease, health disparities and inequity among minority populations in comparison to non-hispanic whites. Authoritative sources have documented large and widespread socioeconomic and racial or ethnic disparities in access to care and in the quality of medical care for many serious health conditions such as heart disease and cancer. 6 1 Coulter, S. L. & Cecil, W. T. (2011). National Health Care Reform: The Impact on Tennessee. Available at 2 Chang, C., Mirvis, D., Gnuschke, J., Wallace, J., Walker, J., Smith, S., Stanpill, S. (2012). Impacts of Health Reform in Tennessee American Community Survey. Selected Characteristics of The Uninsured in Tennessee American FactFinder. U.S. Census Bureau. Available at 4 Booske, B., Athens, J., and Remington, P. (2011). County Health Rankings: Mobilizing Action Toward Community Health Tennessee. Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute. Available at org/sites/default/files/states/chr2011_tn.pdf 5 Coulter, S. L. & Cecil, W. T. (2011). National Health Care Reform: The Impact on Tennessee. Available at 6 Robert Wood Johnson Foundation to the Commission to Build a Healthier America (2008). Overcoming Obstacles to Health. Available at 3

6 Figure 1 Tennessee s Uninsured Population by Race This research provided an interesting view of how the coverage issue plays out in Tennessee. To focus the study, it was determines that using the state s six Metropolitan Statistical Areas (MSAs) would be the best approach. Each MSA represents one of the six major population centers in Tennessee: Chattanooga (Hamilton and Marion counties); Jackson (Madison and Chester Counties); Knoxville (Anderson, Blount, Knox, Loudon, Sevier, and Union counties); Memphis (Fayette, Shelby, and Tipton counties) Nashville (Cheatham, Davidson, Dickson, Montgomery, Robertson, Rutherford, Sumner, Williamson, and Wilson counties); and the Tri-Cities (Carter, Hawkins, Sullivan, Unicoi, and Washington counties). The 27 MSA counties account for a little more than 70% of the state s total population. To see a map of the MSAs, please look at Figure 2. An overwhelming majority of the state s minority population also calls these 27 counties home; almost 90% of the total African-American population and a little more than 75% of the state s Hispanics live in the MSAs (Please see Appendix 5 for further discussion and tabulations by county). Figure 2 Metropolitan Statistical Areas of Tennessee By combining the multiple data sources about the uninsured population it was determined that Tennessee has about 307,000 uninsured African-Americans and Hispanics. In Table 1, the numbers are broken down by race and by MSA. 4 HEALTH CARE REFORM: The Impact on Minority Populations in Tennessee

7 Table 1 Minority Population and insurance coverage in Tennessee Metropolitan Statistical Areas Total Population African- American Population Uninsured African- Americans 1* Hispanic Population Uninsured Hispanics* Chattanooga MSA 362,000 68,000 14,000 12,000 6,000 Jackson MSA 113,000 35,000 8,000 3,000 2,000 Knoxville MSA 778,000 48,000 10,000 20,000 12,000 Memphis MSA 1,016, , ,000 49,000 27,000 Nashville MSA 1,625, ,000 67, ,000 63,000 Tri Cities MSA 407,000 11,000 2,000 7,000 3,000 TOTAL MSA 4,301, , , , ,000 Non-MSA 2,095, ,000 28,000 62,000 37,000 *To determine the number of uninsured African-Americans and Hispanics, the number of total uninsured in the county from the 2007 Small Area Health Insurance Estimates, US Census, was cross referenced with the propensity for one of those individuals to be uninsured, as derived from the 2009 American Community Survey. Please see Appendix 5 for the full calculations. The Health Institute estimates that about two thirds of the uninsured population will receive coverage (This is the same as the overall estimate as to how many of the uninsured will become insured that was made in National Health Care Reform: The Impact on Tennessee, because there was no obvious reason to suspect that minority populations will gain insurance at a lower rate). This means that research estimates about 142,000 African-Americans and 75,000 Hispanics residing in MSAs will be newly covered, compared to 19,000 African-Americans and 25,000 Hispanics living outside of the MSAs who will be newly covered. However these calculations did not control for the possibility that (a) such individuals may have lower incomes and, thus, be relatively more likely to qualify for Medicaid; and (b) those African-Americans or Hispanics that are likely to qualify for tax credits may actually be disproportionately located outside of the MSAs. Coverage vs. access The increase in coverage will undoubtedly improve the health status of minorities. In the Institute of Medicine s Coverage Matters Report, a seminal study on the effects of being uninsured, researchers looked at the impact insurance has on the health status of individuals. The major findings from this report were that uninsured people receive less medical care and less timely care if they receive it than insured people. The uninsured also have worse health outcomes and are most often already fiscally disadvantaged. Lastly, while safety-net care from hospitals and clinics improves access to care, it does not substitute for being insured. 7 Nonetheless, it is critical to realize that extending coverage is just one component in eliminating disparities in access to health care for minorities. Health care is a finite resource, and while coverage is a necessary prerequisite, it is not sufficient unless there is corresponding capacity within the system. PPACA gets us halfway there for minority populations it greatly reduces the number of minority uninsured. In actuality these people may gain insurance, but not gain access to care because many of Tennessee s primary care providers may be already operating beyond capacity. 7 Institute of Medicine. (2001) Coverage Matters: Insurance and Health Care. Washington: National Academies 5

8 Another challenge, according to Dr. Cyril Chang, a health economist and Professor of Economics at the University of Memphis, may include decisions by physicians to limit their acceptance of Medicaid. Because of the issues of capacity as well as Medicaid reimbursement rates, there may not be the incentives in place for primary care physicians to take on new Medicaid patients, states Dr. David Mirvis, Senior Research Fellow, Methodist LeBonheur Center for Health Economics and Adjunct Professor, Department of Public Health, University of Tennessee, Knoxville. The proposed higher reimbursement rates for primary care under the reform will help, Mirvis said. But it remains to be seen whether the increased rates will be sufficient to overcome the access issue. III. DIVERSITY AMOUNG MEDICAL PROFESSIONALS AND INSTITUTIONS THAT SERVE MINORITIES Diversity among medical professionals Another factor influencing disparity in health care for minorities is insufficient racial diversity among medical providers. This paper will take an in-depth look at this issue. Solutions targeting diversity have been offered since the early 1970s. Through the use of existing health professions education and training programs authorized under the Public Health Service Act Title VII and VIII 8, funding is available for medical schools and other facilities to promote community-based and rural practice, primary care, and opportunities for minorities and disadvantaged students. 9 Additionally, PPACA further highlights the importance of providing solutions around cultural competency 10 challenges within the health care workforce. 11 A number of studies have shown the navigational burdens and cultural barriers experienced by minority patients as they try to maneuver through the health care system, especially for patients with chronic diseases. 12,13,14 This is a major concern because minority health care professionals may be more likely to take into account sociocultural factors when organizing health care delivery systems to meet the needs of minority populations. 15 Therefore, PPACA has allocated funds to ensure the integration of cultural competency and linguistics training for the health care workforce. 8 Definition- Public Health Services Title VII and VIII (PHSA, Title VII and VIII)- The purpose of programs funded and administered under Titles VII and VIII of the Public Health Services Act is to expand the geographic, racial and ethnic distribution of the health care workforce. Available at 9 Redhead, C.S., Williams, E.D (2010). Public Health, Workforce, Quality and Related Provisions in the Patient Protection and Affordable Care Act (P.L ), Congressional Research Service. Washington, D.C.: Penny Hill Press. Available at download/130996/data/ph.pdf.pdf 10 Definition: Cultural competence has emerged in part to address the factors that may contribute to racial/ethnic disparities in health care. Cultural competence in health care describes the ability of systems to provide care to patients with diverse values, beliefs, and behaviors, including tailoring delivery to meet patients social, cultural, and linguistic needs. The ultimate goal is a health care system and workforce that can deliver the highest quality of care to every patient, regardless of race, ethnicity, cultural background, or English proficiency. Available at 11 Redhead, S.C., Williams, D.C., (2010). Public Health, Workforce, Quality, and Related Provisions in the Patient Protection and Affordable Care Act Public%20Health%20Workforce%20Quality%20and%20Related%20Provisions%20in%20PPACA%20P.L.% % pdf 12 Center on Aging Society, Georgetown University (2004). Cultural Competence in Healthcare: It is Important for People with Chronic Conditions 13 The Common Wealth Fund Cultural Competence in Healthcare (2002). culturalcompetence_576.pdf 14 U.S. Department of Health and Human Services (2004). Setting the Agenda on Research in Cultural Competency in Health Care The Common Wealth Fund, Cultural Competence in Healthcare (2002). culturalcompetence_576.pdf 6 HEALTH CARE REFORM: The Impact on Minority Populations in Tennessee

9 PPACA was signed into law on March 23, 2010, and includes increased funding, specific provisions and initiatives focused on the expansion of workforce diversity, which could have an even greater impact on closing the gap as it relates to health disparities and inequity in the United States. According to the Joint Center for Political and Economic Studies (2010) 16, through reauthorization and expansion of the Title VIII programs, PPACA has the potential to improve diversity in such fields such as primary care, long-term care, dentistry, mental health, and nursing. So why has the federal government through PPACA placed such a strong emphasis on ensuring workforce diversity in health care? And is there evidence demonstrating a causal relationship between lack of diversity and disparities in access? A 2004 report by the Institute of Medicine titled In the Nation s Compelling Interest: Ensuring Diversity in the Health Care Workforce underscored the importance of increasing racial/ethnic diversity in health professions to reduce health disparities. 17 Racially and ethnically diverse practitioners are more likely to practice in medically underserved areas and treat patients of color who are uninsured and underinsured, the report said. 18 Among 1975 graduates of U.S. medical schools, black and Hispanic physicians were more likely than non-hispanic whites to practice in areas with a shortage of physicians and to care for black and Hispanic patients. 19 In fact, minorities often choose to serve vulnerable communities. 20 In turn, due to negative experiences felt within the health care system minority patients establish better trust with and, indeed, seek out physicians from their own racial or ethnic group. 21 A study published in 2000 in Health Affairs showed that minority patients tend to seek care from minority physicians for a range of reasons including cultural sensitivity, the patient-physician relationship and the ability to communicate effectively. 22 However, to further understand the correlation between patient patterns of choosing a physician solely based on factors such as ethnicity and race would require a more in-depth exploration and research analysis of the doctor-patient race concordance hypothesis 23 which is beyond the scope and intent of this paper. It is also evident that minority physicians are more likely to become primary care professionals, but this should not be the major rationale for diversifying the health professions. 24 Doing so could potentially 16 Andrulis, D.P., Siddiqui, N.J., Purtle, J.P., Duchon, L. (2010). Joint Center for Political and Economic Studies. Patient Protection and Affordable Care act of 2010: Advancing Health Equity for Racially and Ethnically Diverse Populations. Washington, D.C. Available at ibid 18 Kington, R., Tisnado, D., Carlisle, D.M. (2001). Increasing racial and ethnic diversity among physicians: An intervention to address health disparities. The Right Thing to Do, The Smart Thing to Do: Enhancing Diversity in the Health Profession. Washington, D.C.: The Academy Press. Available at 19 Kormaromy, M., Grumbach, K., Drake, M., Vranizan, K., Lurie, N., Keene, D., Bindman, A. (1996). The Role of Black and Hispanic Physicians in Providing Health Care for Underserved Populations. The New England Journal of Medicine, 334, (20), Available at 20 Sullivan, L.W., Mittman, I.S. (2010). A State of Diversity in Health Professions A Century After the Flexner Report. The New England Journal of Medicine, 85 (2), Available at in_the_health_professions_a.21.aspx 21 DeVille KA (1999). Trust, Patient Well-Being and Affirmative Action in Medical School Admissions. The Mount Sinai Journal of Medicine, 66, (4): Available at 22 Saha, S., Taggart, S.H., Komaromy M., Bindman, A.A. (2000). Do Patients Choose Physicians of Their Own Race? Health Affairs, 19 (4), LaViest, T.A., Carroll, C. (2002). Race of Physicians and Satisfaction of Care Among African-American Patients. Journal of National Medical Association, 94 (11), ibid 7

10 marginalize minority health care practitioners to only see specific populations while at the same time desensitizing non-hispanic white clinicians to an obligation to provide care for communities of color. Recruitment and placement may be a priority; however, major findings suggest that African-Americans, Hispanics, American Indians and Alaska Natives, and Native Hawaiians and Other Pacific Islanders remain underrepresented in medicine relative to their numbers in the U.S. population and populations in specific states, regions and localities. 25 For example, while Hispanics comprise approximately 16.3 percent of the U.S population, they account for less than 4 percent of all physicians. And African-Americans comprise 12.6 percent of the nation s population, but only five percent of physicians. 26 In Tennessee, out of a total of 411 graduates from medical school in 2010, 254 were white (62%), 97 were Black (24%), 6 were Hispanic (1.4%), 2 were American Indian or Alaska Native (0.4 %), 42 were Asian (10%), 1 was other non-hispanic or Latino race (0. 2%) and 9 were self-identified as foreign (2%), according to the Association of American Medical Colleges. 27 It should be noted that Meharry Medical College in Nashville is a traditionally African-American organization and draws on African- American applicants from across the country, which helps explain the number of African-American graduates in the statistics above. Table 3 Medical School Graduates in Tennessee (2011) Medical School* Black or African- American White or Caucasian East Tennessee-Quillen 4 53 Meharry 69 7 Vanderbilt 9 83 Tennessee Total *These statistics were taken before data was available from Lincoln Memorial University s DeBusk College of Osteopathic Medicine s first graduating class. Ensuring diversity within the health care workforce could have a positive impact for patients as it pertains to access, quality of care, and chronic disease management, as well as help to empower patients to engage in managing their health. And as PPACA is fully implemented, the need to have a more global perspective, and recognize and commit to ensuring diversity in the health care workforce will become even more important. In light of the findings regarding underrepresentation of minorities in medicine in the United States, more attention should be focused on recruitment as a specific strategy of implementation within the health care workforce at the state and local level while simultaneously addressing workforce diversity 25 Lee PR, Franks PE. (2010). Executive Summary: Diversity in U.S Medical Schools: Revitalizing Efforts to Increase Diversity in a Changing Context, 1960s-2000s. Philip R. Lee Institute for Health Policy Studies, School of Medicine, University of California, San Francisco. Available at 26 Smedley, B.D., Stith-Butler, A.Y., & Bristow, L.R. (Eds.). (2004). In the Nations Compelling Interest: Ensuring Diversity in the Health Care Workforce. Washington, DC: National Academy Press. 27 Association of American Medical Colleges. (2010). Total Graduates by U.S. Medical Schools and Race and Ethnicity. Available at aamc.org/download/145668/data/table30-gradsschlraceeth2010-web.pdf.pdf 8 HEALTH CARE REFORM: The Impact on Minority Populations in Tennessee

11 and equity in PPACA. PPACA calls for monitoring diversity in the health care workforce, but does not specify a strategy for doing so. Other challenges that exist around implementation of increasing racial/ ethnic diversity in the health care workforce in PPACA include: Recruitment strategies and addressing the institutional climate of colleges and universities that have a legacy of being historically white Inequities associated with the quality of K-12 education, which would address the pipeline of qualified applicants in the health care workforce. To adequately prepare culturally diverse individuals for success in higher education health professions programs, disparities in learning opportunities, particularly in the sciences, need to be addressed at the pre-college level. 28 College academic preparation and creating an outcome-driven sustainable partnership between colleges and medical schools Medical school application process, associated cost and admissions standards and criteria Medical student support and retention. A consistent theme among minority students was that medical schools should have a formal minority affairs function; it was also stressed that the program should be adequately funded and staffed, and that it should have some real power within the school 29 Minority faculty recruitment and retention as well as development and fully engaged institutional leadership The American Medical Association (AMA) also acknowledges that diversity in the health care workforce among physicians (i.e. African-American, Hispanics) is disproportionate to the U.S. population. In general, minority representation in medical schools and residency training has not changed significantly over the past several years. For example, the percent of entering medical students who self-classify as African- American has been %; the percent of Hispanic students has been %; the percent of Asian students has been 20-21%; and the percent of white, non-hispanic students has been 62-63%. 30 And according to the same AMA Masterfile, race and ethnicity is known for about 78% of the total physicians. In 2006, 71.4% of these physicians were white, 15.8% were Asian, 6.4% were Hispanic, and 4.5% were Black. 31 In light of these statistics, the AMA has put incentives in place to increase and retain a diverse health care workforce among physicians by funding programs that provide access to education for diverse populations, as well as pipeline and retention programs. Current state efforts to address diversity in the physician workforce So what are the current institutional practices and policies at the state and local level to address the disproportionate number of minority physicians as it pertains to recruitment and retention? In 2002, Vanderbilt University began establishing the Office of Diversity in Medical Education 32 to increase diversity and attract more medical school applications from a broad range of people, including minority students. 28 ibid 29 Gonzalez P., Stoll, B., (2002). The Color of Medicine: Strategies for Increasing Diversity in the U.S. Physician Workforce (Community Catalyst). Available at 30 American Medical Association. Report of the Council on Medical Education. Available at 31 ibid 32 Available at 9

12 In addition, Vanderbilt takes a broader definition of diversity which includes representation from different races/ethnicities, sexual orientation, economic backgrounds, rural versus urban upbringing, and varying religious backgrounds. 33 In a Vanderbilt report, The Changing Face of Medicine, George C. Hill, PhD, Levi Watkins Jr. Professor and Associate Dean for Diversity in Medical Education states that If we want to provide an excellent medical education for all students, then the students have to learn in a diverse environment from people who have different points of view. 34 Further, Dr. Hill shares the view of the American Medical Colleges, that the need for a more diverse physician workforce is imperative, along with reducing racial disparities in health care. Demographic studies show that the United States will face a shortage of physicians in the next 20 years as the population ages. More physicians from all backgrounds will be needed to meet the growing demand. In June 2006, the AMA recommended a 30% increase in U.S. medical school enrollment and an expansion of Graduate Medical Education (GME) positions to accommodate this growth. 35 A review of the literature shows that solutions to the problems of recruiting and retaining minority physicians have been limited. In addition those strategies have not been rigorously tested, nor has sufficient funding been provided for full implementation. Anecdotally, outreach, programs and partnerships have shown some progress, but minimal success has been shown in changing policy to address inequity in the medical workforce and in health care delivery. With regard to the actual number and/or percentage of minority physicians practicing in Tennessee, the data is limited because it traditionally has not been kept by the sources that keep other data about physicians. In addition, currently available data make it difficult to break down the racial and ethnic composition of physicians nationwide. (The data that is available is shown in Appendix 7 and Appendix 8.) More important, The Complexities of Physician Supply and Demand: Projection Through 2025 states that the supply of primary care physicians that many already believe to be insufficient is likely to get tighter as demand outpaces supply faster for primary care than any of the specialty groups. The need to improve data collection, workforce studies and expand collaboration among health professions organizations on data and workforce services is a necessary component of progress toward solutions. 38 The AAMC provides important workforce recommendations related to PPACA for increasing diversity, ensuring cultural competency and quality. Included below is how the authors believe Tennessee should follow up on these general recommendations. 33 ibid 34 Vanderbilt. The Changing Face of Medicine (2010). Available at 35 American Medical Association (2008). The Complexities of Physician Supply and Demand: Projections Through Available at medical-mastermind-community.com/uploads/physician-supply.pdf 36 Rumala, B.B., Carson, F.D. (2007). Recruitment of Underrepresented Minority Students to Medical School: Minority Medical Student Organization, an Untapped Resources. Journal of the National Medical Association, 99 (9) Available at nih.gov/pmc/articles/pmc / 37 Valcarcel, M., Diaz, C., Borrero, P.J. (2006). Training and retaining of underrepresented minority physician scientist-a Hispanic perspective: NICHD-AAP workshop on research in neonatology. Journal of Perinatology, 26, 49 Available at pdf/ a.pdf 38 ibid 10 HEALTH CARE REFORM: The Impact on Minority Populations in Tennessee

13 AAMC Recommendation on Increasing Diversity Continue advocacy for and promotion of efforts that would increase enrollment, retention and graduation of racial and ethnic minorities from medical school and residency programs within the state of Tennessee Tennessee Policy Action Require cross-collaboration between diverse stakeholders (i.e. education, medical and public health disciplines, etc.) that will address failures in the K-12 education system, minority students attending high-poverty schools that lack academic and financial resources, pipeline shortages and lack of science exposure at the state and local level Create a standardized state assessment to evaluate the climate of racial and gender inclusivity on college and medical school campuses (i.e. representation of minority faculty, student, etc.) and the application of diversity principles throughout the mission and vision statement of the institution Ensure culturally appropriate academic advising on both college and medical school campuses and through residency programs. And in doing so enhance retention by implementing comprehensive programs that address the student needs in the areas of finances, academics and career advising. Establish accountable and ongoing partnerships between medical schools and historically black college and universities in Tennessee that would align academic requirements, preparation and enrollment of minority students AAMC Recommendation on Ensuring Cultural Competency Increase efforts to strongly support the education and training of leaders in medical education and health care focused on cultural competency and equity within the health care system Tennessee Policy Action Establish and/or strengthen existing initiatives and incentives that are in concert with teaching institutions and government agencies, regarding the development, testing, and implementation of progressive, cross-cultural health care interventions Mandate transparent monitoring and documentation of efforts related to cultural competency and diversity for students, faculty and administration. Incorporate accountability for achievement of outcomes AAMC recommendation on integrating measures to improve the quality of care Efforts to undertake a study of the geographic distribution of physicians so that a better understanding of where service is delivered is vital. Tennessee Policy Action Authorize and adequately fund a state level automated data management system that would provide updated, organized and workable information to efficiently assess gaps and disparities within physician workforce and health service delivery for the state of Tennessee. Fully integrate and track descriptive characteristics such as race, ethnicity and gender of medical physicians in the data management system to further address maldistribution and diversity at a state level as well. 11

14 What effect will PPACA have on the Institutions that have traditionally cared for the uninsured? Access to medical care is the availability of care and the ability of an individual to obtain care when he/ she needs it. Lack of coverage has been shown to be a barrier to obtaining health care services Despite this, the uninsured do manage to get health care. Traditionally, this care has been rendered by charitable physicians and hospitals, and by safety net hospitals and community health centers. PPACA allocates $15.6 billion between 2014 and 2015 for community health centers and $1.5 billion for the National Health Service to recruit minority physicians. From 2016 on, the community health center allocation increases by approximately the average increase in costs incurred plus one percent per year. What impact this will have remains to be seen, but it will presumably be positive. PPACA also eliminates $18 billion in disproportionate share payments (DSH) to hospitals that serve the uninsured and underinsured. The premise is that the increased number of people with coverage will more than offset the need for subsidization of charity care. There is also a provision in the law that requires hospitals to report on and meet certain quality guidelines. If they do not, then their payments will be reduced. The BlueCross BlueShield of Tennessee Health Institute interviewed Dr. Reginald Coopwood, CEO of The Regional Medical Center at Memphis (The MED) regarding this subject. He had done a thorough analysis of the disproportionate share payments issue and felt fairly comfortable that the gains from the newly insured would just about equate to the losses of DSH money. He qualified this by stating that assumed a constant volume of patients and no loss in revenue per patient. Dr. Paul Stanton, president of East Tennessee State University at the time of the interview and a vascular surgeon by training, (Dr. Stanton has since retired) agreed that the effects of those two provisions would probably offset one another, again with the same qualifiers. Both Dr. Stanton and Dr. Coopwood are members of the BlueCross BlueShield of Tennessee board of directors. Darin Gordon, TennCare Director, raised the possibility that newly covered individuals might elect to get their care in different venues than they did while uninsured. Certainly it is possible to see competition for this group of individuals that previously had few options. Obviously, if there is a significant shift of people to different institutions, then the financial ramifications will be negative for the current safety net hospitals. Dr. Coopwood acknowledged that the penalties for lack of reporting of quality metrics could be an issue. The Med is chronically underfunded, as are most inner city hospitals, and has a lack of access to capital. As such, they do not have the reporting infrastructure built that many private hospitals have. He is a staunch advocate of a culture of quality in his institution. However, he notes that development of that culture takes time and infrastructure, both of which are in short supply. It is too soon to accurately predict how these variables will impact access to care for minorities. These issues bear close observation by Tennessee s policy makers, lest an imbalance occur that creates unintended negative consequences. 39 Finkelstein, A. et. al. (2011). The Oregon Health Insurance Experiment: Evidence from the First Year. Working Paper Maxwell et. al. (2011). Massachusetts Health Care Reform Increased Access to Care For Hispanics, But Disparities Remain. Health Affairs 29 (8). 41 Bahls, C. (2011). Achieving Equity in Health. Health Affairs: Health Policy Brief. 29 (10). 12 HEALTH CARE REFORM: The Impact on Minority Populations in Tennessee

15 IV. HEALTH CARE ACCESS INDEX Access to care may be impacted by physical proximity, transportation, physical barriers, ability to pay, insurance coverage, or by the capacity of the system to accept more patients. In this paper, the authors are specifically examining the increase in insurance coverage vs. the other aspects of access to care. Access is often measured as a function of distance (or travel time) to the nearest medical facility 42 and for most general health care research needs, it is sufficient. 43 Other factors influencing geographic access to care include the distribution of the underlying population (with and without medical insurance) and the availability of health care providers, both physicians and facilities. 44 Effective primary care can improve the quality of care and health outcomes, and lower medical spending. 45 Access to and the delivery of preventive health services generates a healthy lifestyle and can improve overall health 46 because individuals with health insurance have a greater opportunity to receive those preventive services. 47 Unfortunately, not everyone has equal and adequate access to care. Geographic areas with low access to care have higher rates of hospitalization and chronic diseases. 48 Overcoming these various barriers is necessary if quality health outcomes are to be attained. 49 In the Health Insitute s first paper, the Access-Challenge test developed by Leighton Ku 50 and his associates was used to look at the issue of access in Tennessee. They found that Tennessee was the 20th worst state in terms of access when looking at the ratio of Medicaid expansion to primary care capacity. Ku s study conceded that access-to-care is more complicated than the study made it out to be because it occurs at a local level, not at the state level. The Health Institute shares this belief that access to care cannot be measured in a single dimension, such as distance to a facility, because this fails to capture the known tendency for patients to avoid utilizing medical services at their nearest facility To the authors knowledge, no comprehensive 42 Rosero-Bixby, L. (2004). Spatial Access to Health Care in Costa Rica and its Equity: a GIS-Based Study. Social Science & Medicine, Volume 59, Issue 7, Pages Jones SG, Ashby AJ, Momin SR, Naidoo A. Spatial implications associated with using Euclidean measurements and ZIP code centroid geoimputation methods in healthcare research Health Services Research, 45(1): Health Services Advisory Group, I. (2011). Colorado Medicaid HEDIS 2001 Results Statewide Aggregate Report. Colorado Medicade HEDIS, 4:1-4: Steinbrook, R. M. (2009). Easing the Shortage in Adult Primary Care- Is it All about Money? The New England Journal of Medicine, 360: Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Institute of Medicine. 47 Newacheck D. P., Paul W. (1998). Health Insurance and Access to Primary Care for Children. The New England Journal of Medicine, 338; Bindman, G. O. (1995). Preventable Hospitalizations and Access to Health Care. The Journal of the American Medical Association, 274; Bloomberg School of Public Health, t. S. (n.d.). John Hopkins Center to Eliminate Cardiovascular Health Disparities. Retrieved February 6, 2012, from Access to Care: 50 Ku, L., et al. (2011) The States Next Challenge Securing Primary Care for Expanded Medicaid Population. New England Journal of Medicine, 364: Rosero-Bixby, L. (2004). Spatial Access to Health Care in Costa Rica and its Equity: a GIS-Based Study. Social Science & Medicine, Volume 59, Issue 7, Pages Coulter, S. L. & Jones, S. (2012). A Geographic Analysis of Patterns of Care in Tennessee. Forthcoming. (This has been researched extensively and our report on Tennessee will be published in the coming months.) 13

16 health care access index exists. To better understand access to care in Tennessee, we developed a seven-dimensional index with the four demand factors being membership volume, 2000 US Census population, inpatient utilization and emergency room utilization. The three supply factors were volume of primary care practitioners, volume of specialty care physicians and volume of acute care hospitals. The index uses BlueCross BlueShield of Tennessee and US Census Bureau data where appropriate. The index was created at the ZIP code level and may be aggregated up to coarser spatial scales (e.g., county, MSA) or projected down to the members/population residing within the ZIP code. For the purposes of this study, the study period was defined as calendar year For the remainder of the technical data specifications and formulas please see the Appendix. Based on the results from this Health Care Access Index the following map was generated. A map for each of the seven components can be found in the Appendix. Figure 4 Overall Access to Care Index Score (see Appendix 4 for graphs of each dimension of the index) See appendix for full-size map V. AN INVITATION TO DIALOGUE The Health Care Access index, as seen in its entirety in Appendices 3 and 4, has shown, for the most part, the six MSAs have favorable or very favorable provider ratios (not access to care) in both PCPs and specialists. However many of the areas surrounding MSAs have unfavorable or very unfavorable provider ratios; this causes many rural patients come to the MSA counties to receive care which makes the MSA provider ratio appear better than it is because of the higher utilization, as seen in Appendices 5 and 6, due to people driving from the rural areas into cities to receive care. 53 The newly insured will only add to the capacity problem facing Tennessee s PCPs and make it more difficult for everyone to receive timely care. This is especially relevant to the African-American and Hispanic populations in Tennessee when considering that an overwhelming majority of both populations call these 27 counties home. There is the additional consideration that newly insured individuals tend to access care at significantly higher rates than those who have had continuous insurance or remain uninsured. 54 We the authors believe this method has merit but this is the first time it has been used. All seven components have been weighted equally, but we realize that they all may not be inherently equal. Since we have no scientific basis at this point upon which to weight them; we chose not to. Although it has 53 ibid 54 Finkelstein, A. et. al. (2011). The Oregon Health Insurance Experiment: Evidence from the First Year. Working Paper HEALTH CARE REFORM: The Impact on Minority Populations in Tennessee

17 not been tested, it does intuitively correspond with what we know about access-to-care in Tennessee. We hope that others will test this hypothesis to help us improve this index. Our purpose is to initiate discussion, not make a proclamation. Please direct comments and suggestions about the Health Care Access Index to health_institute@bcbst.com. VI. CONCLUSIONS Although initiatives have been launched to address health care diversity in Tennessee through various policies and programs on medical campuses, it has not been enough to keep up with the current workforce needs and is much less the anticipated increase in demand from the newly insured. On a national level, due to population growth, aging and other factors, demand will outpace supply through at least 2025 as seen in Figure 5. Figure 5 Baseline Physician PTE Supply and Demand Projection With an estimated influx of 600,000 newly insured individuals into the state s health care system, about 250,000 of whom will be African-American or Hispanic, immediate and strategic measures to address diversity in the workforce, as well as equity and access are vital to ensuring sustainability and reaching the most vulnerable populations. Overall conditions for the entire state of Tennessee and its residents are expected to continue to deteriorate because of a number of factors including, but not limited to: Limited pipeline and diversity. Currently, the state s infrastructure to educate, train and increase the numbers of health care providers is limited. And is unlikely to significantly change in the near future. In addition, it is imperative that the state secures a workforce that understands the needs of communities of color by reflecting the population served. Increased disease burden. Tennessee faces some of the highest rates of obesity, diabetes and hypertension in the country, placing a significant burden on the health care system. Additionally, populations that are disproportionately impacted and face significant co-morbidities (i.e. minority populations, low-income, the elderly) create a synergistic impact on demand at the same time that they see reduced quality of life and productivity. Increased number of insured. Under PPACA most of the approximately 960,000 residents of Tennessee who are currently uninsured will enter into the health care system. And although many will remain uninsured, 600, ,000 people are expected to become newly insured. This will 55 ibid 15

18 place an additional strain on the workforce because people who are insured tend to use the health system more frequently than the uninsured. 56 The initial need may be higher due to the pent-up demand from people who have been uninsured. RECOMMENDATIONS In the Health Institute s initial paper on health care reform, a looming delivery capacity crisis in Tennessee was identified. In this paper, the authors have examined in some detail the impact this capacity crisis will have on minorities in Tennessee, who currently constitute a disproportionate share of the uninsured. This paper has demonstrated that when PPACA takes full effect in 2014, although more minorities will have health care coverage, actual access to health care will still be difficult, given that the areas in which these populations are concentrated already have significant access problems. This paper has also demonstrated, through literature review and data, that increasing the number of minority providers does result in increased access for minority patients. The recommendation that follows from this is fairly obvious: Tennessee needs to increase the number of minority physicians. How to do this is not quite as obvious. Simply increasing the number of medical school slots, and filling them with minorities has a number of barriers. First, even if the funding became available for more med school slots, that alone won t solve the issue. There have to be residency slots for med school graduates to fill. PPACA does address this in Sections 2551 and 5601, but it is essentially a zero sum game, and that will not fundamentally help the problem. Second, there are political barriers to quotas as they apply to coveted items like medical school admissions. Creating interest and recruiting minority students in the life sciences should begin at an early age. It is pretty difficult to suddenly decide to be a doctor sometime in your junior year in college, if you haven t been taking the right courses and had some degree of focus. The state and its physicians also need to improve throughput in the health care system. The levels of increased productivity needed range from 10 to 30 percent, depending on the area of the state. There is no way, given the time it takes to produce a doctor, that gap can be filled in a timely manner. Tennesseans will have to make more use of and more efficient use of mid-level practitioners to achieve this kind of productivity enhancement. PPACA, through its support of Accountable Care Organizations, helps set the stage for a redesign of health care delivery in a more efficient fashion. This opportunity should not be missed. 56 Finkelstein, A. et. al. (2011). The Oregon Health Insurance Experiment: Evidence from the First Year. Working Paper HEALTH CARE REFORM: The Impact on Minority Populations in Tennessee

19 APPENDIX 1 Graphic Model of Healthy People 2020 The Federal Interagency Workgroup developed a graphic model to depict the ecological and determinants approach that Healthy People 2020, a plan devised by the U.S. Department of Health and Human Services, will take in framing the national health objectives. This particular graphic was designed to emphasize this new approach, and is not meant as a comprehensive representation of all public health issues and societal domains. The graphic framework attempts to illustrate the fundamental degree of overlap among the social determinants of health, as well as emphasize their collective impact and influence on health outcomes and conditions. The framework also underscores a continued focus on population disparities, including those categorized by race/ethnicity, socioeconomic status, gender, age, disability status, sexual orientation, and geographic location. U.S. Department of Health and Human Services. (2010). Healthy People 2020 Available at 17

20 APPENDIX 2 Summary of sections of PPACA that address workforce diversity Table 2. Workforce Diversity Section No. Collect and publicly report data on workforce diversity 5001 Increase diversity among primary care providers 5301 Increase diversity among long-term care providers 5302 Increase diversity among dentist 5303 Increase diversity among mental health providers 5306 Health professions training for diversity 5402 Increase diversity in nursing professions 5309 Investment in HBCU s and minority-serving institutions 2104 Community-based training for AHEC s targeting underserved populations 5403 Grants for Community Health Workers, providing CLAS 5313 Grants to train providers on pain care, including CLAS 4305 Support for low income health professions/home care aid training 5507 *CLAS-culturally and linguistically appropriate service 18 HEALTH CARE REFORM: The Impact on Minority Populations in Tennessee

21 APPENDIX 3 Health care access Index detailed discussion and formula derivation To the authors knowledge, no comprehensive access to care index exists. We believe one is needed and have developed a comprehensive health care access index at the ZIP code level based on seven dimensions. For the study period, the following seven factors were summarized for all ZIP codes within the state of Tennessee and contiguous counties in neighboring states. (Here, summarized means each countable observation within each of the seven factors was summed up to each respective ZIP code.): Demand factors: 1. Membership volume (BCBST enterprise membership) 2. Census population (2000 US Census Bureau data) 3. Inpatient utilization (BCBST data, any cause) 4. Emergency room utilization (BCBST data, any cause) Supply factors: 1. Volume of primary care physicians (BCBST contracted) 2. Volume of specialty care physicians (BCBST contracted) 3. Volume of acute care hospitals (BCBST contracted) Membership was defined as any BlueCross BlueShield of Tennessee member residing within the ZIP code during the study period. Census population was defined using the total population count of 5,689,283 people from the 2000 US Census Bureau ZIP code data. Inpatient and emergency room utilization included stays/visits for any reason from members residing in the ZIP code during the study period. For all provider volume metrics, the physical locations of the facility or the primary practice address for physicians were used. Primary care specialties were defined as any provider with the following listed specialty: family medicine, general practice, internal medicine, nurse practitioner - acute care, nurse practitioner - adult health, nurse practitioner - family practice, nurse practitioner - pediatrics, pediatrics, or physician assistant (primary care). Specialists were defined as any provider not included in the list of primary care practitioners. Primary and specialist care combined, BlueCross BlueShield of Tennessee contracts with 98% of actively practicing physicians. Facilities were defined as any BlueCross BlueShield of Tennessee contracted acute care hospital; BlueCross BlueShield of Tennessee contracts with all acute care hospitals in Tennessee. 19

22 APPENDIX 3 (CONT.) After summarizing the aforementioned factors at the ZIP code level, a spatial radial aggregation process was conducted to summarize these factors using a 30-mile radial band around each ZIP code. This was done to account for the fact that underlying factors do not necessarily conform to ZIP code boundaries, and therefore people can equally have access to nearby ZIP codes relative to the actual ZIP code in which they reside. Thus, people have the ability to cross ZIP code boundaries to seek medical care. Additionally, this helps account for the omission of any distance-related factors that was not purposefully included in our index. Distance calculations were omitted from the index for two reasons. First, the Health Institute wanted an index that could more easily be replicated across health plans or by others trying to do so, and these types of calculations usually involve a geographic information system (GIS) or other sophisticated software packages and knowledgeable personnel. Second, this index is calculated at the ZIP code level, not the individual member address level and earlier work has shown that measurements can vary (though typically with small variances) depending on the methods used. Thus again, this is a very resource intensive effort that could present a barrier to others trying to replicate our methods. The product of this radial spatial aggregation is a newly summarized set of factor values per ZIP code, which represent the summation of the factors for the ZIP code in question plus any ZIP codes within 30 miles. Next, each factor was independently standardized using a z-score calculation, which is simply a statistical measurement that captures how far a given observation (i.e., ZIP code) is from all other ZIP codes for the particular factor in question. For example, assume the average number of people living within a ZIP code is 5000 with a standard deviation of 1000 (i.e., standard deviation is a statistical measure that captures how variable the data points are). If a ZIP code had 6000 people in it, then relative to the average and standard deviation of all ZIP codes, it is exactly 1 standard deviation above the average. So for the population factor, it would receive a score of +1. If a ZIP code had 4000 people in it, then it would receive a score of -1, because it is exactly 1 standard deviation below the average. This type of scoring was done for all seven supply and demand factors and then used to create an overall standardized index score. Values above 0 (i.e., positive values) represent favorable access and values below 0 (i.e., negative values) represent unfavorable access across all seven factors. Using the seven factors and the combined index allows the user to visualize and analyze access to care on any or all of the seven factors independently or simultaneously. The following table shows an example of the final output: 20 HEALTH CARE REFORM: The Impact on Minority Populations in Tennessee

23 APPENDIX 3 (CONT.) Sample data showing final output of the seven standardized factors and the combined overall Health Care Access Index at the ZIP code level ZIP code Member Volume Population Emergency Room visits Inpatient Stays Primary Care Physicians Specialty Care Physicians Hospitals Overall Index Some of you may be asking yourselves, Why did they use a normally distributed z-score method versus a non-normally distributed approach like percentile ranking? Contrary to popular beliefs, z-scores can be applied to non-normal data. The z-scores won t follow the normal curve (they ll follow the original distribution of the non-normal data) so you cannot use a probability lookup table to see if an observation is likely/less likely to be above/below some value. However, this does not influence our analysis because we the authors are using the methodology to create a comparative reference/ranking point. That is, compared to the average, we want to know how all the ZIP codes compare. 21

24 APPENDIX 3 (CONT.) To evaluate ZIP codes across the index gradient, each of the seven factors was independently standardized using z-score calculations and applied to each ZIP code. This approach allows the user to make relative comparisons of a given ZIP code for each of the seven factors and then in a comprehensive combined index, relative to all other ZIP codes. The standardized formula for this calculation follows, such that: where Zij is the standardized z-score for the i th factor for the jth ZIP code, Xij is the raw value of the i th factor for the j th ZIP code, µ i is the overall mean of the i th factor across all ZIP codes, and σi is the overall standard deviation of the i th factor across all ZIP codes. Because four of the seven factors had scales opposite of this standard calculation (i.e., high values were disadvantageous, such as population, membership volume and utilization), we modified the formula in order to retain consistency across scales, given by the following: As with all z-score calculations, the mean of the score within a given factor i is 0 with a standard deviation of 1. For the index, values above 0 (positive) represent favorable access and values below 0 (negative) represent unfavorable access across all seven factors. Each ZIP code was given a z-score value for each factor, and an overall z-score was calculated by summing these seven z-scores across the ZIP code and then standardizing that summed value, given by: where Zcj is the standardized comprehensive z-score for ZIP code is the summation of the seven factors i to k for ZIP code j, n is the total number of ZIP codes under consideration, and is the standard deviation of the summation of factors i to k across n ZIP codes. This allows the user to visualize and analyze access to care on any or all of the seven factors independently or simultaneously. 22 HEALTH CARE REFORM: The Impact on Minority Populations in Tennessee

25 APPENDIX 4 - HEALTH CARE ACCESS INDEX MAPS Overall Health Care Access Index Score 23

26 APPENDIX 4 - HEALTH CARE ACCESS INDEX COMPONENT MAPS BlueCross BlueShield of TN Member Volume Tennessee Population Volume (2000 US Census) ER Utilization 24

27 APPENDIX 4 (CONT.) Inpatient Stay Utilization PCP Count Specialist Count 25 HEALTH CARE REFORM: The Impact on Minority Populations in Tennessee

28 APPENDIX 4 (CONT.) Facility Count 26